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0083 UNCLE WILLIES WAY - Health
* Uncle Willies ��a % , Hyannis P 292 314 A = . . . . . . . . . . . : . . � . . . � . . . % � � � � ) . � . | . ; ( . � ) . . , ] i o 1 �- TOWN OF BARNSTABLE LOCATION 0037 e-A---Le U�/ �e�1' AS! SEWAGE#-2®/� VILLAGE ASSESSOR`S MAP&&PARCEL �� INSTALLER'S NAME&PHONE NO. �� � � � � ��S` 707 SEPTIC TANK CAPACITY-e'�9,00'J'7,"°'d= LEACHING FACILITY: NO.OF BEDROOMS �. OWNER PERMIT DATE: COMPLIANCE DATE: Separation Distance Between the: " Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility / �� Feet Private Water Supply Well and Leaching Facility(If any wells.exist on site or within 200 feet of leaching facility) / Feet Edge of Wetland and Leaching Facility(If any wetlands exist within / 300 feet of leaching facility) / Feet FURNISHED BY �i y!J � -da o \4 CIN Qo q 4-s � � W o bd "t No. 0 02 Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes Zipplication for Mid oal 6pgtem Comaruction per 't Application for a Permit to Construct( ) Repair(�pgrade( ) Abandon( ) ❑ Complete System Individual Components Location Address or Lot No. G��Ze 011e/gyp �// Owner's Name,Address,and Tel.No. Assessor's Map/Parcel 1qzLy 00P 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(min.required) �r/4 gpd Design flow provided gpd Plan Date ,a �a /� Number of sheets / Revision Date Title Size of Septic Tank -c�,Y l JET/ d7 /®0O!F f4ype of S.A.S. -1�-3' Xmi �� � 0<4:X Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by thi rd of Health. Q Signed Date Application Approved by ��, Date ( �-- Application Disapproved by: Date for the following reasons Permit No. Date Issued v '" r...,t_v'""..v".., w►-.� i. -e ...tir..wrw'-+ .,,;..5.-+".-.-3 c�.4..s.v'*'� 7 T,� � ... .„ .. No. C V 5 Fee THE COMMONWEALTH OF MASSACHUSETTS? Entered in computer: PUBLIC,HEALTH DIVISION - TOWN`'-OF BARNSTABLE, MASSACHUSETTS Yes i Application for �Mp'!5al dip.5tem Construction der ft Application for a Permit to Construct( ) Repair(Upgrade( ) Abandon( I ❑ Complete System Individual Components Location Address or Lot No. �/ y i �� /�,/ Owner's Name,Address,and Tel.No. •✓N/ 1 A`cVG Assessor's Map/Parcel 177."PI Z Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. ��� `/ad$�oc�"U!t �7 s"o�0)' �1..I v/.b ,�jl+i+i�1✓'o.�. �.!' Type of Building: Dwelling No.of Bedrooms � Lot Size sq. ft. Garbage Grinder ( ) Other.� Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures ,Design Flow(mina.required) `�O gpd Design flow provided _ ' d__1_ gpd Plan Date Number of sheets / Revision Date Title Size of Septic Tank eo-X 6:' /O oo IFfFfype of S.A.S. /3 X ✓�. Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by thi e rd of Health. Signed Date Application Approved by —� Date �— Application Disapproved by: Date for the following reasons Permit No. G Date Issued �— THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS (Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed Repaired Upgraded ( ) P ( ) Pg ( ) Abandoned( )by at ap 1 't l!//LI/`e'.f' Ay�,Ok Afileas been constructed in accordance with the provisions of Title 5 and.the for Disposal System Construction Permit No CPO 12 — a�S dated Installer ,19 tc�G.lal Designer 4!2,,4AP./,-!�\\ 4 wr",ra !�J' #bedrooms Approved design fldlw �/$` gpd f The issuance of this perm t shall not be construed as a guarantee that the system illl uridion as desitgned. Date �i ' Inspector \► ---- — —-,-1— —=— ------ —_ -- — ------ -- No. Fee Feew THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION —BARNSTABLE, MASSACHUSETTS ni!gpoml *pgtem Construction Permit Permission is hereby granted to Construct ( ) Repair (!i') 0pgrade ( ) Abandon ( ) System located at J> -may///✓�''/✓� and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided: Construction must be completed within three years of the date of this Date �" j a'— Approved by ��""' TRANS.NO.: CITY/TOWN: - APPLICANT: ' ADDRESS: i wll��J DESIGN FLOW: g d REVIEWED BY: DATE:. . ' N/A OK NO GENERAL, - Le al boundaries denoted 310 CMR 15.220 4 (a)] , � Street Lot tax parcel number and lot number noted plan [310-CMR 15.220(4)(u)] Locus Provided [310 CMR 15.2204(t)]- Plan proper scale?(1"=40'for plot plans, 1"=.20'or fewer for components) 310 CMR 15.220(4) Easements shown [310 CMR 15.220(4)(b)] System located totally on lot served [310 CMR 15.405(1)(a)for upgrades]-i not, a variance is required [310 CMR 15.412(4)] Location of impervious surfaces(driveways,parking areas etc.) 310 CMR 15.220(4)(d) Location all buildings existing and proposed 310 CMR . 15.220(4)(c)] Location and dimensions of system components-and reserve areas. [310 CMR 15.220(4)(e)] System Calculations 310 CMR 15.220(4)(f) daily flow septic tank capacity (required andprovided) ' soil absorption system(required andprovided) whether system designed fo'r garbage grindei North arrow 310 CMR 15.220(4)( Existing and proposed contours [310 CMR 15.220(4)O] Location and log of deep observation holes(existing grade el. on each test) [310 CMR 15.220(4)(h)] " Names of soil evaluator and BOH representative [310 CMR 15.220(4)(h)and(i)] Location and date of percolation tests(performed at proper elevation?) [310 CMR 15.220(4)(i)] Percolation test results match loading rate?.[310 CMR 15.242] Certification statement by Soil Evaluator[310 CMR 15.220(4)0)] Observed and Adjusted groundwater(method for adjustment given'or indicated) [310 CMR 15.103(3) and 310 CMR 15.220(4)(n)] , Address 4114r Sheet 1 of 7 N/A OK NO Location of every water supply,public and private, [310 CMR ' 15.220(4)(k)] within 400 feet of the proposed system location in the case of surface water supplies and gravel packed public water supply within 250 feet of the proposed system location in the case within 150 feet of the proposed system location in the case ' of private water supply wells Location of all surface waters and wetlands located up to 100 ft. beyond setbacks listed in 310 CMR 15.21 land any catch basins t located within 50 ft. [310 CMR 15.220(4)(1)] Water lines and other subsurface utilities located [310 CMR 15.220 4 m if water line cross see 310 CMR 15.211 1 1] Profile of system showing invert elevations of all system components and the bottom of the SAS [310 CMR15.220(4)(o)] ; Stamp of designer[310 CMR 15.220(1) and 310 CMR 15.220(2)] Stamp of Registered Land Surveyor(required if construction activities within 5 ft.of lot line) 310 CMR 15.220(3 Test Holes adequate(two in each of the primary and reserve unless trenches as permitted in 310 CMR 15.102(2)or as approved for an upgrade under LUA at 310 CMR 15.405(1)(k) Test hole adequate to demonstrate four feet of suitable material? [310 CMR 15.103(4)] Test Holes adequate to confirm adequate groundwater separation? 310 CMR 15.103(3)1 Benchmark within 50-75' of system [310 CMR 15:220(4)( )] Materials specifications noted? [various sections of 310 CMR Ve 15.000] System components not>36"deep(unless Local Upgrade Approval or LUA requested) 310 CMR 15.405 1 ) Address V/ Nat Owv:J?' .w Sheet 2 of 7 t . . - N/A OK NO SEPTIC TANK.... *` ; Size OK? [310 CMR 15.223(1)] Inlet tee located ten inches below flow line [310 CMR 15.227(6)] Outlet tee 14" or 14"+5"per foot for increase ft depth [310 CMR 15.227(6)] Outlet tee with gas baffle or a roved`filter 310 CMR 15.227(4)] Note regarding installation on stable compacted base [31,0 CMR' 15.228(1)] Separation between inlet and outlet tees(no less than liquid depth) [310 CMR 15.227(2)] Inlet/Outlet elevations at least 12" above high groundwater (except as described 310 CMR 15.227(5))of permitted for upgrades under LUA [310 CMR 15.405(1)(k)] t� Minimum cover 9" (Tanks buried more than 9' must have risers on all openings and on the d-box) [310 CMR 15.2228(t)and 310 CMR 15.232(3)(0 Three access covers(inlet and outlet must be 20" or greater)- w middle access at least 8" b 7/07 310 CMR 15.228(2)] Access to within 6 " of grade -one port for systems<]000gpd, two for systems>1000 g d [310 CMR 15.228(2)] All at-grade covers secured to unauthorized access? [310 CMR 15.228(2)] > 10 ft from building foundation 310 CMR 15.211(1)] Buoyancy calculation Required/Done [310 CMR 15.221(8)] H-20 Where appropriate? [310 CMR 15.226(3)] Setbacks from resources [31.0 CMR 15211] - Multi,Compartment Tanks K Required when other than single-family dwelling or flow>]000 d [310 CMR 15.223(1)(b)] First compartment 200%daily flow; Second compartment-100%0 daily flow [310 CMR 15.224(2)and(3)] "U"pipe through or over.baffle,outlet of each compartment with as baffle or approved filter 310 CMR 15.224(4)] • 4 Address �� �� �" Sheet 3 of 7 N/A OK NO' BUIIDING`SEWER AND OTHER PIPING Located at least ten feet from any water line? [310 CMR 15.222(2) Disposal piping at least 18" below water line(when water and sewer cross, see 310 CMR 15.211(1)[1]) Cleanouts required/provided ? [310 CMR 15.222(8)] Thrust blocks specified in force mains?310 CMR 15.22](6)(c)]. Slope of sewer line not less than 0.01 (1/8"/ft) 0.02 preferable [310 CMR 15.222(6)] Proper pitch on all runs?(.005 within gravity-distributed trenches and beds) [310 CMR 15.251(9)and 310 CMR 15.252(2)(c)] .Siphonproblem/ leachfield below pump chamber) Endca s or vent manifoldspecified? Size and orientation of discharge holes specified?(not smaller than 3/8" not larger than 5/8") [310 CMR 15.251(8)and 310 CMR 15.252(2)(h)] Materials specified (310 CMR 15.251(5) specifies various pipe types allowed) DISTRIBUTION Stable compacted base [310 CMR 15.221(2)and 310 CMR 15.232(2)(a)] Splash plate or baffle tee required on inlet/provided?(when pressure sewer to d-box or steep pitch of gravity sewer)'[310 CMR 15.323(3)(a)]' r V Riser if deeper than 9" [310 CMR 15.232(3)(f)] Inside minimum dimension 12" [310 CMR 15.232(2)(b)]. Minimum sum 6" [310 CMR15.232(3)(e Watertight cover if<2000gpd); waterproof manhole,if>2000gpd [310 CMR 15.232(3)(d)] PUMP..GHANIBERS z i Capacity (emergency storage above working-design flow)? [310 CMR 231(2)] Proper setbacks [310 CMR 15.211 (same as septic tanks)] ` Watertight 20-in minium access manhole at least 20"MUST BE TO GRADE [310 CMR 15.231(5)] y° Service components accessible(not too deep with piping, disconnects accessible Alarm floats-alarm on circuit separate from pumps specified? Exceeds two units must have two pumps operating in lead-lag mode. [310 CMR 15:231(6)and (8)] Stable Compacted Base 310 CMR 15.221(2)] Buoy anc calculations needed'?Provided? 310 CMR 15.221(8)] 4 oAddress `�"..l'�`� �"'w� W Sheet 4 6f 7 N/A OK NO SOIL'ABSORPTION SYSTEMS.(SAS),GENERAL F Calculations correct? 4 feet of naturally occurring material demonstrated? [310 CMR 15.240(1)] Required separation togroundwater? [310 CMR 15.212)] Aggregate specified as double washed 310 CMR 15.247(2)] System Venting required/provided?(system under,driveway or >36" deep) [310 CMR 15.241] Inspection ports specified and within 3"final grade? [310 CMR 15.240(13)] Breakout requirements met?(No violation of breakout elevation within 1.5 ft of SAS unless barrier) [310 CMR 15.211(1)[4] and Guidance Document] GALL'ERIES,PITS;CHAMBERS 310 ("—.