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HomeMy WebLinkAbout0104 UNCLE WILLIES WAY - Health 104 Uncle'Willies Way -'Hyannis P A = 292 003014 t 0 G i i, n �•-•Hzar ous Materials Inventory Sheet Checklist t�104 ate P-hysical Street Address-Check database to ensure it exists L_ Working Phone Number /actual Amounts -( ie. gas being used to fuel machines, thinner to clean brushes all count as hazardous materials-no blanks) ,_---SWrage Information -location of storage, how long is storage for? If none, note that. Disposal Information=where and who? If none, note that. Applicant Signature -understand what is listed and noted Staff Initial=any questions, know who to ask Vehicle Washing/Rinsing? -give a vehicle washing policy and explain it ,- Attach the Business Certificate with your sign off and comments "The inventory form should explain what.the business consists of and the procedures they are doing. Notes need to be left to explain what you discussed with them. YOU WISH TO OPEN'A BUSINESS? For Your Information: Business Certificates cost $30.00 for 4 years. A Business Certificate ONLY REGISTERS THE BUSINESS NAME in town (which you must do by M.G.L.- it does not give you permission to operate.) You must first obtain the necessary signatures on this form at 200 Main St., Hyannis. Take the completed form to the Town Clerk's Office, Vt FL., 367 Main Street, Hyannis, MA 02601 (Town Hall) and get,the Business Certificate that is required by law. £ � Fill in please: Date: oci f 0 � Y � APPLICANTS NAME: JGjzt(U— (n Fu:f ram, YOUR HOME ADDRESS: [OLJ Ur1Oe_ u,,i'I j j"zS UJCLSti4 �Vr� ` c BUSINESS TELEPHONE # HOME TELELPHONE #: NAME OF.CORPORATION: NAME OF NEW BUSINESS 5 TYPE OF BUSINESS CJ-e.4 ai IS THIS THIS A HOME OCCUPATION? YES X NO ADDRESS OF BUSINESS` 1011 ur)FI f w, I Wes . U,/c (-h annA� MAP/PARCEL NUMBER (Assessing) When starting a new business there are several things you must do to be in compliance with the rules and regulations of the Town of Barnstable. This form is to assist you in obtaining the information you may need. -You MUST GO TO200 Main St. (corner of Yarmouth Rd. & Main Street) to make sure you have the appropriate permits and licenses required to legally operate your business in town. 1. BUILDING COMMISSIONER'S OFFICE This individual has been informed of any permit requirements that pertain to this type of business. Authorized Signature** COMMENTS: 2. BOARD OF HEALTH This individual been i pformed the p rmi e uiremen s that ain to this type of'business. 6 Authorize ignature** - ' ,-`U)STCOMYWITHAII COMMENTS: HAZARDOUS MATERIAIS REC, ULATIONg 3. CONSUMER AFFAIRS (LICENSING AUTHORITY) This individual has been inform ed�of the licensing requirements that pertain to this type of business. Authorized Signature** COMMENTS: I� Date: y //6 /� TOWN OF BARNSTABLE TOXIC AND HAZARDOUS MATERIALS ON-SITE INVENTORY NAME OF BUSINESS: ��- BUSINESS LOCATION: > +9- 6 INVENTORY MAILING ADDRESS: TOTAL AMOUNT: TELEPHONE NUMBER: _S-GE- 46�9: _ 7o Z-3 CONTACT PERSON: �Jo 2� - EMERGENCY CONTACT TELEPHONE NUMBER: row ��S- 33 3:3 MSDS ON SITE? TYPE OF BUSINESS:___e5�L-,ldn S INFORMATION/RECOMMENDATIONS: Fire District: ho 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 materials use, storage and disposal of 111 gallons or more a month requires a license from the Public Health Division. LIST OF TOXIC AND HAZARDOUS MATERIALS The Board of Health and the Public Health Division have determined that the following products exhibit toxic or hazardous characteristics and must be registered regardless of volume. Observed/Maximum Observed/Maximum Antifreeze (for gasoline or coolant systems) _ Misc. Corrosive NEW USED Cesspool cleaners Automatic transmission fluid Disinfectants Engine and radiator flushes Road Salts (Halite) Hydraulic fluid (including brake fluid) Refrigerants Motor Oils Pesticides NEW USED (insecticides, herbicides, rodenticides) Gasoline, Jet fuel, Aviation gas Photochemicals (Fixers) Diesel Fuel, kerosene, #2 heating oil NEW USED Misc. petroleum products: grease, Photochemicals (Developer) lubricants, gear oil NEW USED Degreasers for engines and metal Printing ink Degreasers for driveways &garages Wood preservatives (creosote) Caulk/Grout Swimming pool chlorine Battery acid (electrolyte)/Batteries Lye or caustic soda Rustproofers Misc. Combustible Car wash detergents Leather dyes Car waxes and polishes Fertilizers Asphalt & roofing tar PCB's Paints, varnishes, stains, dyes Other chlorinated hydrocarbons, Lacquer thinners (inc. carbon tetrachloride) NEW USED Any other products with "poison" labels Paint &varnish removers, deglossers (including chloroform, formaldehyde, Misc. Flammables hydrochloric acid, other acids) Floor &furniture strippers Other products not listed which you feel Metal polishes may be toxic or hazardous (please list): Laundry soil & stain removers (including bleach) Spot remover & cleaning fluids ers) Other cleaning solvents Bug and tar removers Windshield wash WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECThON" �b APR 12 2005 TOWN OF BMNISTABLE HEALTH DEPT.: TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FOR M PART A CERTIFICATION Property Address: 104 Uncle Willy Way Hyannis Owner's Name: Pam Richards. Owner's Address: Date of Inspection:- J O o Name of Inspector:(please print) Wi 1 1 i am R- -Robinson Sr. Company Name: William E. Robinson Septic Service Mailing Address: P O Box 1089 Centerville. MA Telephone Number: (5081 775-8776 CERTIFICATION STATEMENT i certify that 1 have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails o Inspector's Signature: /ti Dute: 3 -3 0—® `5 'Me system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health-or DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments ""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 page 1 , Page 2 of l I , OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address:_104 Uncle Willy' s Way Hyannis Owner . Pam Tuchards Date of Inspection: 3_3 G_o Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: 1/ 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. i 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 exfrltration 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. l ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to-broken or _ obstructed pipe(s)or due to a broken,settled or uneven distribution box.System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced explain: The system required pumping more than 4 times a year due to broken or obsu xted s .The system will pass inspection if(with approval of the Board of Health): pipe(s). broken pipe(s)are replaced obshvctinn is removed N explain: 4 Page 3 of 11 OFFICIAL INSPECTION FORM=NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 104 Uncle Willy' s Way Hyannis Owner: Pam Richards Date of Inspection:- 3 [�_y- G G— C- Further Evaluation is Required by the Board of Health: 1 Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: Cesspool or privy is within 50 feet of a surface water I_ Cesspool or privy is within 50 feet of a bordering vegetated.wetland or a salt marsh r 2. System will fail tl unless the Board of Health and Public Water Supplier,( many)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 u PP Y �Y supply. The system has a septic tank and SAS and the SAS is.within a Zone 1 of a public water supply. _ The system has a septic tank and SAS and the SAS is,within 50 feet of a private water supply,well. - The system has aseptic tank and SAS and the SAS is'less than 100 feet but 50 feet or more from a private water supply well- Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and - the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: 3 :� Page 4 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 104 Uncle Willy' s Way Hyannis Owner: Pam Richards Date of inspection: 3 —3 G—o D. Syllem 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 _ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped _ Any portion of the SAS,cesspool or privy is below high ground water elevation. _ Any portion of cesspool or privy is within 100.feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone 1 of a public well. �. .Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 f^_et 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 tine 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.] (Yes/No)The system fails.I have determined that one or more ofthc 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 _ L the system is within 200 feet of a tributary to a surface drinking water supply _ L the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—1WPA)or a mapped Zone 11 of a public water supply well I I 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 faricd.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 151304.The system owner should contact the appropriate regional office of the Department. 4 .Page 5 of 11 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 104 Uncle Willy' s Way Hyannis Owner: Pam Richards Date of Inspection: —3 U—O Check if the following have been done.You must indicate`yes"or"no"as to each of the following: Yes No/ Pumping information was provided by the owner,occupant,or Board of Health Were any of the system components pumped out in the previous two weeks? ✓ _ Has the system received normal flows in'the previous two week period? Have large volumes of water been introduced to the system recently or as part of this inspection T Were as built plans of the system obtained and examined?(If they were not available note as N/A) — Was the facility or dwelling inspected for signs of sewage back up? _ Was the site inspected for signs of break out? U _ Were all system components,excluding the SAS,located on site? !� _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on:. Yes ..no/ ✓ 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(3)(b)) M 5 Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 104 Uncle Willy' s Way Hyannis Owner: Pam Richards f Date of inspection: 3 3 c) -o 5 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):. Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): ySz, Number of current residents: d-/d, Does residence have a garbage der(yes or no): A, o Is laundry on a separate sewage system(yes or no):X°O [if yes separate inspection required] Laundry system inspected(yes or no): Seasonal use:(yes or no):k d Water meter readings,if available(last 2 years usage(gpd)): 2 0 0 4 - 1 1 6, 2 5 0 Sump pump(yes or no): /-U 2003 - 129,750 Last date of occupancy: � -3u -6 COMM ERCIAL/IUSTRIAL Type of establisl t: Design flow(base 310 CMR 15.203): gpd Basis of design fl w(seats/persons/sgft,etc.): Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no):_ Non-sanity aste discharged to the Title 5 system(yes or no):_ Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Was system pumped as part okhe inspection(yes or no): /?