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HomeMy WebLinkAbout0099 WAGON LANE - Health .99 ,Wagon Lane Hyannis F o x n t, A t i S I� 4 TOWN OF BARNSTABLE LbCATION 99 W-aoon LAIV SEWAGE # aooR - Q96 -YMLAGE a►r n r�-� ASSESSOR'S MAP& LOTJ20�� II�tTALLER'S NAME&PHONE NO. fi Excr4yAT 2o.y;�SbB•y� - DGS3 SEPTIC TANK CAPACITY /oo0 !cL LEACHING FACILITY: (type) Son oa:l CAQen3 C-0 (size) J3-s,0S X a NO.OF BEDROOMS 3 BUILDER OR OWNER Cheuxicq ;de- /Y'!Qr Al c4,n o PERMIT DATE: 7-/S -Q R COMPLIANCE DATE: 7-17- 09 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 A1- 1 ' A'Z i3 z - 25 d C-3 .D- 3 30 b%A'11-c-T twat! GARAGC �- y �y c c =s 30•� S 99 WA60N I-ANE 's4r C e �^Q��n,G reu a ov P r &N �J, prj-), 4 Svc IT I(d,,, %jr �V� ��� 2cf,)Y- 327 S b. r TOWN O PA ,;RNSTABLE' L(N;AnON SEWAGE # VILLAGE 4',4"4 S ASSESSOR'S MAP & LOT D6rALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) NO.OF BEDROOMS t' l a e � �� I� 7 BUILDER OR OWNER PERMITDATE: 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 b� o TOWN Of BA.RNSTABLE wP LOCATION I waecm SEWAGE# k VILLAGE- //V " ASSESSOR'S MAP&LOT INSTALLER`S NAME&PHONE NO. SEPTIC TANK CAPACITY SOD® LEACHING FACILITY: (type) T 1 T (size) 100 GA( aSX�S� NO.OF BEDROOMS BUILDER OR OWNER PERMITDATE: 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(I€any wetlands exist within 300 feet €leachinglacility) ® ���I K Feet Furnished by ./U`1.=4,0,ir H ra o � � n � a b � 1 . O R � � 1 0? Commonwealth of Massachusetts Title 5 Official Inspection Form �- Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 99.Wagon Lane Property Address Shawn & Katelyn Manfredo Owner Owner's Name information is required for every Hyannis ✓ Ma 02601 4/6/2021 page. Cityfrown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A. Inspector Information filling out forms on the computer, use only the tab Sean M. Jones key to move your Name of Inspector cursor-do not S.M.Jones Title V Septic Inspection use the return Company Name key. 74 Beldan Lane VQ Company Address Centerville Ma 02632 Cityrrown State Zip Code ,ern 774-248-4850 smjonestitle5@gmail.com, S14522 sean@smjonestitle5.com License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails 4/6/2021 Inspector's Signaturt_.'� Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: 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. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form �- -1 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 99 Wagon Lane Property Address Shawn & Katelyn Manfredo Owner Owner's Name information is required for every Hyannis Ma 02601 4/6/2021 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The property located at 99 Wagon Lane Hyannis is served by a Title V septic system consisting of a 1000 gallon septic tank, distribution box and 2 precast leaching chambers. Although the system was found to be in proper working condition at the time of inspection this report does not guarantee future performance under similar or increased usage. 2) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): I t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 18 r Commonwealth of Massachusetts Title 5 Official Inspection Form j> Subsurface Sewage Disposal System Form -Not for Voluntary Assessments e/ 99 Wagon Lane —u— Property Address Shawn & Katelyn Manfredo Owner Owner's Name information is required for every Hyannis Ma 02601 4/6/2021 page. Cityfrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): 3) 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. a. 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: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 99 Wagon Lane Property Address Shawn & Katelyn Manfredo Owner. Owner's Name information is required for every Hyannis Ma 02601 4/6/2021 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form I." Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 99 Wagon Lane Property Address Shawn &Katelyn Manfredo Owner Owner's Name information is required for every Hyannis Ma 02601 4/6/2021 page. Citylrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® 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 water supply well. I ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ ® 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. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section CA. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 99 Wagon Lane Property Address Shawn &Katelyn Manfredo Owner Owner's Name information is required for every Hyannis Ma 02601 4/6/2021 page. City town State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered"yes"to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed.The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes" or"no"for each of the following for all inspections: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans.of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth)of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] t5insp.doc•rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form �- Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 99 Wagon Lane v� Property Address Shawn & Katelyn Manfredo Owner Owner's Name information is required for every Hyannis Ma 02601 4/6/2021 ' page. Cityrrown State Zip Code Date of Inspection D. System Information . 1. Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms(actual): 3 "I 349 gpd DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): provided ' Description: Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): Detail: Sump pump? ❑ Yes ® No current Last date of occupancy: Date t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 99 Wagon Lane Property Address Shawn & Katelyn Manfredo . Owner Owner's Name information is required for every Hyannis Ma 02601 4/6/2021 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc•rev.726/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form j� Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ,(P � 99 Wagon Lane u— Property Address Shawn & Katelyn Manfredo Owner Owner's Name information is required for every Hyannis Ma 02601 4/6/2021 page. CityrFown State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known)and source of information: system repaired 7/17/2008 per town records Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 2 feet Material of construction: ❑ cast iron ❑40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Inlet cover under deck and is not easily accessible. t5insp.doc•rev.U26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form 1" Subsurface Sewage Disposal System Form-Not for Voluntary Assessments u= 99 Wagon Lane Property Address Shawn & Katelyn Manfredo Owner Owner's Name information is required for every Hyannis Ma 02601 4/6/2021 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: 1.5 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 gallons Sludge depth: 5" Distance from top of sludge to bottom of outlet tee or baffle 3' Scum thickness 2" Distance from top of scum to top of outlet tee or baffle 7" Distance from bottom of scum to bottom of outlet tee or baffle 10" How were dimensions determined? Opened covers and took measurements Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank does not need to be cleaned now but should be done soon and again every 2 years for proper maintenance. water level was even with outlet, tank was not leaking and was structurally sound. access cover under wood patio and has access cover cut out. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form �- i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments - � 99 Wagon Lane Property Address Shawn & Katelyn Manfredo Owner Owner's Name information is required for every Hyannis Ma 02601 4/6/2021 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day i t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments e � 99 Wagon Lane Property Address Shawn & Katelyn Manfredo Owner Owner's Name information is required for every Hyannis Ma 02601 4/6/2021 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0" Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Distribution box was functioning as intended I t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form � Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 99 Wagon Lane Property Address Shawn & Katelyn Manfredo Owner Owner's Name information is required for every Hyannis Ma 02601 4/6/2021 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No" Alarms in working order: ❑ Yes ❑ No" Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ® leaching chambers number: 2x500 ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc-rev.7/260018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 18 Commonwealth of Massachusetts �n Title 5 Official Inspection Form Subsurface Sewage Disposal Systems Form-Not for Voluntary Assessments � 99 Wagon Lane Property Address Shawn & Katelyn Manfredo Owner Owner's Name information is Hyannis Ma 02601 4/6/2021 required for every Y page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): s.a.s. consists of 2 h20 precast leaching chambers in the stone driveway. Leaching facility was video inspected from the vent and found dry with no observed stain lines. 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments note condition of soil signs of hydraulic failure, level of ondin , condition of vegetation, ( 9 Y p 9 9 etc.): t5insp.doc•rev.7/2612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments � 99 Wagon Lane Property Address Shawn & Katelyn Manfredo Owner Owner's Name information is required for every Hyannis Ma 02601 4/6/2021 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 13. Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 18 /011 Commonwealth of Massachusetts p Title 5 Official Inspection Form t Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 99 Wagon Lane Property Address Shawn&Katelyn Manfredo Owner Owner's Name information is required for every Hyannis Ma 02601 4/6/2021 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately A I {� lot C3 � 3 3� to„r.. I' GARAGE ' y 99": wAGone 4st,JE I t5insp.doe•rev.712612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18 c Commonwealth of Massachusetts +� 1, Title 5 Official Inspection Form I o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 99 Wagon Lane Property Address Shawn & Katelyn Manfredo Owner Owner's Name information is required for every y Hyannis Ma 02601 4/6/2021 page. Cityrrown . State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 12'+ feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: I ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Groundwater was established by accessing town of Barnstable groundwater contour maps. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form + a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 99 Wagon Lane Property Address Shawn & Katelyn Manfredo Owner Owner's Name information is required for every Hyannis Ma 02601 4/6/2021 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria)and 6(Checklist)completed ® D. System Information: For 8: Tight/Holding Tank— Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18 No. 0 09�� (f� A g _FEE COMMONWEALTH OF MASSAC14USETTS Board of Health, DO l MA. APPLICATION FOP, DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) - ❑Complete System ❑Individual Components Location99 Owner's Name Co() nth Map/Parcel# a r �' Address Lot# Telephone# Installer's Name Designer's Name —Dowf'N(apaC l ,.neer cR Address a C)f } Address —1,39 CJ.�. Telephone# _ Telephone# -3 2—4,� o Type of Building P'�\de.0�_ Lot Size 1 o Q sq.ft. Dwelling-No.of Bedrooms 3 Garbage grinder( ) Other-Type of Building No.of persons Showers ( ),Cafeteria ( ) Other Fixtures Design Flow (min.required) gpd Calculated design flow Design flow provided gpd Plan: Date 7114.JtL Number of sheets Revision Date Title T1+1r,b tke,.Vict Description of Soils) Soil Evaluator Form No. Name of Soil Evaluator 1�Qif "i Date of Evaluation (lt !) DESCRIPTION OF REPAIRS OR ALTERATIONS The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agrees to not to pl a the tem in operation until a Certificate of Compliance has been issued by the Board of Health. Signed Date q �. `lam 7 15 - Inspections �� '�.��-�� ¢�its e+r=r?'�yr.tx�}��'�,',,1s �L{aya,'�.�F'"3w`�''��.'s`�t.,.t�^*rw z,3Z€`�'3.-.'i'.� ''�� ` ,-(+1. �'Mn+'�. .a "T' .X,�'�i�'r �t aan,',.� �+e'�.+��i�;'::r-•..: c -. No. 00g'd1W FEE C®MMONWEALTR Of MASSACHUSETTS Board of Health, (��( �.C.�1/ MA. APPLICATION FOP, ➢ ISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( - ❑Complete System ❑Individual Components Location C1 c L� l` I \ Owner's Name CQ (,j n��-y\-14 tCt t- t2 l Map/Parcel# a �� [t /P -7 Address A&A Lot# Telephone# Installer's NameUt ' (_- 1 _ Designers Name ,�I L a Address , L' T�Cl' °� C �C.�C Address C' 73cl r cl t 1 n-T \act ( o f_.) Telephone# �k L '_ n Telephone# 5�J - �, - t-( � T Type of Building I` �'S 1 C�E twl L_�� Lot Size �� /o� J sq.ft. Dwelling-No.of Bedrooms Garbage grinder ( ) 'Other-'Type of Building No.of persons Showers ( ),Cafeteria ( ) Other Fixtures Design Flow (min.required{) gpd Calculated design flow Design flow provided gpd Plan: Date 7 1 f 4 t Q�i�-J Number of sheets Revision Date Ti/ Ts4tc � �tAe. 00n Description of Soil(s) Soil Evaluator Form No. Name of Soil Evaluator (Ivy' 1Cth�Date of Evaluation t ni�C) li DESCRIPTION OF REPAIRS OR ALTERATIONS The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agrees to not,too place the system in operation until a Certificate of Compliance has been issued by the Board of Health. Signed � Jt ��� Date q l(� /)&- 7—o s -0 Inspections r. ��Dj� No.� KV .FEE I — COMMONWEALTH OF MASSAC14USETTS Board of Health, t7 G r n S At o NrA. CERTIFICATE OF COMPLIANCE Description of Work: ❑Individual Component(s) ❑Complete System The undersigned hereby certify that the Sewage Disposal System; Constructed ( ),Repaired (✓}/Upgraded ( ),Abandoned ( ) by: ( . 11) i X C Ct V r, I t,` .(-, --r`t � at 0i C� \/\I C1 CI Cr e-1 � c, +-� Cf I-A v,i-1 t ;it t� , has been installed in yccorda ice with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to application`-No. )c 6" 7 R/0 , dated 7' S��a Approved Design Flow 3 t(°t (gpd) Installer kb ' / F C.\/ , r• Designer: Tx (Ct�: C C)Cl Inspectors•., �'Date:. The issuance of this permit shall not.be construed as a guarantee that the system will function as designed. No. p O Og d (/o FEE COMMONWEALTH Of MASSACHUSETTS Board of Health, MA. DISPOSAL SYSTEM CONSTRUCTION PERMIT Permission is hereby granted to; Construct( ) Repair( �1�Upgrade( ) Abandon( ) an individual sewage disposal.system at cl c 1 \/\) C i C r r L Ct t i P as described in the application for a�o�'- ?tib 7_IS-off Disposal System Construction Permit No. dated Provided: Construction shall be completed within three years of the date of this permit. Allc�l onditions must be met. Form,1255 Rev.5/96 A.M.Sulkin Co.Boston,MA Date T f�-o o Board of Health Town of Barnstable Barnstable Regulatory Services Department j ace Cft BnxMABL& MAW Public Health Division 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Thomas