-,15.253 Chambers and Gal. in trench configuration supplied with inlet every 20 ft. [310 CMR 15.253(6)] Each structure with one inspection manhole(if>2000 gpd must , be tograde) [310 CMR 15.253(2)] Aggregate I'minimum-4'maximum. [310 CMR 15.253(1)(b)] 2' sidewall credit maximum [310 CMR 15.253(1)(a)] In bed configuration, inlet every 40 sq. ft. [310 CMR 15.253(6)] TRENCHES 3.10:CMW45.251 f _ Width 2'minimum 3'maximum [310 CMR 15.251(1)(b)] 100 feet-maximum length [310 CMR 15.251(1)(a)] Minimum separation 2x effective depth or width whichever greater(3x if reserve between trenches) [310 CMR 251(1)(d)] 1Z Situated along contours 310 CMR 15.251(2)] Breakout OK? [310 CMR 15.211(1)[4] and Guidance Document] BED:SAS (1VIagimum size of bed or:feld 5000 gpd), minimum 2 distribution lines [310 CMR'15.252(2)(a)] Maximum separation between lines 6' [310 CM,R15:252(2)(d)] Maximum separation between lines and outside of bed 4' [310 CMR 15.252 2 (e)] Aggregate depth below discharge pipes 6"minimum, 12" maximum. [310 CMR 15.252(2)( )]; Separation between beds 10'minimum. [310 CMR 15.252(2)(f)] Bottom area used in calculations only [310 CMR 15.252(2)(i)] ���\�f � 4 Address ��// "W'�''•�W���C//� // �) Sheet 5 of 7 . ' r N/A OK NO DID THE PLAN INVOLVE " Pressure Dosed System ? Provided pump and piping calculations as required [310 CMR 15.220(4)(r)] Pressure dosing required on all systems>2000gpd or alternative systems under remedial approval [310 CMR 15.254(2) and I/A Remedial Use Approvals] If used in gravelless system -make.sure jet is,directed as not to scour soil interface [Guidance Document] Inspections once per year(systems<2000 gpd)pr quarterly (>2000 dgood to note on plan [31.0 CMR 15.254(2)(d)] ' Construction in fill - Did the plan specify that the fill shall meet the specification of 310 CMR 15.255(3)? Impervious barrier and/or retaining wall ? [Guidance Document] Impervious barrier installation must be supervised by designer[310 CMR 15.255(2)(b)]. Retaining wall must be designed by Registered Professional Engineer 310 CMR 15.255(2)(a) Side slope not exceed 3:1 ? 310 CMR 15.255(2)] Breakout requirements met? [310`CMR.15.252(2)and Guidance Document] or At least 5 ft. from impervious,barrier to edge of SAS (10 ft. recommended) [310 CMR 15.255 (2)(e)] Gravelless System fVA Ap royal Letters] 1, Vz— Check DEP Approval letters for credits-and design conditions If used with pressure dosing do not allow pressure discharge to scour soil interface Alternative Se tic Syste i[UA A` royal Letters) Was DEP Approval Letter provided and/or have you ' reviewed the letter for conditions? > 'Is the technology being properly applied and does it meet all '. DEP ApproVal Conditions? Is there a note on the plan regarding the requirement for e p etual maintenance reement? Any alarms involved on separate circuits Did the applicant`submit an operation and maintenance manual? Has applicant submitted a copy of a maintenance ',Variances ` Are the variances listed on the plan? [310 CMR 15.220 (4)( )] a RLS Stamp necessary on plan if a component is within five.' feet of property.line [310 CMR 15.412(4)] New construction or increased flow proposed- [Refer to 310 CMR 15.414] ' Address �'r ��� �� (/� ' w Sheet 6"of 7 a ' . .A N/A OK NO Nitrogen Sensitive Areas° Is the system in a Designated Nitrogen Sensitive Area(Zone H fo a public supply well)? [310 CMR. 15:214, 310 CMR 15.215 and , 310 CMR 15.216-also refer to,Policy regarding upgrades of such existing systems] Is the system proposed on the same lotus served by private well ? 310 CMR 15.214(2)] ,. Are the nitrogen loads proposed in compliance? [310 CMR 15.216(1)] ri . Miscellaneous a " Pumping to septic tank? [310 CMR 15.229] Shared System 310 CMR 15.290] AddressVNbUE �'J Sheet.7 of 7 SEP/13/2012/THU 02: 11 PM SandwichTownOffices FAX No. 1 508 833 0018 P. 001/001 Town of Barnstable Regulatory Services Thomas F. Geller,Director ' BARNWAHM A Public Health Division 3 Thomas McKean,Director 200 Main Street, Hyannis,MA 02601 Office: 508 62- 644 Fax: 7211-2> 8-790-6304 Date: t zo� Sewage Permit# °��� Assessor's Map/Parcelzq Installer&Designer Certification Form. Designer; ]. �( Installer: � Address: Y , f Address: y�g 1 On q )�F-,C/ �1 wwj was issued a permit to install a -: F dat ) (uistaller) septic system at U 11AINWEZ21 based on a design drawn by C (address)1 lf� " dated (designer) I certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. Stripout (if required) was inspected and the soils were found satisfactory. Y I certify that the septic system referenced above was installed with major changes i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system)but in accordance with State&Local u- '-Pions. Plan revision ar certified as-built by designer to follow. Stripout(if rP acted and the soils were Found satisfactory. H OF1�q�s �r DAVID ` (Installer's Signature) a MASON 'not No.1066 0 �; 1ST A i }Y (DesignbOsSignature) PLEASE RETURN TO BAR_NSTABLE PUBLA, 1E OF COMPLIANCE WILL NOT BE ISSUED M ia, poi tt A mb P ORMC AND AS_ BUILT CARD ARE RECEIVED BY THE BAWNSTABLE-PUBLIC HEALTH DIVISION, Tf ANK YOU. _,._ gAoflice Fovinskdesigneru tificatioa forua.doc Commonwealth of Massachusetts 31 a Title 5 Official Inspection Form t .i.l Subsurface Sewage Disposal System Form -Not for.Voluntary Assessments 83 Uncle Willies Way " Property Address 4 �� Cliana Harwood Owner Owner's Name r, information is . required for every Hyannis MA 02601 4-20-18 ; page. City/Town j „ t' 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. A. General Information 1 Inspector: Shawn Mcelroy Name of Inspector Upper Cape Septic Services Company Name P.O. Box 73 Company Address E. Falmouth MA 02536 City/Town State Zip Code 1-508-495-0905 S13971 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 in4he 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 E uati by the-Local Approving Authority spector's Signature Date The system inspector shall submit a copy of this inspection report to the'Approving Authority(Board of Health or DEP) within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate 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.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 1 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments r a / � ,. 83 Uncle Willies Way Property Address Cliana Harwood Owner Owner's Name information is required for every Hyannis MA 02601 4-20-18 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: . ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: System is in good working order with no sign of failure. 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form i.t Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;... ` 83 Uncle Willies Way Property Address Cliana Harwood, Owner Owner's Name information is r required for every Hyannis 's MA 02601 4-20-18 page. City[Town w , ' State Zip Code Date of Inspection a 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 orbreakout 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): ❑ 3 'broken pipe(s) are replaced ❑ Y ON ❑ ND (Explain below): { ❑ obstruction is removed " '; ❑' Y ON ❑ ND.(Explain below): ❑ distribution box is leveled or replaced ❑Y ❑ N ❑ AND (Explain below): 1 , ti `f ia• rr. .. t# ` • t...h . ..t s .� Y ❑ 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 ON ❑ ND (Explain below): ❑ obstruction is removed ❑Y ON ❑ 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, .r*safety and the environment: f" ❑ Cesspool or privy is within 50 feet*of a surface water 01: ❑` ' Cesspool or privy is within 50'feet of a bordering vegetated wetland or a salt marsh t5ins.doc•rev.6/16 t,i'• Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 a r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 83 Uncle Willies Way Property Address Cliana Harwood Owner Owner's Name information is required for every Hyannis MA 02601 4-20-18 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than day flow t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts .:. 3 Title 5 Official- I nspection Foy V C.I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments-., 83 Uncle Willies Way _ Property Address Cliana Harwood Owner Owner's Name information is Hyannis "" �''t r : MA 02601 4-20-18 required for every y page. City/Town = State Zip Code Date of Inspection B. Certification (cont.) ,T., Yes, . No•• -4 , r«: r. ,, •, ❑ ® Required pumping more than'4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ` ❑ - Z Any portion of the SAS,,cesspool.or privy is below high ground water elevation. Any portion of cesspool or,privy is within 100 feet of a surface water supply or tributary to'a`surface water supply. c0 ® , Any portion of a cesspool or privy is within a Zone 1 of a public well. '' , , a ,t •=a c� o,µ �: . •', ,: -,:. i i ❑ ® Any portion•of'a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a'cesspool,or p6y 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 } t and chain of custody must be attached to this form.] The system is a cesspool serving a facility with a design flow of 2000gpd- �; .J, )f El - ® . • 10,000gpd. .. . r. ❑ 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.:, a E) Large Systems:To be considered a large system the system must serve a facility with a design i flow,of 10,000 gpd to 45,000Y pd.P -k . :,., For large-systems, youwmust indicate either"yes'•' or,"no"to each of the following, in addition to the questions in Section:D.t- • ^ r , . z— 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 ❑.} ' ° t Area—`IWPA) or a mapped Zone II of a public water supply well If.you,have`answered;"yes"Wanyquestion'in Sectio61E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts r� Title 5 Official Inspection Form �wr � I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 83 Uncle Willies Way Property Address Cliana Harwood Owner Owner's Name information is required for every Hyannis MA 02601 4-20-18 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been .done. You must indicate "yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of-,he 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 facil-ty 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? ® ❑ Wasthe facilily 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): 4 Number of bedrooms (actual): 4 DESIGN flowbased on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 4/-10 t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Ya ► - ; . ' ;w Title 5 Official Inspectidn' f6rm ,i.F Subsurface Sewage Disposal System Form -Not for Voluntary Assessments, 83 Uncle Willies Way Property Address Cliana Harwood Owner Owner's Name information is required for every Hyannis MA 02601 4-20-18 page. City/Town r State Zip Code Date of Inspection D. System Information �. Description: ; Number of current residents: 0 Does residence have a garbage grinder?, ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected?� t ❑ Yes ® No Seasonal use? El Yes ® No Water meter readings, if available,(last 2 years usage (gpd)): Detail: Sump pump? a ,,. ❑ Yes ® No Last date of occupancy: r 4-2018 Date Commercial/Industrial Flow Conditions: Type of Establishment: • Design flow (based on 310 CMR 15.203): a�- +s ! Gallons per day(gpd) t - .,,Basis of,design flow (seats/persons/sq:ft., etc.):; Grease trap present?.