-0 If yes,volume pumped:_gallons--How was quantity pumped determined? Reason for pumping: - TYP�OF SYSTEM eptic tank,distribution box,soil absorption system _Single cesspool Overflow cesspool —_Privy _Shared system(yes or no)(if yes,attach previous inspection records,if any) _Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) _Tight tank Attach a copy of the DEP approval _Other(describe): Approximate age of all components,,d to installed if known)and source of information: Were sewage odors detected when arriving at the site(ye.s or no): /v 6 I'agc 7 of I I OFFICIAL INSPECTION FOI04—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE.SEIVAGE DISPOSAL SYSTEM INSPECTION FORM PART C ` SYSTEM 1NFOR11'IATION(continued) Property Address: 1 04 Uncle Willy' s Way _Hyannis Owner: Pam Richards Date or Inspection: 3 -`3-- BUILDING &NVER(locate on site plan) Depth b/fftloin rade. Materiaonstruction:—cast iron 40 PVC other(explau►): Distant private water supply well or suction line: Comm nis(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TASK./(locate: on site plan) ►► Depth below grade:�_ Material of eonslruction:—� o Icte metal fiberglass J,ol)'eUrylene _oUrcr(explain) — If tank is metal list age: Is CC111fICa1C) age confinned•by a Ceniftcate of Compliance(yes or no):—(attach a cop),of iJ Dimensions: 44 W Sludge depth: cJ > > Distance front top of sludge to bottom of outlet Ice or baffle: _ Scum d►ickncss: 3 v 1 Distance from lop of scum to lop of outlet Ice or baffle: r I Distance Gorn boron►of scum to bottom of outlet ice or baffle: I 1 ► I Io%v were dimensions determined; (} Comments(o►►pumping recommendations, inlet and outlet ice or baffle condition,structwal integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): 'j GREASE TRAP:_(locate on site plan) - Depth below grade:_ Material of construction: concrete metal fiberglass—}►01)'Cd►ylene—other (explain): — Dimensions: j Scum Thickness: f Distance Gom top of scum to top of outlet tee or baffle: Distance Gom bottonl/of scum to bottom of outlet Ice or baffle: Date of last pumping: Conunents(on pumping recwnn►endations, inlet and outlet Ice or baffle conditions,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): 1 . 1 7 'age 8 of 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORA] PART C SYSTEM INFORMATION(continued) Property Address: 104 Uncle Wi1ly' s Way Hyannis Owner: Pam Richards DRtt of lospectlon: TIGHT or IIOLDIAG TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grad . Material of const ction: concrete_metal_fiberglass_polyethylene other(explaut): Dimensions: / Capacity: alluns Design Flow; gallons/day Alarm presc (ycs or no): Alarm level Alann in working urdcr o -cs ur no): Date of las pumping: Comment (condition of alarm and float switchcs,ctc.): DISTRIBUTION BOX: /ofpIescnimustbe o pened)(locate onsite plan ) Depth of liquid level above outlet invert: Conunents(note if box is level and distribution to outlets equal,an),evidence of solids carryover,any evidence of - leakage into or out of box,etc.): I'UMP CHAMBER. (locate on site plan) Pumps in working order(yes or no):— Alartns in workingirdcr(ycs or no):— Conumenis(note condition of pump chamber,condition of pumps and appurtenances,etc.): J. Page 9 of 11 OFFICIAL INSPECTION FORM=NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 104 Uncle Willy' s .Way Hyannis Owner: Pam Richards Date of Inspection: 3 SOIL ABSORPTION SYSTEM(SAS): /(locate on site plan,excavation not required) \ If SAS not located explain why: Ty/- leaaching hing pits,number: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.): 4� CS 1-7� L_ C, 1 2 7 6 t z 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 o4esspool: Materials of onstruction: Indication o groundwater inflow(yes or no): F Comment/(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: Comment(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): 9 Page 10 of 11 OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 104 Uncle Will s Way Hyannis Owner: Pam Richards Date of Inspection: 3 —I u 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. 1 nZ� V"JA PPll S A y' J 10 . Page l l of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 104 Uncle Willy' s Way Hyannis Owner. Pam Richards Date.of Inspection: 3 -'3 o a1.5 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water , ' 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) Accessed USGS database-explain: You must describe how you established the high ground water elevation:. f 11 COMMONWEALTH OF MASSACHUSETTS "EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS z w DEPARTMENT OF ENVIRONMENTAL PROTECTION w m j d TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 104 UNCLE WILLIES WAY HYANNIS, MA 02601 ��C�I�E� Owner's Name: MR DAVIS Owner's Address: 104 UNCLE WILLIES WAY HYANNIS,MA 02601 Date of Inspection: 3/28/02 APR 2 9 2002 TOWN OF BARNSTABLE Name of Inspector: (please print) JOHN GRACI HEALTH DEPT. Company Name: SEPTIC INSPECTIONS Mailing Address: P.O. BOX 2119 TEATICKET, MA. 02536 Telephone Number: 508-564-6813 FAX 508-564 270 CERTIFICATION STATEMENT 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 tilde 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 1.5.340 of Title 5,(310 CM 15.000). The system: X Passes _ Conditionally Passes _ Needs Fo i Evaluation by the Local Approving Authority Fails Inspector's Signature: Dater 3/28/02 The system inspector shall subs/it, a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days.of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Notes and Comments SYSTEM PASSES TITLE V INSPECTION. RECOMMEND PUMPING NOW AND THEN EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE: ****I'll is report only describes conditions at the time of inspection and under the conditions of use at (hat fiitic. '1'llis inspection does not address how the system will perforul in the.fu(ureund'er the same or different conditions of Ilse. Page 2 of,l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY M +S O O OLU Y ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 104 UNCLE,WILLIES WAY HYANNIS, MA 02601 Owner: MR DAVIS Date of Inspection: 3/28/02 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. Svstem Passes: X I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments SYSTEM PASSES TITLE V INSPECTION. RECOMMEND PUMPING NOW AND THEN EVERY TWO YEARS TO PROLONG THESYSTEM'S USEFUL LIFE. B. System Conditionally Passes: _ One or more system components as described in,'the"Conditional Pass"section reed to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Flealth, will pass. Answer yes, no or not determined(Y,N,ND) in the for the following statements. If"not determined"please explain. n/a 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 extiltration or tank failure is inuninent. 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: n/a n/a '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: n/a n/a 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): n _broken pipe(s)are replaced _obstruction is removed ND explain: n/a Page 3 of, 1 I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 104 UNCLE WILLIES WAY HYANNIS, MA 02601 Owner: MR DAVIS Date of Inspection: 3/28/02 C. Further Evaluation is Required by the Board of Health:'. Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which,will protect public health,safety and the environment: Cesspool.or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Suppli:r, if any)determines that the system is functioning in a manner that protects the public health,safety and environment: The system has aseptic 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 I 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 n/a **This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: n/a „ _ k Page 4 of,l 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 104 UNCLE WILLIES WAY HYANNIS, MA 02601 Owner: MR DAVIS Date of Inspection: 3/28/02 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for alLinspections: 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 %2 day flow _ X Required pumping more than 4 tunes in the last year NOT due to clogged or obstructed pipe(s).Number of times Pumped uLa. a X Any portion of the SAS,cesspool or privy is below high,ground water elevation. X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone I of a public well. _ X Any portion of a cesspool or privy is within 50 feet of a private water supply well. X Any portion of a cesspool or privy is Tess than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and,the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.[ (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 X the system is within 400 feet of a surface drinking water supply X the system is'within 200 feet of a tributary to a surface drinking water supply X the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—I WPA)or a mapped Zone Il 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 Scc:liun U above the hrgc syslcin h"is fiiiled. the lul-`uf.iuty l;il-ge i. .