F.Geiler,Director FAX: 508-790-6304 Thomas A.McKean,CHO April 24, 2008 c Countrywide REO Marketing 2270 Lakeside Blvd. Mailstop RLS-3-32 Richardson, TX 75082 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE,TITLE 5 'The septic system located at 99 Wagon Lane, Hyannis MA was last inspected on April 18, 2008,by Shawn Mcelroy, a certified septic inspector for the State of Massachusetts. The inspection of the septic system showed that the system"Failed" under the guidelines of 1995 TITLE 5 (310 CMR 15.00) due to the following: • Backup of sewage into facility or system component due to an overloaded or clogged SAS. • Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS. You are ordered to repair or replace the septic system within Sixty (60) days from the date you receive this notification. Failure to repair/replace the septic system within the deadline period will result in future enforcement action. PER ORDE OF THE OARD-OF HEALTH Thomas McKean,R.S.,.CHO Agent of the Board of Health CERTIFIED MAIL# 7006 2150 0002 1038 7213 Q:\SEPTIC\Letters Septic Inspection Failures\99 Wagon Lane.doc Jy LA),n ' Commonwealth of Massachusetts Title 5 Official Inspection For Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 99 Wagon Ln � 191 . Property Address Countrywide RED Marketing 2270 Lakeside Blvd Mailstop RLS-3-32 Richardson, TX 75082 �Jl Owner Owner's Name information is required for Hyannis MA 02601 4-18-08 every page. Cityfrown state Zip Code Date of Inspection Inspection results must be submitted on this form.Inspection forms may not be altered in any way. A. General information 1. Inspector: Shawn Mcelroy E Name of Inspector - = Upper Cape Septic Services Company Name 29 Atwater Dr v, ` Company Addresst�*4 E. Falmouth MA 02536 -Y1 V Cityffown State Zip Code c,,-) 1-800-495-0905 $13971 {;� Telephone Number License Number C B. Certification µ I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. 1 am a DEP approved system inspector pursuant to Section 15.340 of Title s(310 CMR 15.000).The system: t , ❑ Passes ❑ Conditionally Passes ® Fails ❑ Needs Further Evaluation by the Local Approving Authority l . J /illl 4-18-08 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner •-,. - and copies sent to the buyer,if applicable, and the approving authority. "*"*This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp•03M8 Tg,-5 Offic d kwpecban Fomc Subsume Sege Disposal System•Page 1 of 15 •J Commonwealth of Massachusetts W Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 99 Wagon Ln ` Property Address Countrywide REO Marketing 2270 Lakeside Blvd Mailstop RLS-3-32 Richardson, TX 75082 Owner Owner's Name information is required for Hyannis MA 02601 4-18-08 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/ahvays complete all of Section D A) System Passes: ❑ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Answer yes, no or not determined (Y, N, ND)in the❑for the following statements. If"not determined,"please explain. ❑ The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND Explain: ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed t5insp•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 15 Commonwealth of Massachusetts Title 5 Official, Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 99 Wagon Ln Property Address Countrywide REO Marketing 2270 Lakeside Blvd Mailstop RLS-3-32 Richardson, TX 75082 Owner Owner's Name information is required for Hyannis MA 02601 4-18-08 every page. City/Town State Zip Code Date of Inspection B. Certification (cunt.) B) System Conditionally Passes (cont.): ❑ distribution box is leveled or replaced ND Explain: ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed ND Explain: 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 Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and'the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. t5insp•03/08 s Tine 5 Oificiat:tnspection:Form:Subsurface Sewage Disposal System•Page 3 of 15 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage:Disposal System Form-Not for Voluntary Assessments M '( 99 Wagon Ln Property Address Countrywide REO Marketing 2270 Lakeside Blvd Mailstop RLS-3-32 Richardson, TX 75082 Owner Owners Name information is required for y Hyannis MA 02601 4-18-08 every page. City/Town State Zip Code Date of Inspection B. Certification (cunt.) C) Further Evaluation is Required by the Board;of Health (cunt:): ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well'. Method used to determine distance: �* This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered_A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ® ❑ 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 dogged SAS or cesspool Static liquid level in the distribution box above outlet invert due to an overloaded ® or clogged SAS or cesspool . r ❑ ® Liquid depth in cesspool is less than 6'below.invert or available volume is less than'/2 day flow El ® 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. t5insp-03/08 Title 5 Ofriaa Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15 Commonwealth of Massachusetts N Title 5, Official, Inspection Farm Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 99 Wagon Ln Property Address Countrywide REO Marketing 2270 Lakeside Blvd Mailstop RLS-3-32 Richardson, TX 75082 Owner Owner's Name information is required for Hyannis MA 02601 4-18-08 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems(coat.): Yes No ❑ ® Any portion of a cesspool or privy is within a.Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis,performed at a DEP certified laboratory,for fecal colifonm bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that:no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] El ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. The system fails. I have determined that one or more of the above failure Z. criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes'or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped!Zone It of a public water supply well If you have answered"yes'to any question in Section E the system is considered a significant threat, or answered "yes'in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5insp•03/08 Idle S OfticiaC:tnsped on Farm:,Subsurface Sewage Disposal System•Page 5 of 15 i Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 99 Wagon Ln Property Address Countrywide REO Marketing 2270 Lakeside Blvd Mailstop RLS-3-32 Richardson, TX 75082 Owner owner's Name information is required for Hyannis MA 02601 4-18-08 every page. Cityrrown State Zip Code Date of inspection C. Checklist Check if the following have been done.You must indicate "yes"or"no"as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ❑ ® Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ • Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? 0 ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions,depth of liquid,depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined'based on: ❑ ® Existing information. For example,a plan at the Board of Health. ® ❑ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] t5insp-03M Tide 5Official Irtspectim Forth:Subsurface Sewage Deposal System-Page 6 of 15 Commonwealth of Massachusetts e Title 5 Of��cial Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 99 Wagon Ln Property Address Countrywide REO Marketing 2270 Lakeside Blvd Mailstop RLS-3-32 Richardson, TX 75082 Owner Owner's Name information is required for Hyannis MA 02601 4-18-08 every page. Cityrrown State Zip Code Date of Inspection D. System Information Residential Flow Conditions:. Number of bedrooms (design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms). 330 Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): Sump pump? ❑ Yes ® No Last date of occupancy: 3-08 Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Galles per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe): t5insp-03f08 Mite 5Oftial'llnspection':Form:Subsurface Sewage Disposal System•Page 7 of 15 Commonwealth of Massachusetts Title 5 Official ifs ection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 99 Wagon Ln Property Address Countrywide REO Marketing 2270 Lakeside Blvd Mailstop RLS-3-32 Richardson, TX 75082 Owner Owners Name information is required for Hyannis MA 02601 4-18-08 every page. Cityrrown state Zip Code Date of Inspection D. System Information (cont.) General Information: ' Pumping Records: Source of information: N/A Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank,distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes,attach previous inspection records, if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed:(if known)and source of information: 1983 Were sewage odors detected when arriving at the site? ❑ Yes ® No t5insp•03108 Trite 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 8 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 99 Wagon Ln Property Address Countrywide RE© Marketing 2270 Lakeside Blvd Mailstop RLS-3-32 Richardson, TX 75082 Owner Owner's Name information is required for Hyannis MA 02601 4-18-08 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cunt.) Building Sewer(locate on site plan): Depth below grade: 24"feet Material of construction: ❑ cast iron ®40 PVC ❑other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints,venting,evidence of leakage, etc.): Good condition. Septic Tank(locate on site plan): Depth below grade: 18" feet Material of construction: - ® concrete ❑metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: yeas Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No -------------------------------------------------------------------------------------------------------------------------- Dimensions: 1000 Gal Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle 20" Scum thickness 0 Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 16" How were dimensions determined? Tape t5insp•03108 Tdie 5 OfficW inspection Form.Subsurface Sewage Disposal System-Page 9 of 15'. Commonwealth of Massachusetts Title 5 Official Inspection Form 4. Subsurface Sewage Disposal System Form-Not for Voluntary Assessments , rY 99 Wagon Ln Property Address Countrywide REO Marketing 2270 Lakeside Blvd Mailstop RLS-3-32 Richardson, TX 75082 Owner Owner's Name information is required for Hyannis MA 02601 4-18-08 every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank in good condition with baffles in place. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection)(Locate on site plan) Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): t5insp•03108 TdleS official inspection Form:Subsurface Sewage Disposal System•Page 10 of 15 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 99 Wagon Ln Property Address Countrywide REQ Marketing 2270 Lakeside Blvd Mailstop RLS-3-32 Richardson, TX. 75082 Owner Owner's Name information is required for Hyannis MA 02601 4-18-08 every page. City/Town State Zip Code Date of Inspection D. System Information (cunt.) Tight or Holding Tank(cunt.) Dimensions: Capacity: gallons Design Flow: gallons per day '- Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order. ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches,etc.): - *Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 Comments(note if box is level and distribution to outlets equal,.any evidence of solids carryover, any evidence of leakage into or out of box„etc.): D-box has historical stains above inlet invert. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No t5insp•03/08 Ti3fe 50friciaf fnspecton Foam:Subsurface Sewage Disposal system•Page 11 of.15 Commonwealth of Massachusetts Title 5 icial Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments w. 99 Wagon Ln Property Address Countrywide REO Marketing 2270 Lakeside Blvd Mailstop RLS-3-32 Richardson, TX 75082 Owner Owner's Name information is required for Hyannis MA 02601 4-18-08 every page. Cityfrown State Zip Code Date of Inspection D. System Information (cost.) Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System(SAS)(locate on site plan, excavation not required): If SAS not located, explain why: Type: ® leaching pits number: ❑ leaching chambers number. ❑ leaching galleries number: ❑ leaching trenches number,length: ® leaching fields - number,dimensions: 1-25x25 ❑ overflow cesspool number: ❑ innovativetaltemative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding,damp soil, condition of yegetation, etc.): Both the pit and the field had signs of failure and back-up. t5insp•03108 Trite 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15 Commonwealth of Massachusetts Ij 'itie 5 Official inspection Form o Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 99 Wagon Ln Property Address Countrywide REO Marketing 2270 Lakeside Blvd Mailstop RLS-3-32 Richardson, TX 75082 Owner Owner's Name information is required for Hyannis MA 02601 4-18-08 every page. City/Town State Zip Code Date of Inspection D. System Information (cunt.) Cesspools (cesspool must be pumped as part of inspection)(locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.): t5insp•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15 Commonwealth of Massachusetts ®_ Title ei i Ins ecti n For Subsurface Sewage Disposal System Form -Not for Voluntary Assessments w 99 Wagon Ln Property Address Countrywide REO Marketing 2270 Lakeside Blvd Mailstop RLS-3-32 Richardson, TX 75082 Owner Owner's Name information is required for Hyannis MA 02601 4-18-08 every page. city/Town state Zip Code Date of Inspection D. System Information (cunt.) 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 ' t 1 i A 35�' �(J t5insp-03/08 Tide 5 Qftial hispection Form.Subs:nface Sewage Daposat System-Page 14 of IS • Commonwealth of Massachusetts Title 5, Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 99 Wagon Ln Property Address Countywide REO Marketing 2270 Lakeside Blvd Mailstop RLS-3-32 Richardson, TX 75082 Owner Owner's Name information is required for Hyannis MA 02601 4-18-08 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cone.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water. 20' feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design planson record If checked, date of design plan reviewed: Dace ® 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: Town maps and USGS show groundwater at 20'_ t5insp•03/08 Tdte 5 Official 6nspection Form.Subsurface Sewage Disposal System•Page 15 of 15 Town of Barnstable THE Jpk Regulatory Services snxivsrAscE Thomas F. Geiler,Director 9$ iMAS& p,EoYA Public Health .Division Thomas McKean, Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 This septic system inspection report was completed by a private inspector who is certified by the State of Massachusetts, Department of Environmental Protection. Although the Town of Barnstable Health Division received the original/copy of this report; this Division does not warranty the functionality of the septic system in the future not does this Division agree with any technical observation s and interpretations contained within