• ❑ Yes ❑ No Industrial waste holding tank present? r » f . + ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system?,a . ,.t._ ❑ Yes ❑ No Water meter readings, if available: t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 c Commonwealth of Massachusetts a Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 83 Uncle Willies Way Property Address Cliana Harwood Owner Owner's Name information is H annis MA 02601 4-20-18 required for every y page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Owner--pumped 2017 Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Maintenance Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 83 Uncle Willies Way Property Address Cliana Harwood Owner Owner's Name information is required for every Hyannis {. MA 02601 4-20-18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4 Approximate age of all components, date installed (if known) and source of information: 2012 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site,plan): { , Depth below grade: 24"feet Material•of construction: ®'cast iron` ® 40 PVC' " t` ❑`other.(ezplain): Distance from private'water supply wiell or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Good condition. Septic Tank(locate on site plan): Depth below grade: 18"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: , 1000 gal Sludge depth: 12" t5ins.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 83 Uncle Willies Way Property Address Cliana Harwood Owner Owner's Name information is required for every Hyannis MA 02601 4-20-18 page. City/Town State Zip Code Date of Inspection D. System Information (con:.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 20" Scum thickness 211 Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 14" How were dimensions determined? Tape 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 is in good condition with baffles installed and no sign of leakage. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal Systen-Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form t�f Subsurface Sewage Disposal System Form Not for Voluntary Assessments 83 Uncle Willies Way Property Address Cliana Harwood Owner Owner's Name information is required for every Hyannis MA 02601 4-20-18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) f -- a .P. .- ' Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence'of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection)(locate on site plan): Depth below grade: Material of construction: - ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: �,, ti > �, . -t� 1 �' gallons per day • Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No t5ins:doc-,rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 c Commonwealth of Massachusetts 3 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments J- > 83 Uncle Willies Way Property Address Cliana Harwood Owner Owner's Name information is Hyannis MA 02601 4-20-18 required for every y page. City/Town State Zip Code Date of Inspection D. System Information (con .) Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Good condition. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal Systen•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection .Form hl Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 83 Uncle Willies Way J' Property Address Cliana Harwood Owner Owner's Name information is required for every Hyannis MA 02601 4-20-18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4 m Type: ❑. leaching pits number: ® leaching chambers number: 3-500's ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: El innovative/alternative system Type/name of technology: Comments (note conditioniof soil, signs of hydraulic failure, level of ponding; damp soil, condition of vegetation, etc.): Leach chambers in good condition and empty at inspection with no visible stain lines. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins.doc-.rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 C Commonwealth of Massachusetts ,.,. Title 5 Official Inspection Form C�4 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 83 Uncle Willies Way Property Address Cliana Harwood Owner Owner's Name information is required for every Hyannis MA 02601 4-20-18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal Systen-Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form �nl Subsurface Sewage Disposal System Form -'Not for Voluntary Assessments 83 Uncle Willies Way ^� Property Address Cliana Harwood Owner Owner's Name information is required for every Hyannis + ' MA 02601 4-20-18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately 3 r T 24 . J/jam f. ZIP + r t t 4: t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form "l Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 83 Uncle Willies Way Property Address Cliana Harwood Owner Owner's Name information is Hyannis MA 02601 4-20-18 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 12 feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: ® Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database- explain: You must describe how you established the high ground water elevation: Original design plans show no groundwater at 12'. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins.doc•rev.6f16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form iNl Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 83 Uncle Willies Way Property Address Cliana Harwood Owner Owner's Name information is required for every Hyannis MA 02601 4-20-18 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 i t5ins.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 occupAm MUST COMPLY WITH T{HONSE FAILURE TO N - ULES AND RE GULAO YOU WISH TO OPEN A BUSINESS? COMPLY MAY RESULT IN FI NES For Your Information-. Business certificates (cost$40.00 for 4 years). A business certificate ONLY REGISTERS YOUR NAME in town (which you must do by M.G.L.-it does-not give you permission to op erate.) ou must first obtain the necessary signatures on this form at 200 Main St., Hyannis. Take the completed form to the Town Clerk's Office, 1 st FI., 367 Main St., Hyannis, MA 02601. (Town Hall) and get the Business Certificate that is required by law. DATE:�1�14 Fill in please: „t;^:•;+ el:a�., ,��. _ :i APPLICANT'S YOUR NAME/S: ��,,:,: ;;,,.::_•t;:.:���'.�d':.�;,, - BUSINESS YOUR HOME ADDRESS: Q (,QYI J •jLL- r-r H y TELEPHONE # Home Telephone umber 22 -5035 �'v ,;•stta• v...... ri;1 SOC I AL SECURITY OR EIN #: E-MAIL: NAME OF CORPORATION: - - o NAME OF BUSINESS - _ TYPE OF BUSINESS IS THIS A HOME OCCUPATION? . YES NO ADDRESS OF BUSINESS.:. -..... - . _j ' - - MAP PARCEL NUMBER r4 Z--- [Assessing) When starting a new business there are several things you must do in order to be in compliance with the rules and regulations of the Town of Barnstable. This form is intended to assist you in obtaining the information you may need. You MUST GO TO 0R 0 Mai1t. - (corner of Yarmouth Rd. & Main Street) to make sure you have the appropriate permits and licenses.required to legally operate your business in this to -;INIJ M i"lnS3si I��V J�1d WO. 1. 'BUILDING COMMISSIONER' OFFICE ,;. Llt~'. NOlitfinCJ�Ij a'Nd S3�nS , :.; � Hil/VV l��dWOD iSnW This individual.has been k f any it requirements that pertain to this type of businessA tho z re* COMMENTS: 2. BOARD OF HEALTH MUST COMPLYWITH ALi This individual has been informed of t e r i . is that pertain to this type of business. REGU K RCOUS MATERIALS IL00. ' 1 Authorized Signatur COMMENTS: 3. CONSUMER AFFAIRS (LICENSING AUTHORITY) > This--individual has been informed of the licensing,requirements that pertain to this type of business. Authorized Signature** COMMENTS: TOWN OF BARNSTABLE Dater/jaj 6 �— TOXIC AND HAZARDOUS MATERIALS REGISTRATION FORM NAME Or-BUSINESS: BUSINESS LOCATION: I _ �7-- INVENTORY MAILING ADDRESS: W1 ; TOTAL UNT: TELEPHONE NUMBER: Z CONTACT PERSON: EMERGENCY CONTACT TELEPHONE N BER: MSDS ON SITE? TYPE OF BUSINESS: y INFORMATION / RECOMMENDATIONS: Fire District: Waste Transportation: Last shipment of hazardous waste: Name of Hauler: Destination: Waste Product: Licensed? Yes No NOTE: Under the provisions of Ch. 111, Section 31, of the General Laws of MA, hazardous material use, storage and disposal of 111 gallons or more a month requires a license from the Public Health Division. LIST OF TOXIC AND HAZARDOUS MATERIALS The Board of Health and the Public Health Division have determined that the following products exhibit toxic or hazardous characteristics and must be registered regardless of volume. Observed / Maximum Observed / Maximum Antifreeze (for gasoline or coolant systems) Miscellaneous Corrosive ❑ NEW ❑ USED Cesspool cleaners Automatic transmission fluid Disinfectants Engine and radiator flushes Road salts (Halite) Hydraulic fluid (including brake fluid) Refrigerants Motor Oils Pesticides ❑ NEW ❑ USED. (insecticides, herbicides, rodenticides) Gasoline, Jet fuel,Aviation gas Photochemicals (Fixers) Diesel Fuel, kerosene, #2 heating oil ❑ NEW ❑ USED Miscellaneous petroleum products: grease, Photochemicals(Developer) lubricants, gear oil ❑ NEW ❑ USED Degreasers for engines and metal Printing ink Degreasers for driveways&garages Wood preservatives (creosote) Caulk/Grout Swimming pool chlorine Battery acid (electrolyte)/Batteries Lye or caustic soda Rustproofers Miscellaneous Combustible Car wash detergents Leather dyes Car waxes and polishes Fertilizers Asphalt&roofing tar PCB's Paints, varnishes, stains, dyes Other chlorinated hydrocarbons, Lacquer thinners (including carbon tetrachloride) ❑ NEW ❑ USED Any other products with "poison" labels (including chloroform,formaldehyde, Paint&varnish removers, deglossers hydrochloric acid, other acids) Miscellaneous. Flammables Other products not listed which you feel Floor&furniture strippers may be toxic or hazardous(please list): Metal polishes Laundry soil &stain removers �- (including bleach) Spot removers&cleaning fluids (dry cleaners) Other cleaning solvents /Bug and tar removers J Windshield wash WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS Applica is Signature Staff's Initials Town of Barnstable P# 73 7 3 F Departitnent of Regulatory Services Public Health Division Date 20b Main Street,Hyannis MA 02601 Date Scheduled , P Time 6 © Fee Pd. J _ SOU Suitabilio Assessment.for S _ ' e Disposal Performed By: Witnessed By: � LOCATION&GENERAL FORMATION s Location Address a� T l//j/eG �`fil/��l �lj� Owner's Name 1::�? a Address Assessor's Map/Parcel: oz Engineer's Name 4.d v�.tJ �' �1.f'�✓ �'r ' NEW CONSTRUCTION REPAIR Telephone# 1'6�7 Land Use: Slopes(%) Surface Stones Distances from: Open Water Body ft Possible Wet Area fk Drinking Water Well ft Drainage Way ft Property 11n6 ft Other ft SIM' TCH:(Street name,dimensions of lot,exact locations of test holes&pere tests,locate wetlands In proximity to holes) Parent material(geologic) Depth to Sedrock Depth to Groundwater. Standing Water in Hole: -Weeping from PI Face Estimated Seasonal High Groundwater DETERMINATION FOR SEASONAL HIGH WATER TABLE Method Used: Depth Observed standing in obs.hole: In. Depth to soll mottles: itt, Depth to weeping from`sido of obs,hole: in, Oroundwater Adjustment Index Well# Rcading Date: index Well level Adj,factor Adj.Groundwater Level , Observation PERCOLATION TEST bate._._,_,._._, Than ' Hole# Time at 9" Depth of Pere Time at G" Start Pre-soak Time @ Time(V-0) End Pre-soak Rate Min./Inch `-. !"