*11l cow;idcled it kigliiliciflll 11il (fl under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The sysleni owner should contact the appropriate regional office of the.Department. Page 5 of,I I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE.DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 104 UNCLE WILLIES WAY HYANNIS,'MA 02601 Owner: MR DAVIS Date of Inspection: 3/28/02 Check if the following have been done. You must indicate "yes" or"no" as to each of the following: Yes No X Pumping information was provided by the owner,occupant,or Board of Health X Were any of the system components pumped out in the previous two weeks X Has the system received normal flows in the-previous two week period `' X Have large volumes of water been introduced to the system recently or as part of this inspection ? X Were as built plans of the system obtained and examined? (if they were not available note as N/A) X Was the facility or dwelling inspected for signs of sewage back up' : X Was the site inspected for signs ofbreak out X Were all system components, excluding the.SAS, located on site? X Were the septic tank manholes uncovered,opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction,dimensions,'depth of liquid, depth of sludge and depth of scum ? X Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance Of subsurface sewage disposalisystems 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)] x. � a. Page 6 of I I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 104 UNCLE WILLIES WAY HYANNIS,'MA 02601 Owner: MR DAVIS Date of Inspection: 3/28/02 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 Number.of bedrooms(actual): 3 DESIGN Flow based on 310 CMR`l5.203 (for.example: 110 gpd x#of bedrooms): 330 Number of current residents: 5 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): NO Seasonal use: (yes or no): NO Water meter readings, if available(last 2 years usage(gpd)): {a ZCoo ` Sump pump(Yes or no): NO Z,Q�,� �� C b u Last date of occupancy: n/a COM M ERCIAL/INDUSTRIAL Type of establishment: n/a Design Flow(based on 310 CMR 15.203): n/agpd Basis of design flow(seats/persons/sgR,etc.): n/a Grease trap present(yes or no): NO Industrial waste holding tank present(yes or no): NO Non-sanitary waste discharged to the Title 5 system(yes or no): NO Water meter readings, if available: n/a ` Last date of occupancy/use:. n/a OTHER(describe): n/a GENERAL INFORMATION Pumping Records Source of information: n/a Was.system pumped as part of the inspection (yes or no): NO If yes; volume pumped: n/agallons=- How was quantity pumped determined? n/a Reason for pumping: n/a TYPE OF SYSTEM X Septic tank,distribution box,soil absorption system Single cesspool Overflow cesspool Privq _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 &copy of the DEP approval Other(describe): n/a Approximate age of all component date installed(if known)and source of information: 19861tY rnvNriz4� qU� Were sewage odors detected when arriving at the site(yes or no): NO. - Page 7 of OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE,SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 104 UNCLE WILLIES WAY HYANNIS, MA 02601 Owner: MR DAVIS Date of Inspection: 3/28/02 BUILDING SEWER(locate on site plan) Depth below grade: 18" Materials of construction:_cast iron X40 PVC_other(explain): n/a Distance from private water supply well or suction line: n/a Comments(on condition ofjoints,venting,evidence of leakage,etc.): TOWN WATER SEPTIC TANK: X(locate on site plan) Depth below grade: 12" Material of construction: Xconcrete metal, fiberglass_polyethylene other(explain)n/a If tank is metal list age: n/a Is age confirmed by a Certificate of Compliance(yes or no): NO(attach a copy of certificate) Dimensions: 1000G L 8' 6" H 5.' 7" W 4' 101 " Sludge depth:2" Distance from top of sludge to bottom of outlet tee or baffle:32" Scum thickness: 2" Distance from top 017sann to top of outlet tee or-baffle: 6 Distance from bottom of scum to bottom of outlet tee or baffle: 16" How were dimensions determined: MEASURED . , Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related_ to outlet invert,evidence of leakage,etc.): SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY. RECOMMEND PUMPING NOW AND THEN EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE. GREASE TRAP: _(locate on site plan) Depth below grade: n/a Material of construction: concrete metal—fiberglass_polyethylene_other(explain): n/a Dimensions: n/a — Scum thickness: n/a Distance from top of scum to top of outlet tee or baffle: n/a Distance from bottom of scum to bottom of outlet tee or baffle` n/a ` Date of last pumping::_n/a Comments(on:pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): n/a Page 8 of I 1 OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM.INFORMATION(continued) Property Address: 104 UNCLE WILLIES WAY HYANNIS, MA 02601 Owner: MR DAVIS Date of Inspection: 3/28/02 TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: n/a Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a Dimensions: n/a Capacity: n/a gallons Design Flow: n/a gallons/day _ Alarm present(yes or no): N/A Alarm level: N/A Alarm in working order(yes or no): NO Date of last pumping: n/a Comments(condition of alarm and float switches, etc.): n/a DISTRIBUTION BOX: X(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: LEVEL WITH BOTTOM OF PIPE Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover,any evidence of leakage into or out of box, etc.): D=BOX 1S STRUCTURALLY SOUND. _a PUMP CHAMBER: _(locate on site plan) Pumps in working order(yes or no): NO Alarms in working order(yes or no):NO Comments(note condition of pump chamber,condition of pumps and appurtenances, etc.): n/a Q Pane 9 of R OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 104 UNCLE WILLIES WAY HYANNIS,-MA 02601 Owner: MR DAVIS Date of Inspection: 3/28/02 SOIL ABSORPTION SYSTEM (SAS):. X (locate on site plan,excavation not required) If SAS not located explain why: n/a t Type n/a leaching pits, number:. n/a CULTECS leaching chambers, number: 4 n/a leaching galleries, number: n/a n/a leaching trenches, number, length: n/a n/a _ leaching fields, number: n/a n/a overflow cesspool, number: n/a „/a innovative/alternative system ' Type/name of technology: n/a Comments(note condition of soil, signs of hydraulic failure, level of ponding,damp soil,condition of vegetation,etc.): CULTECS APPEAR TO BE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY. DID NOT EXPOSE, ry NO INSPECTION COVER RAISED.THEY ARE 4.DEEP AND WERE PROBED DRY. BOTTOM IS AT 51. CESSPOOLS: (cesspool must be pumped as part of inspection)(iocate on site plan) Number and configuration: n/a Depth—top of liquid to inlet invert: n/a Depth of solids layer: n/a Depth of scum layer: n/a Dimensions of cesspool n/a Materials of construction: n/a Indication of groundwater inflow(yes or no): NO Continents(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.): n/a PRIVY: :.(locate on site plan) Materials of construction: n/a Dimensions: n/a Depth of solids:n/a-, Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): n/a _ l) Page.,10.of OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 104 UNCLE WILLIES WAY HYANNIS, MA 02601 Owner: MR DAVIS Date of Inspection: 3/28/02 x 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. A Ci g g o% _ g ® I L AA�y 1 in w Page:I I•of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 104 UNCLE WILLIES WAY HYANNIS,MA 02601 Owner: MR DAVIS Date of Inspection: 3/28/02" SITE EXAM _Slope _Surface water _Check cellar - Shallow wells Estimated depth to ground water 10+feet Please indicate(check)all methods used to determine—the high ground water elevation: NO Obtained from system design plans on record If checked;date of design plan reviewed: n/a YES Observed site(abutting property/observation hole within 150 feet of SAS) NO Checked with local Board of Health-explain: n/a NO Checked with local excavators, installers,(attach documentation) . NO Accessed USGS database-explain: n/a You must describe how you established the high ground water elevation: HAND AUGER- 10+ FT. 01/29/99 FRI 14:18 FAX 1508 775 7337 RETAIL ADV Q 001 for OF 33 January 29, 1999 �o Susan Rash Chairman of the Board of Health 367 Main Street Hyannis, MA 02601 Dear Chairman Rash; I am writing to request a hearing regarding my septic system. I am trying to sell my home and am required to install a new leaching field. I have an estimate of$2,100 from Mid Cape Septic. Now 1 am told 1 must pay another $1,000 to have an engineer draw plans because I am near wetlands. I am a widow with two children. I find it very difficult to raise this amount of money. I am requesting that with the help of the Board of Health and my septic contractor we could get this done. Thank you for your attention to this matter. Sincerely, Kandy Rutherford 776-5683 Home - 862-1197 Work 02/09/1999 16:30 5085647270 JOHN GRACI SEPTIC PAGE 02 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTA]AFFAIRS John Grad DEPARTNENI'OF ENVMONMfiNTAL PROTECTION ONE WINTER STREET BOSTON MA 02108(617)292-3500 DEP Title V Septic IIISpCCtOt P.O.1)ox 2119 TeaTidce4 Ma. (508)56"813 TRUDY COXE ARpEO PAUL GELWCCI secretary C7p1prpor DAVID B.STRUMS Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION ProP"Address: 104 UNCLE WILLIES WAY HYANNIS LOT 14 Name of Owner KANDY RUTHERFORD Address of Owner: nfa We of lnspedion: 1/13/88 Name of Inspector;(Please Print)JOHN ORACI I A/Il a DEP 8ppioved system ln*VCW pursuant to Sscdon 15.340 of T/de 5(310 CMR 15.WO) Company Now: Joan Grad Tide V Inspections Mailing Address: PO Box 2119 Tekphone NWfdw- (608)6644813 CERTIFICA3 nu STATFIL!EW f certify that I have personally inspected the sewege disposal system at this address and lhpt the Information and complete as,of the time of Inspection.The inspection was perfarMed based on m training end meted below is tnre,accurate maintensrtce of vn-slte Y n9 expsAsnce in the proper function and �9e draposal systems.The system: Psases Cot>dRi- "y Passes _ Needs F X Fails Evaluation By the Local Approving Authority InspedoPs Signature: Date:1/14/8D The Syster ttin is Ms for S n.If theme a�of this inspection repot to the Approving Authority(Board of Health or DEP)wahtn thirty(30)days of somplailling subrNt the repot to the system is a shared system or has a design now of 10.000 9Pd of greater,the inspector and the aystem owner system "*"and appropriate reponat ofRce of the Department of Environmental Protectton.The original should be sera to the Y� Copies Sent to the txiyer,if eppliwbls,and the approving authority. NOTES AND COMMENTS SYSTEM FAIL$TITLE V INSPECTION.THE UtZUID LEVEL WAS OVERR PIPE. LEACH PIT IS IN HYDRAULIC THERE WAS NO LEACHING LEFT AT THE TIME OF THE INSPECTION. . revised%2M Page t of 11 02/09/1999 16:30 5085647270 JOHN GRACI SEPTIC PAGE 03 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM -PART A CERTIFICATION(continued) Property Address: 104 UNCLE WILLIES WAY HYANNIS LOT 14 Owner: KANDY RUTHERFORD Date of Mspectlon:1r13188 INSPECTION SUMMARY: ch@ckA, 8,C,-or D: A. SYSTEM PASSES: _ I have not found any Inflo oft which Indicates that any of the failure condatons described in 310 CMR 15,303 exist.Any failure crtterlo not evaluated are indicated below. COMMENTS: Na IL SYSTEM CONDITIONALLY PASSES: One or more system components as dewribed In th&,Cor4tWr0j Pass section need to be replaced or repaired,The system,upon canptetion of the replacement or repair,as approved by the Board of Health,will pass. Indicate yes,no,or not determined(Y.N,or ND).Describe basis of determination In al Instances.If'not determined".explain why not. Iy The septic tank is metal.uniesa the owner or operator has provided the system Inspector with a copy of a Certificate of Compliance(attached)lndicating'Qat the tent was Installed within twenty(20)years prior to the date of the Inspection:or the septic tank,whether or net foetal,Is crooked,structurally unsound,shows aubatanttl Infiltration or exfiltratton,or tank failure is Imminent.The system wAl pass inspection If the ads"septic tank Is replaced with a Compytng septic tank as approved by the Board of Health. 8 Sewage backup or breakout or No static water level observed in the distributlon bon Is due to broken or obstructed pipe(s) or due to a broken,settled or uneven distribution box.The system will pass Inspection if(with approval of the Board of Health). broken pips(s)are replaced _ obstruction Is removed distribution box Is levelled or replaced J9 The system required pumping more Ihan four times a year due to broken or obstructed pips(s).The system will pass .Inspection If(with approval of the Board of HeaHh): _ broken pipe(s)we replaced obstnx ion is removed revised Si12/98 Page 2 of 11 02/09/1999 16:30 5085647270 JOHN GRACI SEPTIC PAGE 04 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 104 UNCLE WILLIES WAY HYANNIS LOT 14 Owner: KANDY RUTHERFORD Date of Inspection:1113011 C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Condition$exist which require fuRher evaluation by the Board of Health in order to determine if the system is failing to protect the public health,safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 16.303(1)(b)THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT ThE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: - Cesspool of privy is within 50 feat of surface water - Cesspool or p"is within 50 feet of a bordering vegetated wetland or a sail 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 AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and sot 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 soil absorption system and the SAS is within a Zone I of a public water supply web. The system has a septic tank and 800 absorption system and the SAS Is within 50 feet of a private water supply well, - The system has a septic tank and soil absorption system and the SAS Is tees than 100 feet but 50 feet or more from a private water supply well,unless a well water ana"for ooliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen Is equal to or less than 5 ppm,Method used to determine distance da_(approximation not valid). 3) OTHER Ilia revised 9/M Page 3 of 11 02/09/1999 16:30 5085647270 JOHN GRACI SEPTIC PAGE 05 V SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Propstty Address: 104.UNCLE WILLIES WAY HYANNIS CLOT 14 Owner: KANDY RUTHERFORD Date of Inspection:11131ge 0. SYSTEM FAILS: You must indicate elther'Yee'or'No'to each of the fol owhhg: X I have detertnlruld that one or more of the following fanure conditions exist as described in 310 CMR 15.303.The bast&for this determination is Identified below.The Board of Neagh should be contacted to determine what will be necessary to correct the failure, Yes No X Backup of Sewage into facility or system component due to an 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 distribuban box above oulld invert due to an overloaded or clogged SAS or cesspool. X Llgtad depth in cesspool Is less thawr below invert or avallabie volume is less than 1/2 day now, X Required pumping more then 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped niL X Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. X Any portion of a cesspool or privy Is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone I of a public well. X Any portion of a cesspool or privy is within 50 feat 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.If the well has been RnalyZed to be acceptable,attach copy of well water analysis for coldonn bacteria,volatile organic ompounds, ammonia nitrogen and nitrde nitrogen. E. LARGE SYSTEM FAIL& You must indicate either"Yes'or'No'to each of the following: The follmft criteria apply to large systems In addition to the criteria above: The system serves a facility with a design flow of 10;000 gpd or greater(Large System)and fhe system is a significant threat to public health and safety and the environment because one of more of the following conditions exist: Yes No X the system Is within 400 feet of a surface drinking water supply X the system is within 200 fed of a tributary to a surface drinking water supply X fhe&ystern Is located in a nitrogen sensitive Ares(Interim Wellhead Protection Area-I`WPA)ore mapped Zone II of a public water supply well) The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 16-30412).Please consult the local regional office of the Department for further Inforrnation. revised g/2/98 Page 4 of 11 .. 02/09/1999 16:30 5085647270 JOHN GRACI SEPTIC PAGE 06 , SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 104 UNCLE VALUES WAY HYANNIS LOT 11 Owner. KANDY RUTHERFORD Date of Msfection:1113M Check if the following have been done:You must Indicate etiher'Yes'or'No'as to each of the following: Yes No X Pumpktg InWnitdon was provided by the owner,beoupent,of Boord of Health. x None of the system components have been pumped for at least two weeks and-the system has been receiving normal flow rates during that period.urge volumes of water have not been Iftoduced Into the system recently or as part of this inspection. X As bulk plans have been obtained and examined.Note If they are not available with WA, x The facility or dwelling was Inspected for signs of sewage back-up. x The system does not receive non-an"or ktdtsIial waste flow. x The site was inspected for signs of breakout, x AN system components,excluding the Soil Absorption System,have been located on the site. x The septic tank manholes were uncovered,opened,and the kotertor of the septic tank was Inspected for condition of baffles or toss,material of conetru;ctlon,dimensions,depth of liquid,depth of sludge,depth of scum.The size and location of the Soil Absorption System on the eRe has been deter mined based on: x Existing Information,For atample,Plan at 9,0,H, X Determined in the field(if any of the failure criteria rNMW to Pad C is at issue.appro)dmatfon of distance Is unacceptable) (1 5.302(3)(b)J x The facility owner(and occupants,If different from owner)were provided with information on the proper maintenance of SubSurtace 01olmal Systems. revised V2M Page 5 of 11 02/09/1999 16:30 5085647270 JOHN GRACI SEPTIC PAGE 07 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 104 UNCLE WILLIES WAY HYANNIS LOT 14 Owner: KANDY RUTHERFORD Date of Inspection:1/13/91 FLOW CONDITIONS Design ffW 9.p.d.ibndroom Number of bedrooms(design): a Number of bedrooms(actuaq:nlri< Total DESIGN flow: dk b-�;O 59 d cS Number of Current residents:$ Garbage grinder(yes or no).-SO Laundry(separate system)(yes or no): NO If yes,separate inspector required Laundry system Inspected(yea or no):.= Seasonsi use(yes or no): = Water meter readings,If available(feat two yeses usage(gpd): nfa Sump Pump(yes or no): NQ Last date of ooarpancy. nfa TYpe of estaellehment: mda Design flow: A Spit(Based on 15.203) Basis of design floor. WA Grease trap present:(yes or no): Industrial Waste Holding Tank present:(yes or no): ho Non-sanbry waste discharged to the Title 5 system:(yes or no):no Water meter readings.N avalleble:nla Last date of occupancy: I& OTHER: (Describe) Lag daft of occupancy: n(a GENERAL INFORMATION PUMPING RECORDS and source of Information: SYSTEM WAC Pump ❑QNF YEAR Awn System pumped as part of Inspection:(yes or no):bQ + If yes,volume pumped IL gallons Reason for pumping: n(a TYPE OF SYSTEM X Septic hVWdWbutlon boxlsotl absorption system Single cesspool oversaw oetlepool Privy Shared system(yea or no)(N yes.attach previous Inspection records,it any) VA Technology etc.Attach copy of up to date operation and maintenance tontrsct Tight Tank Copy of DEP Approval Other: n(A APPROXIMATE AGE of all components,date Installed(If known)and souree of Information: SYSTEM IS 14 Ave e e ' Sewage odors detected when arriving at the site:(yes or no) bQ . r&A"d 9090 Page 6 of 11 02/09/1999 16:30 5085647270 JOHN GRACI SEPTIC PAGE 08 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continuad) Property Address: i"UNCLE WILLIES WAY HYANNIS LOT 14 Owner: KANDY RUTHERFORD Dane of Inspaadon:1113M BUILDING SEWER: (Locate on aita plan) Depth below grade: 1•tt` Material of construction:_ cast iron X 40 PVC _ other(explain) Distance from private water supply well or suction Ike: XCIMIN Der: a& Comments: (condition of Joints,venting,evidence of leakage,etc.) SEPTIC TAIGA(: X (locate on site plan) Depth below grade: 1 Material of construction:X concrete_ metal_ Fiberglass _ Po"It ylene_ other(wvlain) n1a If tank is metal,Ifst age Is We confirmed by Cen ticate of Compliance(Yee/No): HO Dia Dimensions: L fl'a-H A•V W 1-10- sludge ate: i Distance from top of sludge to bottom of outlet tea or baffle: Ai 9oun thwmess:V Distance from top of scum to top of outlet toe or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: 3L' How di ne Colons ware determined: J>d A_SU Fn Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid I"In relation to outlet invert,structural Integrity,evidence of leakage, etc.) nEPTIG T NK Nn t 1 COMPONENTS ARE syRUCTugAi i Y c0 IND.RPCOMMyNn PUMPMG SYSTEM NOW Amin THEN MAINTAINFO FVERY TWO YEARS_ GREASE TRAP: (bate on site plan) Depth below graft. Material of construction:_concrete_ metal_ Fiberglass _ Po"hyleme_other(e)plain) !YA Dimensions: Off Smn thicirms: WA Distance from top of scum to top of outlet tee or baffle: a& Distance from bottom of scum to bottom of outlet in or belle aft Data of last pumping: W& Comments: (recommendation for pumping,condition of inlet and outlet two or baffles,depth of liquid]oval in relation to outlet invert.structural integrity,evidence of leakage, etc.) n1a revised 8IYW Pap 7 of t 1 02/09/1999 16:30 5085647270 JOHN GRACI SEPTIC PAGE 09 • I SUBSURFACE-SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 104 UNCLE WILLIES WAY HYANNIS LOT 14 Owner: KANDY RUTHERFORD Date of Inspectlon:1113MS TIGHT OR HOLDING TANK: NO (Tank must be-pumped prtor to,or at time of,inspection) (locate on aft plan) Depth below grade: ids Material of construction:_ concrete_ metal_ Fiberglass _Polyethylene_ other(explain) ale Dimensions: WA Capacity: A& Gallons Design f w n/a gallons/day Alarm present: MQ Alarm laves:jV& Alarm In vaorking order:Yes_No: RD Date of previous pwnprtg: W& Commends: (condition of inlet tee,condition of alarm atul float t;lNltohes,etc.) DISTRIBUTION BOX: X (locate on site plan) Depth of liquid level above oL t Invert:ala Comments: (note if level and distribution is equal,evidence of solids carryover,evidence of leakage Into or out of box,etc.) DISTRIBUTION BOX was UNACCE4SABLE-011E TO A TRAMPOLINE FROZEN IN THE GROUND PUMP CHAMBER: fig (fie on site plan) Pumps in woAdng order:(Yes or No): NO Alarms In working order(Yes or No): h Q Comments: (note condition of pump chamber.condition of pumps and appurtenances.etc.) alA rev►asd 9r2/98 Page 8 of i i 02/09/1999 16:30 5085647270 JOHN GRHCI SEPTIC PAGE 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Adidn=s- 104 UNCLE WILLIE&WAY HYANNIS LOT 14 Ownef: KANDY RUTHERFORD Date of Inspediof1:1113M SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,it possibts;wacavation not required.location maybe approxhnated by non4rbus vs metiwds) if not located,wOaim nia Type: isact*v pits,number. 