`b Site Suitability Assessment:'Site Passed Sitc Failed: Additional Testing Needed(YIN) Original: Public Health,Division', Observation Hole Data-To Be,&mpleted'on Back---------- ***If percolation test is to be conducted within 100' of wetland,you must first notify the. Barnstable Conservation Division at least one(1) weelc prior to beginning. Q:\SEPTIC\PERCFORM.DOC DEEP-OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Sdil Color Soil- Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones;Boulders. • i to .Y,46'Cravell G -� DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. CollsistencV.%O ve j. DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other' Surface(in.) (USDA) (Munsell) ''.`�, .M ttl(ng (Structure,Stones,Boulders. o i to c e t: DEEP OBSERVATION HOLE LOG Hole# Depth.from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones',Boulders, Consistency, Flood Insurance Rate Map: Above 500 year flood boundary No - ,' Yes 'Within500 year boundary No✓, Yes Within 100 year flood boundary No. Yes Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring per I titerial exist in all areas-obstrved throughout the area proposed for the soil absorption system? W If not,what is the depth of na rally occurring per sous matarlal? Certification I certify that on (date)I have,passed the soil evaluator examination approved by the Department of Enviro ental Protection and that the above analysis was performed by me consistent with . the required training,ex p se a er'ence described in�10 CMR 15.017. Signatur Datb Z 201� Q:\s.EPTlCTERCFORM.DOC a a LOCATION SEWAGE PERMIT NO. an c VILLAGE Li rs n n INSTA LLER'S NAME & ADDRESS JOHN A. AALTO BACKHOE SERVICE West Barnstable, Mass. 026.68 B U I'L D E R OR OWNER DATE PERMIT ISSUED DATE CVdIMPLIANCIE. ISSUED , � - � � \�" �� z x �' � � �, �. �� � '�r � � ��. 04 �.� c c , � � � �' r>o................ Ficz ....... THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH ' .............. a �- 3 ApplirFa#ion for UiipniFai Works Tnnitrnr#inn jhrmit Application is hereby made for a Permit to Construct (x ) or Repair ( ) an Individual Sewage Disposal System at: ....Uncle 1 e Wi 11 i e s Way-------•-••-.... •...........................•-•-------L52 -.. . .......................................... ............ .._. ....• -•-- �L ocation-Address or mot No. - ..�... Owner Add es Installer Address Type of Building Size Lot.....1.1.,15.8......Sq. feet U Dwelling—No. of Bedrooms................................ .....Expansion Attic ( ) Garbage Grinder ( ) `4 Other—T e of Building No. of persons............................ Showers — Cafeteria Q' Othe1lfi tures ......----••--- -----••---••. ..... ---•-•. w Design Flow............................................gallons perlbdrm,per day. Total daily flow--- ...330 ................. ...................... WSeptic Tank—Liquid capacity-l0.0-Ogallons Length-_$!.(.!!... Width4 '10" Diameter................ llepth.5'_4."_•. x Disposal Trench—No. .................... Width.................... Total Length_.;................. Total leaching area....................sq. ft. Seepage Pit No...___--_-..._._-- Diameter................... Depth below inlet.................. Total leaching area.....267.....sq. ft. Z Other Distribution box (x ) Dosing tank ( ' ) Percolation Test Results Performed by.CAPja..COGS...S.l]rMey....CQUSultaritgDate.....DeC-.._•.aQ.X---- 977 aTest Pit No. 1...... ........minutes per inch Depth of Test Pit---1-2.1._....... Depth to ground water....non(......... G14 Test Pit No. 2......2........minutes per inch Depth of Test Pit---12.1......... Depth to gro b '�Ss na Ri ..............................•-----..............---••---•----••-------................----••......--......... 4... ........... _. ............ O Description of Soil-- -- ------.fit_ _........ �o? R�;Wr1u:K-•._ �,... x W J Glvet..- Zl/r�. �u►ef' 9�. 0�.. !e!"�r/f. u.•---CHAPMA U Nature of Repairs or Alterations—Answer when applicable............................................. ��. ....... sTEF` �`� x No- o � ----------••------•--•----._...--••------------•----------------•--------................._•-••-••-- FF Agreement: o ON The undersigned agrees to install the aforedescribed Individual Sewage isposal System in acc ance with the provisions of TIT1 5 of the State Sanitary Code—The undersig ed further agrees not to place the system in operation until a Certificate of Compliance has been i sue y the'board of health. Sig ed•---- Date Application Approved By...... ( 12. �`ay, •-•...._.. Date Application Disapproved for the following reasons:------••------------------------------------------------------••------------•---------------------•------•------ -•-------•-----------•------••--•------•---•--•---••••--•-----------------•-----••------.....---------....- Date PermitNo.................................................._...... IssuecL...................................................... Date Fss................. THE COMMONWEALTH OF MASSACHUSETTS BOARD-OF HEALTH _`.....TOYM.................OF.............BARNS.TABLE........................................... "Appltri tlan for Uhiposg ,arks Tonstrnrttun rrmtt I V_ 0 , Application is hereby:made for a Permit to Construct (X ) or Repair ( ) an Individual Sewage Disposal System at: Uncle Willies Wa :. Location-Address or Lot No. ............................ ..........- ----- •.._...---•- ,-..................... ..........-•................................. ............................................. Owner- Address a ........................::.................... ..•--........_•---___._.._.........._.........____ _...._......_._..---•••.....__......________Address ....................____________•---••.... Installer d Type of Building Size Lot.....I 1,ISE......Sq. feet U Dwelling—No. of Bedrooms_______________________3______._.________.Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building ........„.................. No. of persons............................ Showers ( ) — Cafeteria ( ) d \ Otherlfi�ctures ...-------------------------------------.---..-_•---••-----------------•------------ ............................................................. W allons er per day. Total daily flow______________..............................gal �I Design Flow..----._.__- -•--- g P330 gallons. WSeptic Tank—Liquidca.pacity-I b—DOgallons Length__�!_6_!T... Width�___�O .._ Diameter________________ Depth__5.__.4---__. x Disposal Trench—No_____________________ Widti�...__...________ Total Length.................... Total leaching area....................sq. ft. Seepage Pit No:........ Diameter.................... Depth below ....6__________.__ Total leaching area..... z7....sq. ft. Z Other Distribution box (X ) Dosing.tank"( ' '-' Percolation Test Results Performed by-Cape__ Cad..Survey...Consultarit0ate...... P�;G_....��.s... aTest Pit No. 1.....;!........minutes per inch Depth of Test Pit...1.2_........... Depth to grou no2ie_-----__. Test Pit No. 2.._..2:r�_minutes per mch _.4Depth of Test Pit__.12_!._______. Depth to td< qs ne-__.___- Q Descriptio of Soi at 4 l m RENB IC------- ._... ' �^ 1W 0HARMAN-_-__ -- U '� GLss 9yri `.� ac •� .. .. � t sj` .tV •a.�'t: W ---•-•----•--------•-. .. _._..-•------ --•••- -- -_...- --•-•..................... ... ............. .... • -•-• ••--• �v.elo._21�54 4 .o �L UNature of Repairs or Alterations—Answer when applicable________________________________________________ �'o ci5�a. `. .............. ..................................`...............•...............................=...........................................................I ...----•--- S.! LAN ,................. Agreement: The undersigned agrees to install the aforedescribeiI Indiv• a1- ewage Disposal System in accordance with the provisions of TlTll! 5 of the State Sanitary d 19° s egornot to place the system in operation until a Certificate.of Compliance has t y e boa lealth. Sig e �� JA j I g .....-••----------•................. ------------ Application Approved BY ............./-••------•---- 1`��,• " Application Disapproved for the following reasons--------------------------=-----•------------------------------••--------. ............. ......................................................_._._.....-•-------•-----------------•-----•-------°'-------...__...------------------...••••-•-•••-•----------••------•-•-•--•--•--------••-•-•-•- Date PermitNo....................................................... IssuecL....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .......... / .......................OF..... .......... � .. ........................ rrfff THIS IS TO CERTIFY, That the Individual Sewage Disposal System. constructed or Repaired ( ) Installer at........,-----_.... ----------•-----------•__----- ---- •-----------•--•---- ;------ has •b iWtA nce W' Itovi� e T h a as described in the application for isposal Works Construction Permit N �.__ --... date?___ _____________________________________ THE ISSUANCE OF THIS CERTIFICATE SH 9 OT E CONSTRUED AS A 416A4 L THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE.......................... .....1,�'-' .... ............. Inspector.............. == THE COMMONWEALTH OF MASSACHUSETTS BOARD' OF HEALTH OF....:. .....-. ...�............................ orko 015onotnuan "am it -- — Permission is hereby granted... ����1���..�....•----•- . to Construct or Repair. ( ) �l Jn�9' �9ua1 a isposal S/ystem atN; t�.... ` ....................................... 1/ Te as shown on the app ication for Disposal,Works Construction �ernut No._____ _ fiat d_ ________________M _... ........... .... Y► 7 � DATE......................................t FORA 1255 HOBBS IN WARREN,,INC.. PUBLISHERS - oCIHE Town of Barnstable aY,y Barnstable Board of Health .::z ►�edcachy nARNSrABLE, t �m� 200 Main Street,Hyannis MA 02601 i639 ArfO�,lp 2007 Office: 508-8624644 Wayne Miller,M.D. FAX: 508-790-6304 Paul Canniff,D.M.D. Junichi Sawayanagi CERTIFIED MAIL#7006-2150-0002-1041-9495 May 19, 2008 Mr. Donizete Ronfirm 83 Uncle Willies Hyannis, MA 02601 Dear Mr. Ronfirm: You are scheduled to appear at the Board of Health Hearing on June 10, 2008 at the Town of Barnstable Town Hall, 367 Main Street, Hyannis in the Hearing Room on the 2nd Floor because of your failure to comply with the Board of Health letter dated September 3, 2007. The meeting begins at 3:00 pm. You will be given the opportunity to be heard and present documentation, witnesses, and any other information that you feel would be beneficial to your case.- Your hearing will begin at 3:00 pm on June 20, 2008. Please be sure to be prompt. I Sincerely, T mas C. McKean, R.S, CHO Director of Public Health sc-dd Q.\Order letters\Sewage Violations\83 Uncle Willies May2008.doc / � THETp'4 Barnstable Town of Barnstable AFMaicaCRY p°"MSTABLE. ' Board of Health �'DlF 4S9 A, Street,°+ 200 MainStreet, Hyannis MA 02601 2007 Office: 508-8624644 Wayne Miller,M.D. F.AX: 508-790-6304 Paul Cannirt;D.M.D. Junichi Sawayanagi I September 3, 2007 Mr. Donizete Ronfim 83 Uncle Willies Hyannis, MA. 02601 i Dear Mr. Ronfirm, r You are granted additional time, sixty(60) days, to upgrade your septic system at 83 Uncle Willie's Way, Hyannis. HISTORY The property owned by you located at 83 Uncle Willies Way, Hyannis, MA. was inspected on May 23, 2007. by Donald Desmarais RS, Health Inspector for the Town of Barnstable because of a complaint regarding overcrowding. The following violation of the Town of Barnstable On-Site Sewage Disposal Systems Ordinance, §360, was observed: §360-20 (I): There were a total of six bedrooms observed in the dwelling (four bedrooms upstairs and two bedrooms downstairs). However, the existing septic system was designed for three (3)bedrooms total only. On May 301h you were ordered to either: (a) remove three bedrooms from dwelling by removing entrance doors, by removing the beds, and by opening all door-way entrances (by partially removing walls) to each room on the second floor to minimum of five feet wide openings within fifteen days of your receipt of this letter. A building permit must be applied for from the Building Dept or (b) Upgrade your septic system to handle more than three bedrooms; up to five bedrooms without a variance, six or more with a variance from the Board of Health. The septic upgrade must be completed within sixty (6O) days from receipt of this order. On June 6, 2007, you requested a hearing before the Board of Health, requesting additional time to upgrade the septic system._ On August 21, 2007, a hearing was held and the Board voted unanimously to grant you i an additional sixty days to upgrade the septic system. You are ordered to upgrade your septic system withi sixty(60) days, on or before October 22, 2007. Sinc el l l O . W e er, M.D. c Chai rm n r Directo of Public Health U� i (?:\Order letters"Sewage Violations\Ronfirnil xtcnsionJ.)ecision2007.doc l ov 19 00 09: 57fa Michael 11. McGuir" e 500 -477--5706 P. 1 iYvv.17.d;:UM tO-4;14M UAKN61FAtri.0 F'6F-VD OF Hc—' i 7H C.605 P.1%t Town of Barnstable ea.ns:ubl2 Board of Health k 2QQ:vieia Stact,HyenAis MA 02601 office: $03-862-4644 W%M-Mille,M.D. rAX: 506-M-6304 Paul Canniff,D.M.D. - ?tstticfii S�wayAns$� July 14,2008 Aracy 1Vie-tins 83 Uncle Willies Hyannis,MA,0260 1 T'w property ovmed by von looated at 83 Uncle Willies Wav,Hyannixy MA was rc inspected on July 10,2008.by Timothy B.az Co_7nell,Healtn lnspt�:for the Yown of Barnstable. The violations that were corrected: - i 360- I : j;rit86a-kx Dgwrmining 8 ite str 2r Replacement : 7 bL=were a total of(6)Mc bedrooms obsorvel SA the d,.ve irg( oir. e&oame ipstairs wA two bedrooms downstairs). However,type existing sa-ptic system was daaigned fcr(3)true,; bedroomst total onlf,. This ryas secompUshed by providing S.Qft cued opcoings between two of the bedrooms on second Boor. Reducing the total bedroorn count on the Aecarld floor to (2)two bedrooms. There were a tool of(4)four bedrooms obwr-yed within home at this time. Abhough the disp000l works constructloe permit is For(3)three bedrooms,it has been deemed that curreDt system can handle approximately 470 gallons per day. There is uo further action required Thus,all of tho violations prey ously noted were corrected, Thank you for your cooperation in this regard. Si ly, & Mi11er,14Y.D..Chaff r3tsans`� Boar of Health ' Q:'•C)/QtT 1t87tt15aMa4�dfO:mtIO�R��L`!1t;E�lni@t�f•,l�IeSLe1 i'JOfi.dOc � - . d , a : Commonwealth of Massachusetts;" Title 5 Official Inspection Form Subsurface Sewage Disposal System Form,-Not for Voluntary Assessments Property Address • owner. Owners N me Information is required for r required every page. City'Town State Lip Code Date of Inspection Inspection results must be submitted on this form. inspection forms may not;be altered in any way. lmportant: A. General Information When filling out forms on the IILnJ , computer:use •1. In ect Name or: only the tab key to move your cursor-do not ---- inspect -'--.o_..Ins._.-.p.._- 7} G cJ.--.__._'^._ l� _..... _---._.�........---...-------•---------..._.------------------_.____— -------...__ f 4 p use the return key. ........-_..---- - vYt P c•C �n'- r �,.-._------------------- ------ --�•-•-- - -------------- ----- Corn pany Name ve c Company Address City/Town--- - ate — Zip Code Telephone Number _ License Numb/ B: Certification m — ---- • • 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 Gonditionally.Passes ❑ Fails ❑ .Needs Further Evaluation by the Local Approving Authority Inspo tor'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 ovr ner and copies sent to the buyer, if applicable, and the approving authority. "•• -•� — — _ � conditions of use conditions at the time of inspection and under the This report only describes p at that time. This inspection does not.address how the system will perform in the future under the same or different conditions of use. [000'�' :5sU.ro: .!'N7 1'itte t.CrfCiW Inspectlrn'noun:Sutr:vtare Sewage Dtsposa;3ystec,•Ran.? <1 7 4;'�� Commonwealth of Massachusetts C = Title- 5 Official, Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments . ;r Cam.. �Lam- ...� �5 -...-.... 3......... .- -- -. . . _ . . ....._. ... ............... - - -- - - - - - ---- ------------- -- - Property Address Owner Owner's Name + information is requiredfor _.... .....:...,.• . ................... .......................... . .. ....... .................. every page. City"Town state Zip Code Date of Inspection - --------------------— --------- -;r------------ r----------—----------- --------------- B. Certification (cons.) 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 in310 CMR 15.304 exist. Any failure criteria not evaluated are, indicated below. Comments: fie, . o _:..:.- -. - . =----------------_-._..._.-..-_-.-_....._..._._._-.-_ .. --- --- -- - -- ` B) System Conditionally Passes: _ ,- r [] One or more system components as described in the"Conditional Pass" section need to be replaced or repaired The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Answer.yes, no'or not determined (Y, N. ND) in the ❑ for the following statements. If"not determined;°.please explain. The septic tank is metal and over 20 years old' or the septic tank(whether metal or not)is,, structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent F SystelTi will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health.' F i " A metal septic tank will pass inspection if it is structurally sound, not leaking'and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND Explain' Observation of sewage backup or break o`ut'or high static water level in the distribution box due to broken or obstructed pipe(s) ,or due to a broken,_settled or-uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s) are replaced [� obstruction is removed i,nsp.�c;• •2�.)' pie`:;+fidnl!nsF:rcd�:r.'r c«o Siariat,cf.5anase p�sV�sa!:>yster —A r f Commonwealth of Massachusetts _� ({ Title 5 Official Inspection ectionrForm ' {i Subsurface Sewage Disposal System Form - Not for Voluntary Assessments r, Cl J ----�-.n---- CI S -------------._.... -�, �( ...............................- _ -_ _.._..--- - Property Address ----•---- -- ---.. cl^ Owner Owner's Name nformation is �- V - �( ( ��-0 required for . _ . . ... '• - `= ---._..._...... _.a.. every page. City%Town tote Zip Code Date of Inspection B. Certification (cont.) B) .System Conditionally Passes(cent.): [] distribution box is leveled or replaced T . ND Explain; . ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(witti approval of the Board of Health) ❑ broken pipes) are replaced ❑ obstruction is removed a ND Explain: - —--------—....-- ---- C) Further Evaluatio is Required by the Board of Health: ❑ Conditions exist which quire further evaluation by the Board of Health in order to determine if the system is failing to pr ct public.health, safety or the environment. 1. System will pass unless atd of Health determines in accordance with 310 CMR 15.303(1.)(b) that the system is of functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within.50 fe of a surface water Cesspool or,privy.is within 50 feet o ' bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Healt (and Public Water Supplier, if any) determines that the system is.functioning in a anner that protects the public health, safety and environment: [] The system has�a septic tank and-soil absor ion system (SAS)and the SAS is within 100'feet of a'surface water supply"or.tributary a surface water supply. [] The system has a septic tank`and SAS and the_ AS is within a Zone 1 of a public water supply. ❑ The system.has aseptic tank and SAS and the SA is within 50 feet of a private water supply well. rlrricmi mspecdon Forn.f:.aNt,irhri;r,sewage oiswsa!system•'age o'_- Commonwealth of Massachusetts Title 5 Official Inspection Form F- Subsurface Sewage Disposal System.Form -Not for Voluntary Assessments 9 p Y _ y " p L ,r --_ L Property Addre( Owner Owner's Name information is L' „ M� () � �� /f-� Y required for -............. ---. _ ------. every page. City!Town State Zip Code Date of Inspection B. Certification (cont.) - __-_-_----`� ----�- - C) Further Evaluation is Required by Pe Board of Health (cont.): ❑ The system has a septic tank and SAS aiid.the SAS is less than 100 fee 0 feet or more from a private water supply well«` Method used to determine distance: ..........-------------- ......................-------- ---..... -— - --------------...__... This system passes if the well water aria is, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the prese e of ammonia nitrogen and nitrate nitrogen is equal to or less than S ppm, provided that no oth failure criteria are triggered. A ropy of the analysis must be attached to this form. •3. Other - - 2 ' ..._._.----...._...._..._._....._._........_..._. ------_...................................................._............... ................ ............................_................._...._. .-._._......:_.................................................................................................._..........................._............. -- D)- System'Failure Criteria Applicable to AII;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. U 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 distnbution'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. El than '/z'day flow' _ Required pumping more than 4 times in the last year NOT due to clogged or, obstructed pipe(s). Number of times pumped: [] Any portion of the SAS, cesspool or privy is below high ground water elevation. tc �] Any portion of cesspool or privy is within 100 feet of a surface water supply or ibutary to a surface water supply. . >anp.ox• ZrJ7 Ti;ie P Offidul lnspecboil Perm_SuMuttare Seriace DISpOSa!SJsie,?1•page a„ • ;�,.; Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments r 2j _. -- ---- Property Addres � Owner Owner's Name information is _ equired for F 1..... ....-,....