1Rw tsAI 1 eN I-PACN PIT leaching Chambers,number, j(a leaching galleries,number: jWa leaching trenefnee,number,length: pia leaching tlsNts,number,dimsnslons: niA overflow ceaspod.number: dA Alternetltrc eyelet»: pia Name of Technology -la Comments: (note condition of soli,signs of hydraulic failure,level of ponding,damp soli,condition of vegetation,etc.) JUP I FACT.PIT 12 PAST TlfHF FFFECTrff O PTH AF LFACHING,THE LlOttin LFVFl WAS OVER THE PIPE ANQ THORE WAS No PAC INCi LEFT IN THro P.r- CESSPOOLS: _ (locate on site plan) Number and configuration: n/A Depth-top of"to Wet invert: pia Depth of Solids layer. pia Depth of scum lays►. fait Dknenslons of cesspool: pica Materials of construction: pia Indlcatlon of groundwater: pia Inflow(cesspool must be pumped as part of Inspection)Ilia Comments: (note condition of sal.signs of hydraulic failure,level of ponding,condition of vegetation,etc.) tad PRIVY: (locate on ante plant) Materials of construction:p(a Dimensions:WA Depth of solids: da Comments: (note condition of Boll,signs of hydraulic(allure,level of ponding,condition of vegetation,etc.) a& rwised 9/2= Page 9 of t i 02/09/1999 16:30 5085647270 JOHN GRACI SEPTIC PAGE 11 SU83URFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 104 UWU MIa,Wa WAY NYANNNt LOT u KANOY IunNBWPCIW vows SKETCH OF SEWAGE DISPOSAL SYSTEM: Include ties to at least two permanent references,landmarks or benchmarks locate all wells within 1107(Locate where public water supply comes Into house) c a� O PA a9 P-co - eABL (c p..a.rorIItmrF page p oe so 02/09/1999 16:30 5085647270 JOHN GRACI SEPTIC PAGE 12 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 104 UNCLE WILLIES WAY HYANNIS LOT 14 Owner: KANDY RUTHERFORD Date of Inspection:11191lY NRCSRaponname: n/a Soil Type: WA Typical depth to groundwater: l,(A USGS Date wsbalte welted: W& Observation Walls checked: NO Groundwater depth:Shallow _ Moderate _ peep _ SITE EXAM _ Slope _ Surface water _ Check CNlar Shallow wells Estimated Depth to Groundwater 10 Feet Please Indicate 81 the methods used to determine High Groundwater Elevaticn: _ Obtained from Design Plans on record _ Observed Ske(Abutting prop",observation hole,basement sump etc.) _ Determined from local coneons Checked With local Board of health _ Checked FEMA Maps _ Checked pumping recorde , Checked local excavators,Installers XUsW USGS Data Describe how you established the High Groundwater Elevation,(Must be canrpleted) USGS MAPS AND CHARTS revised 90M Page 11 of 11 02/09/99 TUE 13:23 FAX 1508 775 7337 RETAIL ADV Q 002 C011unonwealth of Massachusett s Executive Office of Envirolunelital Affairs Dept. of Environmental Protection One winter Street;Boston,Ma. 02108 Jahn GrAd D.E.P. Title V Septic Inspector P.U.Box 2119 WILLIAM F.WELD 'reaticket,MA 02536 Governor (508)564-6813 ARGEO PAUL CELLUCCI Lt.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: 104 UNCLE WILLIES WAY HYANMS LOT 14 Date of Inspection: 1l13199 Address of Owner: Name of Inspector: JOHN GRACI (It different) I am a DEP approved system inspector pursuant to Section 15.340 or Title%(310 CMR 15.000)ANDY �D Company Name,Address and Telephone Number: CERTIFICATION STATEMENT I Certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: Passes Conditio 'Kilo Inspection Is based on criteria defined In Title V _ ally Passes code 31D CMR 1620.rdyfindnarweof how(hesyskel. Needs er Evaluation Performing at the time of the inspection.My in:pecd;By the Local Approving does proving Au not imply any warranty or guarantee of the longevity of the X Falls septic°ystdm and any of its component,use,IIre. Inspector's Signature: Date: 1114199 The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this inspections. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer,if applicable and the approving authority. INSPECTION SUMMARY: Check A,B,C,or D: A] SYSTEM PASSES: I have not found any information which indicates that the system violates any of the failure criteria defined as in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. COMMENTS: B] SYSTEM CONDITIONALLY PASSES: _One or more system components need to be replaced or repaired. The system,upon completion of the replacement or repair,passes inspection. Indicate yes,no, or not determined(Y, N, or ND). Describe basis of determination in all instances. If "not determined",explain why not. The septic tank is metal, unless the owner or operator has provided the system inspector with a Copy of a Certificate of C6111pllance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection;or the septic tank,whether or not metal,is cracked, structurally unsound,shows substantial infiltration or exfiltrabon,or tank failure is imminent.The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised UQ7197) One Winter Street a Boston,Massachusetts 02108 a FAX(617)556-1049 . Telephone(617)2925500 02/09/99 TUE 13:24 FAX 1508 775 7337 RETAIL ADV Q 003 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) r Property Address: 104 UNCLE WLLIES WAY HYANNIS LOT 14 Owner: KAHDY RUTHERFORD Date of Inspection:fr13/9e — Sewage backup or.breakout or high static Water level obseryed.in.the distribution box is due to a broken, or obstructed pipe(s)or due to broken,settled or uneven distribution box.The system will pass inspection if (with approval of the Board of Health).Describe observations: broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board or Health): broken pipe(s)are replaced obstruction is removed CJ 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 the public health,safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM is NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER,IF APPROPRIATE)DETERMINES THAT THE SYSTEM 15 FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system and is within 100 feet to a surface of water supply or tributary to a surface water supply, The system has a septic tank and soil absorption system and is within a Zone 1 of a public watersupply well. — The system has a septic tank and soil absorption system and is within 50 feet or a private water supply well. — The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a Private water supply well, unless well water analysis for coliform bacteria and Volatile organic compounds indicates that the well is free from pollution from that facility and the presense of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method usedto determine distance 3)Other (approximation not valid) D) SYSTEM FAILS: You must Indicate either"Yes"or"No"as to each of the following: x I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is Identified below. The Board of Health shoufd be contacted to determine what will be necessary to correct the failure. Yes No _x_ Backup of sewage in facility or system component due to an 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 cesspool. K_ — SAS is in hydraulic failure. 1revlee40427AJ7t 02/09/99 TUE 13:24 FAX 1508 775 7337 RETAIL ADV R 004 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 104 UNCLE WILLIES WAY HYANNIS LOT 14 Owner: KAN13YRUTHFRFORD Date of Inspection:1H31g8 D]SYSTEM FAILS(continued) Yea No x Static liquid level in the distribution box above outlet invert due to an overload x ed or Clogged SAS or cesspooi. Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow. x Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Numbers of times pumped x Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. — ,x' Any Portion of a privy or cesspool P R vy is within 100 feet of a surfs ce water supply or tributar y ry to a surface x dace water supply. _ Any portion of a cesspool or privy is within a Zone 1 of a public welt: —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 weft with no acceptable water quality analysis. If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic compounds,ammonia nitrogen and nitrate nitrogen. El LARGE SYSTEM FAILS; You must indicate either"Yes"or"No"as to each of the following: The following criteria apply to large systems in addition to the criteria: The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No X the system is within 400 feet of a surface drinking water supply — X the system is within 200 feet of a tributary to a surface drinking water supply — X the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area(IWPA)or a mapped Zone If of a - public water supply well) The owner or operator of any such system shall bring the system and facility requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further Informationmentprogrom f�gvisetl04i27R,!'/I 02/09/99 TUE 13:25 FAX 1508 775 7337 RETAIL ADV Q 005 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECLIST Property Address: 90411NCLE WILLIES WAY HYANNIS LOT 14 Owner: KANDYRUTHEIFORD Date of Inspection:1/13198 Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following: —X— — Pumping information was requested of the owner, Occupant,p t,and Board of Health. x None of the system components have been pumped for at least two weeks and the and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. x As built plans have been obtained and examined. Note if they are not available with N/A. X _ The facility or dwelling was inspected for signs of sewage back-up. x _ The system does not receive non-sanitary or industrial waste flow. -X— -- The site was inspected for signs of breakout. x — All system components,excluding the Soil Absorption System,have been located on the site. x The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge,depth of scum. x _ The slze and location of the Soil Absorption sed on The facility owner(and occupants, if different from owner)on hwere provided with information been oon the proper maintenance of x Sub-Surface Disposal Systens. — Existing information. Ex. Plan at B.O.H. x — Determined in the field(it any failure criteria related to Part C is at issue,approximation of distance is unacceptable)[15.302(3)(b)j 0GV13Gd 04 2r19)j 02/09/99 TUE 13:25 FAX 1508 775 7337 RETAIL ADV Z 006 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 104 UNCLE WILLIES WAY HYANQIS LOT 14 Owner: KANDY RUTHERFORD Date of Inspection:111319E RESIDENTIAL: FLOW CONDITIONS Design flow: 3w 9-p.d.fbedroom for S.A.S. Number of bedrooms: a Number of current residents: 7 Garbage grinder(yes or no): N Laundry connected to system(yes or no): Y_: Seasonal use(yes or no). No Water meter readings,if available:(last two(2)year usage(gpd): nta Sump Pump(yes or no): No Last date of