�� .. . ... ��._..... every page. City Town State Zip Code Date of Inspection B. Certification (cont:)---- --'----------- — - D) System Failure Criteria Applicable to All Systems (coat:): Yes ... No W ❑ 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'SO feet of a private water supply well. C] 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 F ❑ 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 r r 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 1000 gpd to.15,000 gpd. For,large systerns, yo. must,indicate either"yes".or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the systern is thin•400 feet of a surface drinking,water supply ❑ ❑ the system is within feet of a tributary to a surface drinking water supply ❑ the system is located ima n ogen sensitive area (Interim Wellhead Protection Area — IWPA)or a mapped Zo II of a public water supply well If you have answered"yes"to any question in Section E t system is considered a significant threat,. or answered"yes" in Section D above the large system has led. The owner or operator of any large system considered a significant threat under Section E or faile rider Section D shall upgrade the system in accordance with 310 CMR 15.304..The system.owner s uld contact the appropriate regional office of the Department. i,nsp.ax•'•:77% A .. .;-ie 6 Official!nsr-ecccn Forn S.ax;;;dara;Sewage oiswsa!S+stem.•Page 5 v r , Commonwealth of Massachusetts � 1.. Title 5 Official Inspection Foam Subsurface Sewage Disposal System Form Not for Voluntary Assessments, ._.... -----------02li--jkl2.... ...... (. Property Add r ss ------------------------------.:.------- _ ------------- Owner owner's Name A information is AA /�2 ( required for ( 1.v1 t 5....... 'l�',q 1 - `.. ................ ..--�.. ... ... ........ .....-- ........ every page. City"Town Mate Zip Code Date of Inspection ------------------------------------------------------------------- C. Checklist Check if the.foflowing 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 El Were any of the system components pumped out in the previous two weeks? [] *lam 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 NIA) [] Was the facility or dwelling inspected for signs of sewage back up? 'KL Was the site inspected for signs of break out? ] Were.all system components, excluding the SAS, located on site? v \ Were the septic tank manholes uncovered, opened, and the interior of the tank e inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? El Was the facilityowner(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 or) U Existing information. For example, a plan at the Board of Health. n 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)] ;x I ;�r,5p.0ot• ,.U� ?ie::GYt'�cial�nspectlr,r.Fern:S�tr;;r'are 9�^rrayr.PisP'x>a!Syure•,.pa;e c - < _\ Commonwealth of Massachusetts Title 5 Official Inspection Fora . Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,` t r rr.. Property Address D� L -Y__.__ .-. .............. _.-_.-.____ _ -_______________________._._...__.._..-.__.__..___.__.__.—_..__.__._ Owner Owner's Name information is ^ required for .. U ----- every page. City'Town state Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms(design):' ' ----- Number of bedrooms (actual): ---'- -- . DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): -=v- Number of current residents: 'Does residence have a.garbage grinder'? ❑ Yes tCNo Is laundry on a separate sewage system?(if yes separate inspection required) ❑ Yes No - Laundry'system inspected? ❑ Yes �INo AL Seasonal use? '2 ❑ Yes [3,No* " Water meter readings,-if available (last 2years usage(gpd)). N µ . �� _ Sump pump? • _ ❑ Yes U_No Last date of occupancy: + Date Commer •al/Industrial Flow Conditions; - Type of Estab hment: - . ..---•---- ---------- --- ---- - ---------. Design flow(base on 310 CMR 15.203): Gallons Fier day(gpd)r Basis of-design flow(se is/persons/sq.ft., etc.): .----- --- --- ----�----- Grease trap,present? ❑ Yes. ❑ No Industrial waste holding tank Ares nt? Q Yes ❑ ' No Non-sanitary waste discharged to the. le-5 system? ❑ Yes ❑ No Water meter readings, if available: _. Last date of occupancy/use: ---------------- —------------------------------ Date Other (describe): -----'-------------- "--- -_---------------------=--- - c5�nsp.tloc•12!J7 '!'ae b:;rtic�al inspe. ,.n.rorn:Siz)s;xace Serrioe Disvzsa!:>vs*.71•rage .,. .c , Commonwealth of Massachusetts Title 5 Official Inspection Fora yt. Subsurface Sewage Disposal System Form Not for Voluntary Assessments Property Address .................... . . ................................................................. .. ...: .-.._............................-............... ...._............_--------- -........... -- Owner owner's Narne " information is required(or ..___. ........__. . ..:_... ... ........ ....._............. ...._..._ .. ........: ..... every page. City Town State Zip Code Date of Inspection - --------=-----------------------------------------— --------------------------- -------------- D. System information (con,t) General Information Pumping Records: - 7T Source of information: � ........._. . --................... .----- - Was system pumped as part of the Inspectiorr•? [_] Yes�<No" If yes, volume pumped: gauons.....................................------............................----------------------------- How was quantity pumped determined .................................... .. ... ..-- -....._.-...- Reason for pumping - . Type of System: )� Septic tank, distribution box, soil absorption system �7 Single ces spool ool 9 i (� Overflow cesspool U Privy U Shared system (yes or no) (if yes, attach,previous.inspection records: if any) Innovative/Alternative technology. Attach a copy of the current operation and Ej maintenance contract(to be obtained from system owner) Tight tank. Attach a copy of the DEP approval_ [�] Other(describe); Approximate age of all components, date installed (if known) and source of information: - ---------/7---7-----i........_------------------ - ----- - _.---- ------------ --. .................. Were sewage odors detected when arriving at thesite? L] Yes No "� •,)OJi c.. - - - JP.'.vY(i�;i11 InSnZC6�1 Fern:E: f.�f•:1CF1�t^Ir14'F.D JJsteM ��•]2 Commonwealth of Massachusetts Title 5 Official Inspection Form _i.. R " Subsurface Sewage Disposal System For Not for Voluntary Assessments 7 nE' t.� � t Property Add ss ---- --fit_-w_: . _ - -____.___------....--.--.._.__...--.-------------- -----=-.-.---.- Owner Owner's Narne :nformationis �/ required for r . _ - -._.._ .. ... ._ ......... every page City!Town St to Zip Code Date of Inspection --------- ---------------------------------D. Syste Information(cont.) Building Sewer cate on site plan): . ..._..................-_.__.....----------= Depth below grade ----------- feet Material of construction'. cast iron ❑ 40 PVC _] other(explain): ............._.._..............................................----------------- Distance from private water supply well or suctio ne: feet----------- -- ------------— __ Comments(or) condition of joints, venting: evidence of age, etc.): __......................._.-.-_._-........._...-.-..._.._-...-._.-.-.-_-........._.-._.-._._._.-.....---.....------ -----------._._..._...----- .....---------- -------------- ._.._...::.... Septic Tank(locate on site plan): tt . Depth below grade: - ....................................-.............--............ __.... Material of construction t (concrete ❑ metal [_]fiberglass.' _ �] polyethylerie ❑ other(explain) " \... If tank is metal.. fist age:, -yet s`-._.-..._,____._._-_._._.__-..._._.__--_--._--._-.--.-_...--- Is age confirmed by,a Certificate of Compliance"? (attach a copy of certificate) ❑ Yes ❑. No_• Dimensions: _f .Z.. ---------+- Sludge depth: --12--------- -- t Distance from top of sludge to bottom of outlet tee or baffle -- I -- •'----- --...... Scum thickness . &._r-! ............-��------------ --- Distance from top of`scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee Ur baffle --------- - -- ---------------- - How were dimensions determined? - ....... .. ----- !';tie!;(Xiciel!nspecorr.Fum,:Sazc;r:are SLmugr.Dsima!3gsro n:•Page 6 0 Commonwealth of Massachusetts , Title 5 Official Inspection Form ` '=i •Subsurface Sewage Disposal System Form Not for,Voluntary Assessments .77 Property............fO%s d'c,- L'.(Q) 7 J s -............ -- Ovine! Owner's Name ^^�,, information is �... �.. (�_.I... V II required for ' every page. City.Town state Lip 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.): ' �e Grease Trap(locate on site plan): Depth t lowgrade: feet '-- -'--'' --------'---- Material of onstruction: 0 concrete ❑ metal Ell fiberglass ❑ pplyethylene ❑ other(explain) Dimensions: .............. `--'--------- --- c Scum thickness . 4 __.... Distance frOITt top of scum top of outlet tee or baffle ---................ k' Distance from bottom of scurn o bottom of outlet tee or baffle ' .......... ----------------------- ----- — Date of last pumping: ' Date'----- -------- ----- ----r-- - - Comments(on pumping recomme 9ations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as.related to outlet inve evidence of leakage; etc.). Tight or Holding Tank (tank must be pure ed at time of inspection) (locate on site plan): , Depth below grade: - '------------------ Material of construction: ❑ concrete ❑ metal-, flberg ss ❑ polyethylene ❑ other(explairn .._-...._-_.f—..-..................--........................•_._-...---.—..._..._._..-_....._.....—._.__..._...... ------------------_.................................... —__— i ie 5(bide,lnspecdrn Porn.SuLx%jr!aCe sewage D soosa!S•Mem:Page!0 or' - Commonwealth of Massachusetts FF;-- -L= Title 5 Official Inspection Form_: ';A t Subsurface Sewage Disposal System Form -Not for Voluntary Assessments , ------ _ .-- c ep c � .`-`� 5--- ._.. -- .............-- ...--- --.--......_._..-_.... ---...- Property Address - .-..:--.. _. -.................................. .. . Owner Owner's Nameintormaltoo is required for every page. City Town State Zip Code Date of Inspection 3 Y D. System formation (cost ) • • Tight or Holding�Ta�k(cont.) Dimensions: .-................................................M.......... - ----------=----- .-. Capaciiy allons r n Desig Flow: _.-.-._...._.. .....:.-.---....................-- --- - ------- _.._... ........- gallons per clay -__— _ _ Alarm present: Yes ❑ No Alarm level: ......--f-....... Alarm in king order ❑ Yes ❑ No Dateof last pumping: ............................-................ ..... ... ..-............--.............................. Date Comments(condition of alarm and float switches, etc.): Attach copy of current pumping contract (required). Is ropy attached'? ❑ Yes �No Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet Invert _�u^'4......._.....................--•-------------------_.._-.: Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any. evidence of leakage into or out of box, etc.): 'Pump Chamber(locate on site plan): Fumps•in working order. ❑' Yes ❑ No Alarms in working order: ' ,_ ❑ Yes ❑ No 'iP.`C:fiCint!n5()e.C110!!FUI�!!:,$l`!Y.It1M)<;Q St'Y/'n JC D! System•!�7 SVJSa! 3e I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not'-for Voluntary Assessments Al, Property Address ........................_..................................................................................................—-------------------.......... Owner Ownor's Name information Is requiredfor ....... .. _ .... ..: ._...._. _.......... . ........ ._.................—........ ........ .........