occupancy:tea COMMERCIAL/INDUSTRIAL Type of establishment: n+a` Design flow:o gallons/day Grease trap present:(yes or no) N; Industrial Waste Holding Tank present:(yes or no)No. Non-sanitary waste discharged to the Title 5 system:(yes or no)No Water meter readings,if available: nre Last date of occupancy: nrt_ OTHER:(Describe) m Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: SYSTEM WAS PUMPED ONE YEAR AGO System pumped as part of inspection:(yes or no)N_ If yes,volume pumped:o gallons Reason for pumping: rva TYPE OF SYSTEM x Septic tank/distribution box/soil absorptions system Single cesspool Overflow cesspool Privy Shared system(yes or no) (if yes,attach previous inspection records,if any) I/A Technology etc.Copy of up to date contract? Other: APPROXIMATE AGE of all components, date installed(if known)and source information: SYSTEM IS 14 YEARS OLD. Sewage odors detected when arriving at the site:(yes or no) No (revised 0427617) 02/09/99 TUE 13:25 FAX 1508 775 7337 RETAIL ADV Cj007 I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Iva UNCLE WILLIES WAY HY ANNIS LOT 14 Owner. KANDYRUTHERFORD Date of Inspection:1113198 SEPTIC TANK: x (locate on site plan) Depth below grade:V Material of construction:x concreate metal FRP Pofyethylene_other(explain) 21a if tank is metal, list age . Is age confirmed by Certificate of Compfiance No (Yes/No) Dimensions:L6.6"H5'7"W4•10^ Sludge depth:3" Distance from top of sludge to bottom of outlet tee or baffle:31' Scum thickness:?" Distance from top of scum to top of outlet tee or baffle:s- Distance form bottom of scum to bottom of outlet tee or baffle: sr, How dimensions were determined: MEASURED Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert,structural integrity, evidence of leakage,etc.) SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND.RECOMMEND PUMPING SYSTEM NOW AND THEN MAINTAINED EVERY TWO YEARS, GREASE TRAP:_ (locate on site plan) Depth below grade:rda Material of construction., `concrete_metal_FRP_PDlyethylene_other(explain) Dimensions:nfa Scum thickness:+ia Distance from top of scum to top of outlet tee or baffle:nra Distance from bottom of scum to bottom of outlet tee or baffle:nra Date of last pumpingn r& Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity, evidence of leakage,etc.) nia BUILDING SEWER: (Locate on site plan) Depth below grade: re^ Material of construction:—cast iron x 40 PVC^other(explain) Distance from private water supply well or suction line:TOWN Diameter: wa Qj,mments:(conditions of joints,venting,evidence of leakage,etc.) ifevlsaU04RTR7) 02/09/99 TUE 13:26 FAX 1508 775 7337 RETAIL ADV Z 008 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 104 UNCLE WtLUES wAY HYANNIS LOT 14 Owner: KANDYRUTHERFORD Date of Inspection:iti3ms TIGHT OR HOLDING TANK: (locate on site plan) Depth below grade:rda Material of construction:_concrete_metat_FRP`Polyethylene_other(explain) Dimensions: Na Capacity: nra gallons Design flow: Na _gallons/day Alarm level:wa Alarm in working order?_Yes No Date of previous pumping: — Comments: (condition of inlet tee,condition of alarm and float switches,etc.) rda DISTRIBUTION BOX: (locate on site plan) Depth of liquid level above outlet invert: nra Comments: (note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box etc.) rda PUMP CHAMBER: (locate on site plan) Pumps in working order:(yes or no)No Alarms in working order(yes or no)_y,__, Comments: (note condition of pump chamber,condition of pumps and appurtenances,etc.) rda traWsetl042719R1 02/09/99 TUE 13:27 FAX 1508 775 7337 RETAIL ADV Q1011 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(conilnued} 194 UNCLE WILLIES WAY HYA14NIS LOT 14 KANDY RUTHERFORD 1113198 Depth of groundwater ,o Please indicate all the methods used to determine High Groundwater Elevation: Obtained from design plans on record. Observation of Site(Abutting property,observation hole,basement sump etc.) Determine it from local conditions Check with local Board of Health Check FEMA Maps Check pumping records Check local excavators,installers x Use USGS Data Describe in your own words how you established the Nigh Groundwater Elevation.(MUST be completed) USGS MAPS AND CHARTS (revised o4nTRJr) Y►qt.-10 at 19 02/09/99 TUE 13:27 FAX 1508 775 7337 RETAIL ADV Q 010 SUBSUR FACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 104 UNCLE WILLIEB WAY HYANNf3 LOT 14 KANDY RUTHERFORD 1r13r98 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references,landmarks or benchmarks locate all wells within 100'(Locate where public water supply comes into house) �L ii 6 A k� 0 k 0 W3L f (revlaed0412TL97) Pats. ! of 10 02/09/99 TUE 13:26 FAX 1508 775 7337 RETAIL ADV Cij009 o SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION.(continued) Property Address: 104 UNCLEIMLLIES WAY HYANNIS LOT 14 Owner. KANDYRUTHERFORD Date of Inspection:1l13l08 SOIL ABSORPTION SYSTEM (locate on site plan,if possible;excavation not required,but may be approximated by non-intrusive methods) If not determined to be present,explain; Iva Type: leaching pits,number: T0W GALLON LEACH PIT leaching chambers,number:Ida leaching galleries,number:rda leaching trenches,number,length: ma leaching fields,number,dimensions:Na overflow cesspool,number:rda Alternate system: wa Name of Technology:_ Comments:(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation, etc.) THE LEACH Prr IS PASTTHE EFFECTIVE DEPTH OF LEACHING,THE LIgUID LEVEL WAS OVER THE PIPE ad THE LEACH PIT. CESSPOOLS:_ (locate on site plan) Number and configuration: rda Depth-top of liquid to inlet invert: n!a Depth Of solids layer: nk Depth of scum layer: nIa Dimensions of cesspool: rda Materials of construction: nla Indication of groundwater: nta rda inflow(cesspool must be pumped as part of inspection) Comments:(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) nfa PRIVY: (locate on site plan) Materials of construction: Ida Depth of solids: Ida Dimensions: nta Comments:(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation, etc.) nta travlaaa o812rA71 02/09/99 TUE 13:22 FAX 1508 775 7337 RETAIL ADV 1Q001 "�' cape Cod Times TF iE CAPE AND ISLANDS DAILY NEwSPAPBR" 319 Main Street,Hyannis,MA 02601 • Phone(508)775-1200 .800-451-7887 Bureaus:Falmouth, Orleans,Sandwich,Provincetown' " p 1 A � , i -VCapeCodTlmes Reach the Cape's total SPECIAL, SECTIONS! II market with Dollar January — Saver and the Cape -, b Cod Time sl Ir f�pry* )❑❑ B�para& uemns li❑ ��"YYII III! �r rY�YV6 I Your Advertising Source pst1.Y 512.50 AskYourAccount for the Cape&Islands inchi Executive About These per Sections Today/ To: Date: Company: No, of Pages: • I From:—� Cape Cod Times FAX: (508)775-7337 Direct Line: (508) 7 Remarks: Urgent ❑ Please Review ❑ Reply p y ASAP ❑ Please Comment LOCAT ION /6y SEWAGE PERMIT NO. Ile- i.y d ? 3 Ids VILLAGE INS�'A LLE.R'S NAME A ADDRESS k 1 I BUILDER OR OWNER DATE PERMIT ISSUED 7- / 7- DATE COMPLIANCE ISSUED . iI i o, v _ # 3 L� qb #18 #- #2 _ 1 G #16 36 1 I # " - MAI #16 _ g�P,Z9� - _ - - #34 2 - #43 I #87 _ r D �i I 2 8 r6 #42 # 25 J 2' - #51 46 - a 50 6 9 13 2 7 �Q #108 292 - - - � -74 0 �h #56 - #58 #59 f �42 1 83 4 >� _ 3I T-1 _ - {#. ._ 1 64 - _ P292 1 war2n i --1 15 - - - _ #46 #8 3 5 70 #75 - #74 s� � 292 172 ---- o - io4 ❑ 7#s23 'I 292 o n � 92 V 36 fm5 �42❑ 18 292 �-1 #92 5 #99 - _ 97 _ 2 _ I r, 97 too „ o -- ' �r 2 2n` �^ #ea # n _ #98 , - �T l� #136 _ A1AP Z92 �► , 61 # �nr292 0 � tos r J 524 I -- 91 / wl 297 i�•�- y�e 1 L#99 , b #43 CF c �T� �7O J�P 7 / 775-1 r?7 A z9 MAP 292 PA3- 14 RCEL i% E BARNSTAB'_S SCALE: 1"=150' 4wo v kU�N t-o2 • - r, ,, ,i 1' 't \\��\. \�"�\\ t\� �'---'/ -Now t r .-•-.•'!'_. � '1��� � �,��.�-'��d,/ v t y Yf�¢�• � � / � } `��t �`\ �'���' ' \1 11111 � 11111111111 O:: �.r� �,� '%'�' i � �,�, 7 t �:,�..•—• f t / L7 � _ z,--` c � wry}. u.�'�ji �c i � • , � i + ,'� ',, i %/;,:'"' �`y—Jy. t' 1/ j I �t+4-`�i \ .� �rps_'/J-I�/=,A yP�nn � t 'i,� / ,:< a �r I 1 , Ju ZMA ".1u4ou LJ4 .� t sse •\`\ Ts` l t (� ,tl ��i , to = 1( 3 _ Tom. •.=l - _y.J\` \���� � (t� i • r 'L , `\ \� '�'�,�,••. 11 J:� ili ?/j rl ' _ Cam+ ��� / � _ I i LOCATION SEWAGE PERMIT NO. �a-C !Y vece�i VILLAGE I INSr A LLER'S NAME i ADDRESS Ck t I NN i d U 1 L D E R /OR / OWNER i DATE PERMIT ISSUED 7_ j7-C1 { DATE COMPLIANCE ISSUED _ � y_ �� { i I I I v 'i I hI ,�� 1V (y (TOWN OF BARNSTABLE LOCA'I10N ��� U nete wit Ith SEWAGE # VILLAGE kAMML ASSESSOR'S MAP & LOT -6 Z OI INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY I.OQ O LEACHING FACILITY: (type) ���, O (size) NO. OF BEDROOMS r BTJTLDER OR OWNER PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Welland 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 � �� �� �®Z 1A n Vb n TOWN OF BARNSTABLE . . LyX�.:T�ON o S SEWAGE # VILLAGE 4V ali n/C ASSESSOR'S MAP& LO ~OD Lo INSTALLER'S NAME&PHONE NO. �L5c A t2-e. ged2 G_. 7 SEPTIC TANK CAPACITY S o 0 LEACHING FACILITY: (type) (size) NO.OF BEDROOMS_,-; _ BUILDER OR OWNER a * PERMTTDATE: 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 � � � W P-> >- �� C., C�J � � G,� � � � �]� i. �. •� r ��..� �•� w S� .�r� rw �1 � I♦ 1 '�W^1 dI/ • a` �I z.: w �'� s. ....� tiC �� � t t No. Fee �� y U i THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS AppItratton for Mtgpogar *pgtem Cow5trurtton Vermtt Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System dividual Components Location Address or Lot No. 10'1 Owner's Name,Address and Tel.No. Assessor's Map/Parcel �_'2.���[, AI-Al tv �'-'`�'��1Z,n i Installer's Name,Address,and Tel.No. 47 1 Designer's Name,Address and Tel.No. 1►`('�-G�(�S�`��- ,! Fes"�, lst,,.�-,S�/V1�`G-G� :50►fi -o kO JNS� .i 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 6 gallons per day. Calculated daily flow __S;3k�p gallons. Plan Date 3-ct`ct.'�'l Number of sheets I Revision Date Title Size of Septic Tank '5-; 15r 1 S' OU 1,6 �- Type of S.A.S. Description of Soil L 01(C1, Yin. S pi Nature of Repairs or Alterations(Answer when applicable) IS Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been is a Qc S ne Date �3- l 1 Application Approved by Date Application Disapproved for the following reasons Permit No. Date Issued `-� - � � tlt , No. �� �v "" Fee jam✓ THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: t es PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE,, MASSACHUSETTS �Z .fitation for Migooar *p.5tem Construction Permit Application for a Permit to Construct !pp ( )Repair( )Upgrade( )—Abandon( ) El Complete System N40dividual Components Location Address or Lot No.1ekA u�;(,�e �� `mac V,�� Owner's Name,Address and Tel.No. Assessor's Map/Parcel ��A11.�\ _"�_`� 41 F..•��'��C� 12,(� '�� �* Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. �. �t112 W� tz l / '3 3 ©l0 Pv�\rc. ' Type of Building:..q�.,_ g: " Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers(., ) Cafeteria( ) Other Fixtures •y Design Flower gallons per day. Calculated daily flow gallons. Plan Date -3-1-`1"1 Number of sheets Revision Date ' Title Size of Septic Tank K S` (, (_ 00 Type of S.A.S. Description of)Soil o to vt�. S nVo ` 4`,LC SALE) Nature of Repairs or Alterations(Answer when applicable) Ay�� Date last inspected: Agreement: ; The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been is al S gne — Ab DatedL Application Approved by �- Date's-- ,2�F 9— 45�15� 't Application Disapproved for the following reasons Permit No. Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY that the On-site Sewage Disposal System Constructed( )Repaired( )Upgraded Abandoned( )by L at' 6'-AL t�< Y:� uk,A rit,%as been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. / dated � �-- Installer Designer —T The issuance of s ertru all n be construed as a guarantee that the s ste will funit C InspeDate ctor 0 Fee THE COMMONWEALTH OF MASSACHUSETTS... PUBLIC HEALTH DIVISION - BARNSTABLE: MASSACHUSETTS Migoaf *p5tem Construction Permit Permission is hereby granted to Construct( )Repair( )Upgrade Abandon( ) System located at ( O ( y h.,C to 4� r cl Gr Yl 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 thi .rmit. Date: -� 4l Approved b ~4� L"0 C,A'T ION ld S E W A G E PE RMIT NO. 'k&T l Y y�x1e c.ea�� ins ivy-�-f g.3 % VILLAGE �S INS A LLER'S // NAME a ADDRESS C, 6�5- 8 U I L D E R OR OWNER kti Sties l DATE PERMIT ISSUED 7_ 7-0Y DATE COMPLIANCE ISSUED l I � I�� -� �� �, � �' °h 1,0 � � - � � ; . �r Q t THE COMMONWEALTH OF MASSACHt1SETTS ROGER { PAUL BOAR® OF HEALTH o MICHNIEWICZ No.30420 ara ............Town... ................OF.........Barnst.abLe...........---------••------.....--••---............_. -p, CIVIL �® � ltr�ati n for Diapniial Works Tnnitrn Finn rumit r Application is hereby made for a Permit to Construct ( x) or Repair ( ,an Individual Sewage Disposa /0•/2• System at: Uncle Willie's Way i Hyannis, MA Lot 14 ................ Location:Address S .............. T. ._........ ^_......- ...... ... ...---•--•...................••-----•-•..... .. - Owner _ lk i/ ess ...........--- •- Installer Address Type of Building Size Lot.l7'_3.37_ ._______.Sq. feet Dwelling—No. of Bedrooms..........3................................Expansion Attic ( ) Garbag Grinder (no) aOther—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( ) dOther fixtures ................... ............................................................. Design Flow___-__-____5.5............................gallons per person per day. Total daily flow..__._.3.3Q..............................gallons. 04 W Septic Tank—Liquid capacity_1000•gallons Length 8 ".____ Width....4__'1.0."- Diameter---------------- Depth__S'_4'.' - . xDisposal Trench—No_ ____________________ Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No........1---------- Diameter......I Depth below inlet-_..L 16_7.'____- Total leaching area__I.94_________sq. ft. Z Other Distribution box (x ) Dosing tank ( ) '-' Percolation Test Results Performed b J. Monahan, Jr.______ -______ Date___.7 _!:_83 a ....... per inch Depth of Test Pit-----14._-_._..__ Depth to ground water........................ Test Pit No. 2.........2_.-.-minutes per inch Depth of Test Pit----- �___•___. Depth to ground water________________________ tx -------------------------------•-----------------------•-------....-------•-•---•---......_..-------......................................................... O Description of Soil___T.P.#1 0"-12" course. sand and gravel; 12"-168" med. sand w/ gravel_ ----------------------------------------••-•- U trace T.P_.-f72 0"-28"__loose-•med-----sand__ /._g �y� __itzG ,---.8��-1�i$"._me41_:-•.S_a41__Wl..$ s3Ye ---- trace;---•---------------•••-----------•••.... - U Nature of Repairs or Alterations—Answer when applicable----------------------------------------_....................................................... -------------------•--_•••••••-•--------•-•--._...--------------------------•------------------------••••-----•-••• Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of iITL E 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has bee issued by th board o I lth. _ Application Approved By....... ...............•-- --.....--•----------------•-••------...... 1®....I ... ............. Date Application Disapproved for t f lowing reasons:................................................................................................................ ......-•---------------..............•--•-•-----•- Date PermitNo......................................................... Issued....................................................... Date S , A OF < � ` ••��--C�-Q-� � Fps......... ��. ... .. o THE COMMONWEALTH OF MASSACHUSETTS ` �o ROGER PAUL CHNIEVVIC BOARD OF HEALTH � MINo.3o420Z ' .o CIVIL ' `'p m. ._......... ......OF.......Elarn.saable_... { Apphratiou for Ui4#uiial Work.6 Tumilrurtion 11trutit 1 •J2 83 Application is hereby made for a Permit to Construct or Repair ( ) an Individual Sewage Disposal System at: Uncle Willie's Way .- Hyannis, Klk Lot 14 .........................._...................................................................... ..... .......................................................................................... Loca' Add te or Lot •� Own r d1ress -•---•-D.r.. ."-- e Installer' •--•-�--------•-•.....................4.1`1.�.�C�''ly, !K-__f_�, .a......�}l.:[_%�.��.r�i�,,..,�i'�•�`< dres 17,337 Q Type of Building - Size Lot.............................Sq. feet Dwelling—No. of Bedrooms........-A................................Expansion Attic ( ) Garbage Grinder (no) aOther—Type of Building ............................. No. of persons............................ Showers ( ) — Cafeteria ( ) Other fixtures ------------------------- --------------------------- W Design Flow.._.......55............................gallons per person per day. Total daily flow_.....33a______.._____.......__._.__... allons. WSeptic Tank—Liquid capacity_�Qaq.gallons Length$'6.�....__. Width__ '10��_ Diameter.................Depth_5..�?.•_.... x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. 3 Seepage Pit No........ ........... Diameter.._.. -------- Depth below inlet_.3-67_`...__. Total•leaching area_19 .........sq. ft. Z Other Distribution box (X ) Zosing tank ( ) Percolation Test Results Performed b .. J• Honahan, . r• __ 7/7/83 aT 2 .4 Y ..... ...............•-•---- 14. • Date-----------------...........--•--•-•--- ,� Test Pit ;�o. 1--------_-------minutes per inch Depth of Test Pit..........--------- Depth to ground water........................ 44 Test Pit No. 2.........`.'_.....minutes per, inch Depth of Test Pit..._�.............. Depth to ground water........................ ® Descri Description of Soi1.._T•P• 0 l2 course EZ^d rind grave") 5 12 1 $ aed. sand w/ ravd? ----- ---------- x trace; T>P.fi`.. Q"-28'.. ousc_ zrec'-----Saud--W�-- rav l rzce, 1E"'-l£�£.. med......arc.......-.:�a`7el_...._ W traces -----------------------------------------------------------------------------------------•------•----------------------------------------------------•--------------------------•-•••-•-•--•--•-•---•--- U ' Nature of Repairs or Alterations—Answer when applicable--------------------------------------------•---_-•-___-_____---____•___•-_-_--•-•-•__•-._____- •••----••-----•-•---••••••-••...•-••••-••-••--•--•-•----•--•------•-••-••-----••----•--•---•-----••••••••••-•-•----------••-•-••••--------•••-•-••--•--•-•-•---•-•--•--••----••••••-••••..............•- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with x`' � g g P Y - the provisions of nrr� -,«..:�,.. 5 of the State Sanitary Code—The undersigned further agrees not to place the system in $ �3 operation until a Certificate of Compliance has ben issued by the board iealt • ..... J _...�' Application Approved By......•-�Y ._• ..--------•-----•-•--------•---•---••--------------•---•-•------ �' 3 ......... P Date Application Disapproved for f o owing reasons:...............................................................---------------_-------------------•-•--•---- Date PermitNo......................................................... Issued-....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ....................................I.....OF.......... ............................................. _._.............. Trrtif iratr of Tome aurr THIS'I� 0 C R IF , That the Individual Sewa Di posal ystem constructed ( or,Repaired ( ) , ' by �... / _ In [ i r r has been inst, led in accorda e with the provisions of TILTr - r of TheState Sa.mtary Code s d r d m the application for Disposal Works Construction Permit No---- '' 9.3 .-•--- dated-./�. _3--..--__I.................... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE................... .................... Inspector....... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH t � ®F..... �G ..........................�. ........ N , ........---•-----...... 7�x�',� ',, �a� ��',$ �$�a$',�i�r Ua�a rra�tt� FEE...-•-•---••--•--....... y Permission is eby granted =:.. �'::� to Constr or Repair ) arf, divid al wa D ystem �, at No........ v ........-- � _. t r(s... _ _" •l•'J.... .. ............. ...�-...... __•__._•.._.._........._.._.. ............................................. Street r, as shown on the applicati for Disposal Works Construction Permit No.._..... .-=_'.<__ Dated..........::.............................. // �/L ••••.......-•--•-......•.•--• .--- ••--•................................... ......-••••--•---•••••. Board of Health DATE........1-- d._------. FORM 1255 ,HOBBS & WARREN. INC., PUBLISHERS- h - `y I Q�oFTHE To� TOWN OF BARNSTABLE OFFICE OF • eeaasaAEL BOARD OF HEALTH NAGS iOtFD NoN k?e 367 MAIN STREET HYANNIS, MASS.02601 II i February 12, 1999 Kandy Rutherford j 104 Uncle Willies Way I Hyannis, MA 02601 Dear Mrs. Rutherford: G Your request for permission to install a replacement soil absorption system at 104 Uncle Willies Way, Hyannis, without first obtaining engineered plans for the new system, is not granted. There are vegetated wetlands within 200 feet of the proposed leaching facility. Also, the groundwater table is less than fourteen (14) feet below the surface of the ground. The groundwater table in this area rises significantly, according to the U.S.G.S. groundwater i adjustment formula developed by Michael Frimptor. In addition, there is a concern that the top of the ground slopes from adjoining properties into your yard, allowing rain water I to travel over the top of your septic system. The Board of Health consistently requires engineered plans for the replacement of septic system components whenever the above described environmental factors are present. S ncer ly yours, i� I Acting airman Board of Health Town of Barnstable RAM/bcs I kandy i POFTHE T TOWN OF BARNSTABLE OFFICE OF ? 