-. every page. City.Town State Zip Code Date of Inspection D. System Information (cont.) r Comments (note condition of pump chamber, condition of pumps and appurtenances; etc.): rT D 3 -------- -- y- Soil Absorption System (SAS).(locate or .site plan, excavation not required): If SAS not located, explain why: Type leaching pits number ---.�- -- [_] leaching chambers 'number: _-------___ —_—.._ ❑. leachinggalleries number: _...-._-..... _ ....g` [] 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..): ....................._.:....._......_ ...........................-................� ....... _._............................ _------------ --..--._......---._-._...------.........................94'C7-.......... .C!�.r....��. ------..._:- ...,.�- 'r mi 1.c ff,c;uI InSpc00n F-i:1:T1'. se'f/a.'gf7 D!sposa!J�,V.e�.Rage - cs Commonyvealth of Massachusetts Title 5 Official Inspection' Form Subsurface Sewage Disposal System Form -Not for Voluntary`Assessments `r �•l V�. a Property Address c 3 /� -- - =--- --- ----- ----------------------------------- - .----- --- -- ---...--._---- -- - - Owner Owners Name information is required for t.... /. ----- ....................... .., every page. City/Town tale Zip Code Date of Inspection ------------ g D. System Information (cont.), Cesspools(cesspool must be pumped as part of.inspection)(locate on site plan): - Number and configuration =. _.....:.............. ------ -- _. Depth- p of liquid to inlet invert -- - ---- --- - Depth of soli Layer --- -- -- -- ------- - ---- Depth of scum layer _...----•---...-..--------------- --- R Dimensions of cesspool - - ----- ----- --- - - Materials of construction .......- __--'-- --- Indication of groundwater inflow ❑ Yes ❑ No Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,' etc.j: --- -- ........................... -------.._.. --- .............--------- - - -._._._._..._--- ---_......_.- -.------------- ---------_ -..._ w Privy (locate on site plan). Materials of construction: -......... -----... ------ _ --- -....—---- -- Dimensions ------------....._.::.:..................--.---------.....-.:._._... _ _....- Depth of solids ------ -._:._._.. .-= ---------------- -------- --=--- Cornments'(note condition of oil, signs of hydraulic failure, level of ponding, condition of vegetation etc.): ;i•i isp.oc,' - .- pie „HiCiO;1llRxcrion Fenn:SutxmrfacR SL^//aye Disposa!5•ryta�,•gage i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address - Owner Owner's Name information is requiredfor- ............. . ... .............. ...-....................... ... .............._........ every page. City/Town State Zip Codo Date of Inspection D. System Information (cont.) Site Exam: Check Slope .. �fface water ❑ Check cellar Shallow wells Estimated depth to high ground water:- --------------------__ foot Please indicate all methods used to determine the high giound water elevation: Obtained from system design plans on record 'If checked, date of design plan reviewed: Date___.....:--•--.---...:.............--._......._......_._._._.._.'_-- ........... - , ❑ Observed site(abutting propertylo6servation hole within 150 feet of.SAS) Checked with local Board of Health-.explain; Checked with local excavators;.installers-(attach documentation) ❑- Accessed USGS database-explain'. You must describe how you established the high ground water elevation: ------- ---------------—.....-........................................................................... cg;nsp.00:•f2tJ7 'rule 5 C)fftclal InS,_RC !Fora:SUIYa;rjnre Sewage 01SW->521 syme,m•Page;5 e' Commonwealth of Massachusetts. !; Title 5 official Inspection Form Subsurface Sewage Disposal System Form -'Not for Voluntary Assessments r Property Address —-=-----_ —-----..._...__..-...•-.......-.-:-...-_....__.............:..........._....,_....._._...-_-._._....:_..._._.-.-......._._._.....-.-.-._._.-...__..._...._._...-._...-—-----—----------- Owner owner's Name information is- requiredfor _................._.... ........ ---- -- i-----:_._..-.__._._- ........... every page. City/Town 7tate Zip Code Date of Inspection i D. System Information (cent.) Sketch Of Sewage Disposal System. Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 het. Locate where public water supply enters the.building. rsa;a• ..l7r ' - i7e,:Cyfi:.nl rnsxcco�:Fcim SuLx;,;dace Sewage Disvmal .'Yre"., EW•A G E PERMIT. NO. LO C4110N_ S VILLAGE IN.STA LLER'S NAME ` & ' ADDRESS JOHN A. AALTO.BACKHOE SERVICE _ i JE MMest Barnstable,, Mass. .026.68 B U I'L D E R OR OWNER i i ATE PERMIT LSSUED P DATE C014PL1ANCE ISSUED I i• ov© �s o00/ i :- r Town of Barnstable Hart,stabl Board of Health nAtt,sras►.z:,�1 9 MASS / 200 Main Street,Hyannis MA 02601 ,p 1639. � �Fb M 2007 Office: 508-862-4644 Wayne Miller,M.D. FAX: 508-790-6304 Paul Canniff,D.M.D. Junichi Sawayanagi July 14, 2008 Aracy Martins 83 Uncle Willies Hyannis, MA. 02601 The property owned by you located at 83 Uncle Willies Way, Hyannis, MA was re- inspected on July 10,2008. by Timothy&O'Connell, Health Inspector for the Town of Barnstable. The violations that were corrected: §360-20 (I): Criteria for Determining System Repair or Replacement • There were a total of(6) six bedrooms observed in the dwelling (four bedrooms upstairs and two bedrooms downstairs). However, the existing septic system was designed for(3) three bedrooms total only. This was accomplished by providing 5.0ft cased openings between two of the bedrooms on second floor. Reducing the total bedroom count on the second floor to (2) two bedrooms. There were a total of(4) four bedrooms observed within home at this time. Although the disposal works construction permit is for (3) three bedrooms, it has been deemed that current system can handle approximately 470 gallons per day. There is no further action required Thus, all of the violations previously noted were corrected. Thank you for your cooperation in this regard. Sin ly, ay Miller,M.D. Chairman, Boar of Health Q:\Order letters\Sewage Violations\83 Uncle Willies BOH letter 2008.doc COMMONWEALTH OF MASSACHUSETTS s EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS q dDEPARTMENT OF ENVIRONMENTAL PR IV ED JUN 2 9 2004 TOWN OF BARNSTAbLE HEALTH DEPT. TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A ` CERTIFICATION 2 MAP Property Address: 83 Uncle Willie's Way PARCEL Hyannis MA 02601 ' b Owner's Name: Donald Fecteau Owner's Address: Same Date of Inspection: May 25,2004 Name of Inspector: PATRICK M.O'CONNELL Company Name: SEPTIC INSPECTION SERVICES CO. Mailing Address: 189 CAMMETT ROAD MARSTONS MILLS MA 02648 Telephone Number: 508-428-1779 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on m {Illffffll training and experience in the proper function and maintenance of on site sewage disposal systems. I ai OF approved sys em inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system:,��� •••.••••• s+ z�i�i p w era � •• ��%yG X_ Passes m Conditionally Passes e`z-- cat Needs Further Evaluation by the Local Approving Authority S t LL FailsLo ' In co ector's Signature: �-- Date: _5/25/04_ �ii���F5INS4E�����``��` C_a � The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or o DEN;within 3)days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd`or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments: 30" standing water in leaching pit. "'"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. - Title 5 Inspection Form 6/15/2000 ` r page l Page 2 of 1 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 83 Uncle Willie's Way,Hyannis Owner: Donald Fecteau Date of Inspection: May 25,2004 Inspection Summary: Check A,B,C,D'or E/ALWAYS complete all of Section D A. System Passes: _XX_ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. . Comments: B: System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not detennined(Y,N,ND)in the for the following statements. If"not determined"please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: • i Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with . approval'of Board of Health): broken-pipe(s)are replaced _ obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: l Page 3 of i 1 OFFICIAL INSPECTION FORM -SNOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 83 Uncle Willie'sVay,•Hyannis Owner: Donald Fecteau Date of Inspection: May 25,2004 C. Further Evaluation is Required by the Board of Health:W 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. I. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: _ Cesspool or privy is within 50 feet of a surface water _ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. . _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water,supply well". Method used to determine distance_ "This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free fi•om pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: Page 4 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) p Property Address: 83 Uncle Willie's Way,Hyannis Owner: Donald Fecteau Date of inspection: May 25,2004 D. System Failure Criteria applicable to all systems: You must indicate"yes" or"no"to each of the following for all inspections: Yes No _X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool _X_ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool _ _X_ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool _X_ Liquid depth in cesspool is less than 6"below invert or available volume is less than day flow ,a _ ._X_ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped _ _X_ Any portion of the SAS,cesspool or privy is below high ground water elevation. _X_ Any portion of cesspool or privy is within 100 feet of a.surface water supply or tributary to a surface water supply. _X Any portion of a cesspool or privy is within a Zone 1 of a public well. X Any portion of a cesspool or privy is within 50 feet of a private water supply well. _X_ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. (This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this forma No_(Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no _ the system is within 400 feet of a surface drinking water supply J _ the system is within 200 feet of a tributary to a surface drinking water supply _ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone 11 of a public water supply well if you have answered"yes"to any question in,Section E the system is considered a significant threat,or answered "yes" in Section D above the large system has failed.The owner or operator of any large system considered a - significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. A , Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 83 Uncle Willie's Way,Hyannis Owner: Donald Fecteau Date of Inspection: May 25,2004 Check if the following have been done You must indicate".yes"or"no"as to each of the following: Yes No _X_ — Pumping information was provided by the owner,occupant, or Board of Health _X_ Were any of the system components pumped out in the previous two weeks ? Has the system received normal flows in the previous two week period _X_ Have large volumes of water been introduced to the system recently or as part of this inspection') X Were as built plans of the system obtained and examined?(if they were not available note as N/A) X Was the facility or dwelling inspected for signs of sewage back up? X Was the site inspected for signs of break out? . X Were all system components,excluding the SASjocated on site? _X_ Were the septic tank manholes uncovered, opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? _X _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? E The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no _X_ — Existing information.For example,a plan at the Board of Health. X_ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)] Page 6 of 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM . PART C SYSTEM INFORMATION Property Address: 83 Uncle Willie's Way, Hyannis Owner: Donald Fecteau Date of Inspection: May 25,2004 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 4 Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd'x#of bedrooms) 440 Number of current residents: 2 - Does residence have a garbage grinder(yes or no): No Is,laundry on a separate sewage system (yes or no): No [if yes separate inspection required] . Laundry system inspected(yes or no): Seasonal use:(yes or no): No Water meter readings, if available(last 2 years usage(gpd)): Two years usage: 37,500=51 gpd. Sump pump(yes or no): No Last date of occupancy: Currently Occupied COMM ERCIALANDUSTRIAL Type of establishment: , Design flow(based on 310 CM 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no): Non-sanitary waste discharged to the Title 5 system(yes or no):T Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records: System pumped October 2003 Source of information: Owner Was system pumped as part of the inspection(yes`or no): No If yes, volume pumped:_ gallons-- How was.quantity pumped determined? Reason for pumping: TYPE OF SYSTEM _X_Septic tank,distribution box,soil absorption system Single cesspool _Overflow cesspool _Privy Shared system(yes or no)(if yes,attach previous inspection records, if any) Innovative/Alternative technology:Attach a copy of the current operation and maintenance contract(to be obtained,from system owner) _Tight tank' Attach a copy of the DEP approval _Other.(describe): d Approximate age of all components,date installed(if known)and source of information: Permit date: 1/24/78 Were sewage odors detected when arriving at the site(yes or no): No Page 7 of I I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 83 Uncle Willies Way,Hyannis Owner: Donald Fecteau Date of Inspection: May 25,2004 BUILDING SEWER: X (locate on site plan) Depth below grade: 18" Materials of construction:_cast iron _X_40 PVC__other(explain): Distance from private water supply well or suction line: 35' Comments(on condition of joints, venting,evidence of leakage,etc.): SEPTIC TANK: X (locate on'site plan) Depth below grade: 16" Material of construction:—X—concrete_metal fiberglass___polyethylene -other(explain) If tank is metal list age:- Is age confirmed by a Certificate of Compliance(yes or no):—(attach a copy of certificate) Dimensions:8.5' long x 5.2'wide—1000 gal. Sludge depth: 2" , Distance from top of sludge to bottom of outlet tee or baffle: 28" . Scum thickness: 1" Distance from top of scum to top of outlet tee or baffle: 7 Distance from bottom of scum to bottom of outlet tee or baffle:.13" How were dimensions determined: STICK WITH HINGE FLAP. Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as.related to outlet invert,evidence of leakage,etc.): ` Baffles intact and clear. GREASE TRAP: No (locate on site plan) Depth below grade:_ Material of construction:_concrete_metal_fiberglass_polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations, inlet and outlet tee of baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): Page 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 83 Uncle Willie's Way,Hyannis Owner: Donald Fecteau Date of Inspection: May 25,2004 TIGHT or HOLDING TANK: No (tank must be pumped at time of inspection) (locate on site plan) Depth below grade: Material of construction: concrete__metal fiberglass_._polyethylene other(explain): ' Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no)-., - Date of last pumping: Comments(condition of alarm and float switches,etc): s' DISTRIBUTION BOX: X (if present must be opened) (locate on site plan) Depth of liquid level above outlet invert: 0". Comments(note if box is level and distribution to outlets equal;any evidence of solids carryover,any evidence of leakage into or out of boz,etc.): PUMP CHAMBER: No (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): Page 9 of l l OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 83 Uncle Willie's Way,Itya'nnis Owner: Donald Fecteau Date of inspection: May 25,2004 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required) If SAS not located explain why: -r Type _X_leaching pits,number: One 6x6(1000 gal.)pit.- leaching chambers,number: leaching galleries,number: , leaching trenches,number, length: leaching fields,number, dimensions: overflow cesspool,number: innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil, condition of vegetation, etc.): Observed 30"standing water in nit,no definite liieh sidewall stains. CESSPOOLS: No (cesspool must be pumped as part of inspection) (locate on site plan) Number and configuration: , Depth—top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation,etc.): PRIVY: No (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): Page 10 of I I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 83 Uncle Willies Way,Hyannis Owner: Donald Fecteau Date of Inspection: May 25,2004 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Uncle Willie's Way 83 . LS"� 22 2 ® °3(o r 'n` Page 11 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: •83 Uncle Willie's Way;Hyannis Owner: Donald'Fecteau x Date of Inspection: May 25,2004 SITE EXAM Slope None Surface water None Check cellar Dry Shallow wells None Estimated depth to ground water: More than 25 feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-.If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with local excavators, installers-(attach documentation) _X_Accessed USGS database-explain: USGS topo map and town GIS You must describe how you established the high ground water elevation: Topo map shows property above el. 50 and town groundwater contour map shows water below el 25. y i SOIL L O S F •` •. y t� �)(A�ll 7:{A\V�uy-x4nl txi avd=ylj,wyi,�iA✓,_� � _ y '�A J 2 PEASTONE �• LOAM fl FILL- ,12°.MAX. - e ..T., 41,C.I. D1sT. BOX ° ° ° �" �• e Go r28C 97.R _ ° /O'MIN. 1000 D; a°' d000— GAL. A' -o,o f• Cr AV&?,. ys GAL. ° Leo°� PRECAST- OR SEPTIC BLOCK, ° o. TANK I6, . . ° SEEPAGE PIT •; - r f f * ICI DOe�o ° o �o el � �dr+)' �i3�" � ` . ` I0 °0 0 e k y a'♦ -'0 .Q I jL"`"F+ rW y 7�, r•, 0 k .20' MINIMUM y' 'FOUNDATION' %z" WASHED STONE. �- , E 10 PQRC. RATQ s (N,—O, ..✓�.,.,.,i ELEVATION SKETCH s� �� x I. �+�, TEST BY : Crt.JiG/rTinECx/../,°N/ etllsa,/ SCALE'• I 4' TOWN INSPECTOR: �.o� L r,..f�_ «t,a . \ . BACKHOE OPERATOR �oif.�✓' .oL:�-� TEST MADE ON . »C 3o Lcp / as u. {a. !t, 1 S G a Q g Rs , -...,. _ - .,•- - -_ �'l-.�... ..� .,,.,.,. .. -....._.,..,.�..�-..... ,...,,.,,,:-x,.so.a...r-.. „�+` R ..a a.•.++e.+.. s '�.iX-a:�'r.+`- .-.,^+. _ `�-.#-s n - :?!w�.#d:.«{`_•m`z... ..- _ . - ,•.i..., - _ �`'b�.s` 'c..a lit�+.:!"�` ' ,�'•..n.....w..""",..'""`.` .'"i` „.�.....•.w,r.,./p� ---"`�"-_ � x 400 91 . . coot. PfE�T ' •• - - � - .l _ _• . ; _' _,,,..,,.,,.,�,�� 4�H-OF RENWICK CHAPMAN .o NO..27Z54 0 1STO •�4. .r NNG� , f ELEVATION •SCHEDULE PROPOSED .SITE PLAN I. . INV. 'AT FOUNDATION OC119t� } SIEVA®E SYSTRM DIESION 2.- 1 NV, INTO SEPTIC TANK E /001t�?�' IN 3. ,1 NV. OUT OF SEPTIC' TANK _ /000 Z 4. INV., INTO DISTRIBUTION BOX / >0"�Q� SCALE I -,,�¢'' �� L 19'T—'? 5. 1 NV. OUT OF DISTRIBUTION BOX = ao, as` w C_ 413 6. INV INTO SEEPAGE PIT = ll�C.�.14�1 CAPE » COD SURVEY, CONSULTANTS ROUTE 132 7. BOTTOM OF PIT HYANNIS, MASS. A DIVISION BOSTON SURVEY CONSULTANTS, INC. 8. BOTTOM OF STONE LAYER = t r - .,. •.b. .. _ .r _. - ,-.i., r ... '- .. ,.. r ^.+..s- --. ..,. - - _ tea. 1 f ASSESSORS MAP : Z�Z l �, No 1�� !��i 2012 Scp ' 9: PARCEL : f 1ES II0L[_. LOGS � � _ FLOOD ZONE: SOIL EVALUATOR : V} C 1) The installation shall comply with Title V and Town of�,�11 ' 3oard of WITNESS : I p Y �+�"�ti� REFERENCE: 1!!I'i �. �j-1 �' ��� health Regulations. �� -- - - -- ------ ------_---- -- DATE: \�. 2) The installer shall verify the location of utilities, sewer inverts and septic /�IL* 1' tCV G4 PERCOLATION RATE: -7.94I , / 1 components prior to installation and setting base elevations. 3 �Mawv� Of Lam 3) All gravity septic piping to be 4 inch Sch 40 PVC at 1/8" per foot. The first — -- ------ --- ----- --c----- — ---- �— v� two feet out of the d-box to the leaching shall be level.`Z \9 RTO TH- I TN-2 4) This plan is not to be utilized for property line determination nor an other � C y -- LDA14 b b AA` other than the proposed system installation. ,� purpose p p Y to y Z to 7., 5) All septic components must meet Title V specifications. e p 1 S 6) Parking shall not be constructed over H 10 septic components. ,i �✓ ,� �6 �� 7) The property is bounded by property corners and property lines. LOCATION MAP / > 3Z 8) The property owner shall review design considerations to approve of total design flow and number of bedrooms to be considered for design. Receipt '_�� •—� of payment for the plan and installation based on the plan shall be deemed C approval of the design flow by the owner. Ib�127 eI 1(�c��� 9) The existing leaching or cesspools shall be pumped and filled with material per Title V abandonment procedures. Those within the proposed SAS shall ' be removed along with contaminated soil and replaced with clean sand per 1 Q, Title V specs. ----- - ---- ---.� Q-- ----- -- 10)System components to be 10 feet from water line. Sewer lines crossing the /1 water line shall be sleeved with 4 inch SCH 40 PVC with ends grouted if `J applicable. The proposed SAS is being installed below the water service SEPTIC SYSTEM DESIGN line. The line is to be sleeved as aforementioned and maintained in place. \ J 11) If a garbage grinder exists it is to be removed and is the responsibility of the owner to ensure such. �O0 / FLOW ESTIMATE 12)The installer is to take caution in excavation around the gas line if such ±BEDROOMS AT 110 GAL/DAY/BEDROOFA AqO GAL/DAY 13 The installer shall verify the location quantity/ /C � ) y , q y and elevation of the sewer � OH � cl( r,I � L,DII (� lines exiting the dwelling prior to the installation. SEPT I C T NK 14)This plan is representative only that a system can fit on a property meeting V / Title V requirements. GAL/DAY x 2 DAYS - GAL r0 USE GALLON SEPTIC TAN I�,(IH ° SOIL ABSORPTION SYSTEM---------- _ P"j�kOF��s 600 '(- �i2-UL�k`7� Cj� U�1 ,Z D B. �s � MASON m 10�t O SIDE AREA: �� C, 3. + IZ�Qj�J XZ X +7 /�J7 gN/TAR Pfi� BOTTOM AREA: ,5 x- IZ� � 0", "J? I G i. Q - SEPTIC SYSTEM SECTION 3.od Iva C, /1 `t lam- �L /� 70 - ` y X -� rLl lC GAL 50.1 D-BOX SEPTIC TA I }C ti✓L —1 1 SITE AND SEWAGE PLAN LOCAT I ON : 83 D►JLLL, 1LUE��> P PREPARED FOR : -Ti" E-EaDl?,UF z L M I0 SCALE DAV I D B . MASONRS DATE : lZ IZ s DBC ENV I RONMEN�AL DESIGNS Z CAST SANDWICH . MA W DATE HEALTH AGENT ( S08 ) 833- 2 177 Z