3ARNSTAIMBOARD OF HEALTH � MAB&66 � I 1639. ya k� 367 MAIN STREET HYANNIS, MASS.02601 February 12, 1999 I Kandy Rutherford 104 Uncle Willies Way Hyannis, MA 02601 Dear Mrs. Rutherford: Your request for permission to install a replacement soil absorption system at 104 Uncle I Willies Way, Hyannis, without first obtaining engineered plans for the new system, is not II granted. There are vegetated wetlands within 200 feet of the proposed leaching facility. Also, the groundwater table is less than fourteen (14) feet below the surface of the ground. The groundwater table in this area rises significantly, according to the U.S.G.S. groundwater adjustment formula developed by Michael Frimptor. In addition, there is a concern that the top of the ground slopes from adjoining properties into your yard, allowing rain water to travel over the top of your septic system. The Board of Health consistently requires engineered plans for the replacement of septic system components whenever the above described environmental factors are present. S,incer ly yours, I Acting CAairman Board of Health Town of Barnstable RAM/bcs I kandy I � TOWN OF BARNSTABLE II LOCATION 1041S t/ SEWAGE # VILLAGE ASSESSOR'S MAP & LOL A� —o INSTALLER'S NAME&PHONE NO. /1/; A IQ e. Sew�� SEPTIC TANK CAPACITY LEACHING FACILITY: (type) _ r-U4,7 (' (size) �iNO.OF BEDROOMS BUILDER OR OWNER a i PERMITDATE: nJkCL12 COMPLIANCE DATE: I 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 I 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 I i Furnished by li. I i Y��a F -EL°'1�(N STANDARD N07-'f,,-'S GROUND SURFACE EL____ -- — GROUND SURFACE EL� _� 1) THIS PLAN IS FOR THE INSTALLATION OR REPAIR OF A SEPTIC SYSTEM AND IS NOT INTENDED FOR SURVEYING OR ZONING PURPOSES. MATERIALS , ,,, �,r ,T T rn nrOl:�� TO 310 C�+.1� >s,nn p TNF STATE ENVIRONMENTAL CODE, u i i N OUTLET PIPE LEVEL 2) ALL INSTALLATION PROCEDURES AND L�TAT RIALJ`� ally, L, I �=,t FIRST TWO FEET ?2 N O VENT REQUIRED Barns to bl e SUBSURFACE DISPOSAL REGULATIONS. TOP EL TITLE 5, AND THE TOWN OF LIQUID LEVEL MIN z' LAYER DOUBLE WASHED 3) NO DETERMINATION HAS BEEN MADE AS TD COMPLIANCE OF AVAILABLE PROPERTY INFORMATION WITH RECORDED DEEDS - 10" t9ox— vs•- iiz' STONE OR ZONING REGULATIONS. INVERT EL 14" ,2 ��� �� EFFECTIVE 4) TOWN WATER SERVICES THIS PROPERTY. �/ GAS BAFFLE AT OUTLET/ INVERT EL S-Gi .-`; SIDEWALL 14 < 5) THERE ARE NO KNOWN PRIVATE WELLS ON THIS PROPERTY OR WITHIN 100' OF THE PROPOSED SOIL ABSORPTION SYSTEM. �' ~f _x INVERT EL 6) ALL COVERS OF SYSTEM COMPONENTS SHALL BE BROUGHT TO WITHIN 12 OF FINISHED GRADE, Tf7TH ONE COVER OF THE INVERT EL _ x 5T i cl 5.3� 3/4'- i 1 2' DOUBLE SEPTIC TANK BROUGHT WITHIN 6" OF GRADE INVERT Alt + (Typical) W ASH E D STONE 7) ALL SYSTEM COMPONENTS SHALL REMAIN ACCESSIBLE FOR INSPECTION. NO STRUCTURES SHALL BE LOCATED DIRECTLY 6" STONE BASE INVERT EL yc CU l i"1 2�C Y�oZG� \ g O � ��,� UPON OR ABOVE THE COMPONENT ACCESS LOCATIONS, WHICH WOULD INTEI?FERE WITH THE PERFORMANCE, ACCESS, INSPECTION Existing 1,000 Gal S-Tank \,mac t k 2.` p S- S j t� t!'s BOTTOM EL PUMPING OR REPAIR. l O� (Typical) 8) NO DRIVEWAY, PARKING OR TURNING AREA, OR OTHER IMPERVIOUS AREA SHALL BE LOCATED ABOVE A SOIL ABSORPTION EL '� I I BOTTOM OF TEST HOLE SYSTEM, EXCEPT WHEN VENTING HAS BEEN PROVIDED. _ 9) SEPTIC TANKS, GREASE TRAPS, DOSING CHAMBERS AND DISTRIBUTION BOXES SHALL BE PLACED ON A 6" STONE BASE 3 I TO ENSURE STABILITY AND PREVENT SETTLING. 10) OUTLET DISTRIBUTION LINES SHALL REMAIN LEVEL FOR A MINIMUM OF THE FIRST T#10 FEET OF THEIR LENGTH. 11) ALL SYSTEM COMPONENTS SHALL BE CAPABLE OF WITHSTANDING H-10 L0,1DING UNLESS THEY ARE UNDER OR WITHIN 10' OF DRIVEWAYS OR PARKING OR TURNING AREAS, IN WHICH CASE H-20 CO,ifPONENTS SHALL BE USED. 12) ALL BUILDING SEWER LINES SHALL HAVE AN INNER DIAMETER OF 4" AND ;SHALL BE CAST-IRON OR SCHEDULE 40 PVC. 13) THE DEPTH OF THE TOP OF ALL SYSTEM COMPONENTS SHALL NOT EXCEED 36" UNLESS VENTING HAS BEEN PROVIDED. 14) IN THE AREAS OF EXCAVATION, EXISTING GRADES SHALL BE REESTABLISHED UNLESS NOTED AS PROPOSED CONTOURS. 15) IF SOILS ARE ENCOUNTERED DURING THE EXCAVATION OF THE SOIL ABSORPTION SYSTEM, THAT DIFFER NOTABLY FROM THE DEEP OBSERVATION HOLE LOG, CONTACT THE ENGINEER BEFORE PROCEEDING. 133, 12 16) CONTRACTOR TO VERIFY LOCATION OF ALL UNDERGROUND UTILITIES. N 85 °56 '53 �, �, / (102 2) � Bottom of slope (99.1) ND / (^ (99.5) ©' 106. 0 "y (99.4) ti (_�V DEED' OBSERVATION f I D[-,E LOG ,I ��>".P�1, �.;� . � •�� � ''est Hole # (EL = 98.7 f) I i D p ev Soil Soil Soil (98.9) DESIGN DA TA �m �ft) Horizon — -Texture Color — (USDA) (Munsell) ,p ' Number of Bedrooms: 3 (105.1) Garbage Grinder. NO 0 - 4" 98.2E 0 LOAM .��N Design Flow- 3�G ! y" - f6" 97.4E B LOAMY SAND 10YR5/8 T ( (98.1) (110 Gal/BR/Day x Number of BR) I ` < `l Septic Tank: j 16" - ,�2" 96.0E C1 LOAMY SAND 10YR5/6 I 1 000 Gal ;�2� _ -� \ (Minimum — Design Flow a 200%) `f t STD 32" 120" 88.7E C2 MED-SAND t0YR6/4 I (98.4) Ir ^ S-- Tank / _ v rJX Leaching Area: I r'\ TBM EL = 100 �0 F sidPwaii To of Ste Q � ` / I ( Sidewalls x gam. x 1�LFt) p�} I P P '� - ( x --Ft z _ I (98.2) Bettor : 3S� Existing Lea eh pit Long Acceptance Rate (LIAR): 0. 74 t 0 h e pumped and filled Deep val Hole Date: RrCHA 8, EAR Leaching Area Design Capacity. -3-�G o' J (Sidewall Area + Bottom Area) z LTAR �7Q Witnessed Bp: N/A Soil Evaluator RICHARD LEARNED (� Pere Rate: < 2 MIN/IN 0 36" — 48" Soil Survey Description: CARVER Geologic MateriaL• OVYTASH I Depth to Standing Water. NA Depth to Weeping Water. NA \ '*` Depth to Mottling(Color): NA Est Seasonal high GW: NA USGS Observation Well. NA (98.9) �_ , t � x rs � .. Date of Last Measurement: NA 6 2) Comments: ci Existing above :! XIS tl� I j I (97.8) ground pool (105.8) 1 - - - _ _ PROJECT LOCATION 104 Un el e Willies Way - - ` - - _ 7C Hyannis, MA ASSESSORS MAP 292 LOT 3-1-4 l to APPLICANT, Kandy Rutherford 104 Uncle Willies Way Hyannis, MA - t ALic_r ��,q� (97.8) 4, PREPARED BY A & M Land Services 33 Old Main Street �J South Yarmouth, MA 02664 � r (508) 398-2121 Fax 394-9642 O� SCALE' 1" = 10' DATE. March 9, 1999 REV. LOCUS MA� 104 Uncle Willies Way Hyannis, MA DWG. N0. 98091 SHEET 1 OF 1 r .?-, - 'L't'. +ate t '� F y.-:.• .j .y. .;q,,,-.-. +*e-. .l,.. r: .. WN-illa 9,� M�* ,e• M.'s , � :' .�� S t •7 R p ♦ r ... .. t.. _ s. _. _. .. .,.,ar:Ca' ._ ... _ a. •r .. , +'i.•-,,. REVISIONS: TEST PIT DA TA DATE OF TES T/NG : � PERC. TEST DATA : SEPTIC TANK DETAIL : s,zE- 0 DIST. BOX DETAIL : LEACHINGFACILITY DETAIL: NO. DATE TEST B Y : __S O E M C)h�A_ pt - _ / TO CONFORM TO T/TL E 5 REOU/REMENTS T. P �. W/TNESSED BYE 3% Acn, 13 - - DATE OF TEST/NG _____,1 -1 `G�3 TANK TO CONFORM TO TITLE 5 REOU/REMENTS. -- -- EL_eV - TEST B __-To'I __Mot`,IA�AN -- - NO. OFOMETS, 5 i 1 • I 1 �I 11t.. tl�ll• . 4 -------I 90. ----_ -- ; , ----- � WITNESSED BY, _S_ 1ACo� 1---- - ; ,. , - ''�-_;- S, 11. - - � --.: ���, � �, �y EMOVfABLE COVER CO I MED'•'j `�Ati1D I 12 -MA BROUGHT TO+ R A1HD rR VEL ` (� ,E) - Git'AyB ' AGE $`�• # `•.� '�•.! t.; , . o FINISH GRADE. •` 2"PEASTOA� „ I p 1 3 CL EAR ! 3 CLEAR Ir -�LC24 MAX. T --- --1--- - -.__. - -- - T I •. M FILL / —--- - _ ---- -- -- --__ - ---- OU LET PIPES • . :.... ..... . OF TEST: 6"M/N 2"MlN -- MG - INLET II li AS REOVIRED I DEPTH 6aa ° RATE' t.F�`] i Nl4t�I 2 Mt1.� PE ��JG� <. --- ---- _ I --- -- INLET TEE - -- -- �O M/N fi - ourcEr TEE D/ST. + t ►�1EI?t BOX II I I v'F_ )I.AN\ I N1 4.1 ---- 4"C./. /000- GAL. I INLET AND OUTLET 4' 0" M/NiMC/M : OUTLET TEE OEPrH #a-,� 2` 6 / r� I._ PRECAST OR BLOCK - ' L. T /4"AT L l OUID DEPTH OF 4 o PTiC TA TEES TO BE CAST L/OU/O DE H CONCRETE I SEEPAGE P/T t --- - —- —-- IRON, SCHED. 40 19 5' I, ' 1 -.- ---- - - I— 24" r, 6' l CONSTRC CTIGYII /O' cu TR TRA4E I DEPTH OF TEST _-__- _ _ P vc. oR casr/N „ - PLACE CONCRETE 29 7` " MIN. RATE }tAl� M�1•� PEP, 4Nc,�i CONCRETE 34 " " " 8' BOTTOM ON LEVEL STASLE845E i- -- - ---- CONSTRUCTION (WArERT/GHTI T LL� I FOUNDAT/ON I, I ---- ,--, --s /NLEr TEE PROVIDED WHERE SLOPE --_--------- 1 1•<r•.. ,. ! •• ' OF INLET PIPE EXCEEDS 0.08 /, OR L • '••'••'•' ' •-- "` - ' ' TANK TO BE ABLE TO W/THSTANO t • I BOTTOM OF TANK ON LEVEL STABLE BASE H-/0LOADING UNLESS UNDER /N A PUMPED SYSTEM. M/Al I / 'WASHED STONE - - — --- ----- PAVEMENT OR IN DRIVE.H-20 i { - - I L OA D/NG UNDER PAVEMENT OR I DR/VE b /O -- �, j I f j I RECOMMENDED MANUFACTURER _�"� _ _ RECOMMENDED MANUFACTURER (OR APPROVED EOUAL ) OR APPROVED O L NOTES PLAN VIEW INVERT ELEVATIONS /. THIS PLAN /S FOR THE DESIGN AND CONSTRUCTION OF THE SEWAGE SCA L E / "= 2-0 ' _-- /NV. AT BUILDING �3`3 • o o _ ��t t ;F �c DISPOSAL FAC/L/T Y ONL Y. 2 A L L CONSTRUCTION METHODS AND MA TERIAL S SHALL CONFORM TO _ _ MASS. D.f_�.O.F. T/TLE 5 A :'V C T.H£ �-.��R��h i�•'� �'_ BOARD OF /NV. AT SEPTIC TANK(/N) 3 S. &a �� '4°�`�' '"'�+,_. n __-/N V, A T•SEPTIC TANK(GUlT) _-- $ • S 5 a }c?r, . aFAL TH, REG�L A T/CNS. P+� � �� �• a,, Aq • A IN AT DIST. BOXON) 8�.3� w.- .� " X l t ♦ _ Y /NV. AT DIST BOX(OUT) AT LEACHING FACILITY, `��•`�� BOSTON, MASS. WORCESTER, MASS. HALIFAX, MASS. NORWELL, MASS. AT 80 T/'O M OF F J 7- $4. 3 � BEDFORD, MASS. LEXINGTON, MASS. -- HYANNIS, MASS. MANSFIELD, MASS. CRANSTON, R.I. DERRY, N.H. ` 1 ,c PROFILE • SCALE• / B C t y .. �. C i�'TC N t a S L SIGN FLOW- _ 4 REOU/RED SEPTIC TANK: - GAL �__ ____ W ; -' �'���•''a "s I t j I SEPTIC TANK PROVIDED = t C OC GAL. CAPE COD SURVEY h r CONSULTANTS • REOU/RED SIZE LEACH/NG FAC/L/rY: ------ ------ --- -- �` -� r P O. BOX 56 HYANNIS, MASS. 02601 617 775 71..5 , - , • 10_Qc� - — -- - - - 0 Ate' } �L --- -- - ---- ---- --- ---- - Y i DIVISION OF t BOSTON SURVEY CONSULTANTSINC. SIZE OF LEACHING FACILITYPROV/DED ENGINEERING • SURVEYING • PLANNING I t I - --- TITLE. ` d TYPE OF SYSTEM: SECTION : SCALE / - - LOr � y� /7 337, t , t �'I `�LI�L�...-t =1`►EzSF KZ.S = 2 $$Grfi�U I ► a � - 79sFx � .o - 9c►p __ �_, - - 1 - - �z� s� I ► I ? 4 I I_ T _ SEWAGE DISPOSAL SYSTEM • t�, - I s 7` - 12 3= 35 OSE -. I i �. - DESIGN 5' , 11 -- --- LOCUS PLAN: FOR: L 07 1 �- - -- -- - --- - ---- -- --- --- -----1 --- --- - �s FRt�Nn S t R,�'H 5r+ Nq q• SCALE AS SHOWN METERS FEET 0 - -- `--- -_1-- CCUs DATE: c -S- 12_ } o `✓ 3 COMP.",DESIGN. IR p M\ � p E � • - -o � CHECK-------- --- ------ -- - - � - --- ---- �---- DA TU/Y/ ' A._c. ELE.VA,'cf,aUg 5t•�owU DRAWN FIELD: TcD --- ---- -- -- - — - -- A-N FILE NO: > rs ti/f Fz�" T O N•Gr VT? C� �'�2�� �$SRR`.T DWG. NO: �� �:� JOB NO. . ; -;::• �: — -- --- 4'�.,.`��� �r•zvM '�'N� EL�1/R't 1D1J S -��Ati./FJ. - SHEET: I OF: I