this report. In addition, by receiving this report the Town of Barnstable Health Division does not automatically approve the number of bedrooms listed within this report. The actual number of bedrooms approved at a particular property would-be listed on the"Disposal Work Construction "Permit". If you should have any questions regarding this report, please contact the'certified Septic System Inspector who conducted the inspection. FROM :damn cape- engineering inc• FAX NO. :15083629880 Jul. 17 2008 02:16PM P1 Town of Barnstable WE Regulatory Services > Thomas F. Ceiler,Director � MASS, < Public Health l.t9a, Division�� Thomas 'MvKea.n, Director 200 Maim Street,Hyannis, MA 02601 OfEce;: 508-€E62-464 4 Fax: 508-790-6304 lnstalller & Designer Certification Form Sewage.Permit# Assessor's Ma p\Parvel z0 /9 7 Designer, � _�� ��� � lnoaller: �_G" l' G�... ._ ..�J 14 E�al il.ire4w: �G� ... Address: , ..... I� e On g-` ( C / ` �✓u � _ AVVK,' , I as issued a.pennit to install a --(dAe) installer) �L�) a� / sE,Pti system atq . �( based on.a design drawn by (adclress. ted esignea I,— i certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocati.oi.). of th.e distribution box and/or septic tank. T certify that the septic system referenced above was installed with. rmajor changes (i.e. greater than I lateral relocation of the SAS or any vertical relocation of any component of the septic system.) but in.accordance with State & Local Regulations, flan revision or certified ads—built by designer to follow. c ti DANIELA- OJALA (Installer's i nat re) CIVIL '^ V q �No.4 02 (Designer's Signature) (Affix Designer's Stamp Here) PLEASE RETURN TO RARNSTABLF PURT,TC FIFALTII DIVISION. CERTIFICATE OF (201vI['I.EANC:1 WaL.L, No,r T31; ISSUER) UNTIL BOTH THIS FORM AND AS-BUILT CARD ARE II DC.'E"WE D BY THE 13A1ZN5TABLE PITBI,TC:HEALTH MV1SION. 'TIIAl•1)K YOU. Q; Cerl.ilicatim Fomi 3-26-04.doc LOCNION SEWAGE PERMIT NO• VILLAGE INSTALLER'S NAME & ADDRESS BUILDER OR OWNEIK DATE PERMIT ISSUED DATE COMPLIANCE ISSUED � ,,,� 1 v E, J No. :3-. �3� F�s.....1....�............... THE COMMONWEALTH OF MASSACHUSETTS BOA F HEALTH _.._....:.1-... `h-........­OF.....................:.......d. `--------------------.------ Appilration for Uhiplaii ai Workii Tnnitrnrnnn rrntit r Application is hereby made for a Permit to Construct ( ) or Repair ( } an Individual Sewage Disposal e. syst ............... ......... 74 a , . a Addr s or t o. IJ WstOw, • .�, Tess Address Ty e f Building Size Lot_.__1.6 ....Sq. feet Dwelling—No. of Bedrooms......._ .....................................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ .No. of persons............................ Showers ( ) — Cafeteria ( ) Q' Other fixtures ---------------------------------------------- W Design Flow.............1/0............. .....gallons per person M day. Total dai flow..__.___..�_�52......................gallons. WSeptic Tank—Liquid capacity.. _.....gallons Length____ _:___..... Width___.`____.__._ Diameter________________ Depth__ yf`.... x Disposal Trench—p No..................... Width_.................. Total Length___._../__�.__..... Total leaching area....................sq. ft. Seepage Pit No...l`. ----- Diameter............... Depth below inlet.__............. Total leaching area._ �. .sq. f . Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by........................................... Date................... ._......._......_.. aTest Pit No. 1.../ _ __minutes per inch Depth of Test Pit___ __.... __. Depth.to ground water_-_ 19�_--._- Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water---________-.---__--_--- ....... R N .......... Description of Soil----C---®--. f '...----•.•• ----� ----- ........... --------------------------------------------------�---------------------_-�-3---------f--------- W, --------------------------------------------------------------------------------------------------------------------------------- --•----••••-----•----- --•--- U Nature of Repairs or Alterations—Answer when applicable.-____.......................................................................................... -•----------------------------------•-----------------...............................................................-•...................•-•---------------------------------------•-••-•---•-•-•---- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLB 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has be issued by the board of health. C, ApplicationApproved By...........-- ---- -•-------. ------•--•-------•--•---•--•----------------••---••--•----- /— Date Application Disapproved for e f of ing reasons:.................................-------•-----•---------------•-------------------------------------------....._ ..............................................................................--........................................................................................................................ Date PermitNo........................................................ Issued_....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH J r ::........ .............. ........OF........ ... .r, �.. y............................ TwWrfffiratr of Toutplianrr TH O TYFY, That the Individual Sewage Disposal - em constructed ) or Repaired ( ) by = = - s ---------••- •-•-----•--•-------------•----................•-••.....••••--•----.._....---••- at -----_-_-_-- ......... ----- -•--- -------- --------- ---- .-- . has been installed in cordance with the prov• • is of IT 5 of The S to Sanitary od s d in the application for Disposal Works Constructi Permi o... ._'�_ -_ __ dated-_j.... .. ..._ ........_... THE ISSIJA CE F THIS CERT FICA T SHALL NOT B7CON. E® AS A GBJAIt NTEE THAT THE SYSTEM'WILL N N SATISFA Y. DATE...../vA .....................•-------•-------•--•------•-----•-•• Inspecto Finc.............................. No. THE COMMONWEALTH OF MASSACHUSETTS BOA� F HEALTH . --.....OF.......................................... ............................................. Allp iration for Uiopooal Workii Tonotrurtion Frratit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at- €... - ......• •-----• � ^° ..:.......... ................. r?�'-s. .......... L atio��Addr "T or t . ♦ y� Ov��er dd ess. .. ........... ......... Q 3� �J I sta 1 r Address U Ty(Fe f Building Size Lot..... �� . 3----Sq. feet w —No. of Bedrooms...... ...............................Expansion Attic ( ) Garbage Grinder ( ) 0-1 p.I Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Q' Other fixtures ------------------------- -------------------------•-- W Design Flow..............�.✓.�..........j...._...gallons per person day. Total d il} flow._._.......�..........`.................-.......gallons. WSeptic Tank—Liquid capacity..... .....gallons Length................ Width................ Diameter................ Depth...-)__••__...... x Disposal Trench—No. .................... Widt 7------------- Total Length...... .'I....... Total leaching area..__.. ---------sq. ft. Seepage Pit No._..1 D"!`t%.... Diameter.......:........... Depth below inlet.... ........... Total leaching area... .�.!��..sq. ft.. Z Other Distribution box ( ) Dosing tank ( ) ~' Percolation Test Results Performed by............................................ .... Date-------------------- aTest Pit No. I.._.l"_2-.minutes per inch Depth of Test Pit................. Depth to ground water... ° E.... G%I Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water....._.................. •••. ................................... r--------... ---j;---- - .......... ......... .. ...... z O Description of Soil...... _. 0 . .. ...: � .�rJ----- s'u �'i .................................................... �a. l�5-�.., 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 TITLE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has be issued by t) e board of health. .'Si ` 1 Application Approved B ..... 11 : - � Date Application Disapproved for t f ollo ing reasons:....................... •-••-•------------•---------••....................•------• ------•-•-••-----.......-- Date PermitNo......................................................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF•`':HEALTH`' � ...':"!r"•°.- ...OF.... . .... ........................:. Tatifiratr of ToanpliFayn� re 4iw "f,; THIS), C. AFY, That the Individual Sewage Disposal S- : m constructed or Repaired ( ) b ....._. . `. �. ......... -------------- ----Y d - ° __.- " has been installed in a dance with the prove s of o T. r of The State Sanitary +C de s d MbW, n the application for Disposal Works Constructio ermit o.- _: `__ ��-_ __• dated--- -- ---- --- ---- ------------ THE ISSUANCE OF THIS CERT- ICAT HALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFA DATE................................................................................ Inspector.................................................................................... THE COMMONWEALTH OF MASSACHUSETTS BOAR OF HEALTH "77— t�/I. r r P_i1•"� .i ......... """........OF....... No .................... FEE..... ' i000tal or n Milan Trani Permission is hereby r ted............... :. .. at to Construct r tr ( ) andI i dual Sewag ispo stem .........................••••---- ......-•••--•. .. ' Street r ` as shown on the ratio for Disposal Works Construction Permit No________________ : __ ...._._._ ./... ................... .....--•--•---•••-----•----- • ---- -- ..................................................... Bo of Health DATE---- --- ................................................. FORM 125 HOBBS & WARREN. INC.. PUBLISHERS i ,I <pl►� GLC-• FAMILY - ':� BGORr�oM ,I 1-1':a GAQBAGE (�¢aNDE2 I. c, ItY�c►-0W .: I10 A 3 = 3306.PP II SePTIG TASK = 330xl5o% =,A9 j 6-P o I II u51✓ l 000 o15Po5�L PIT u5E 1000 GAL. 5►DcvJA�� AeGA I�0 5.� _ 97 /G �•� 1I' BoTroM AREA= II 5 a S.F x 1• o A . 5,c) i -T OTA �•S/ Tt�TAI. pA 1 L."( FLoy( = 330 ( PD, 9 .3 T _......_._.. Q zo PE2Go�ATIoN RA?E I''!N 2MIN o�►-E55 �/�? Q i a�� q M� 0N OF M v� fiICHARD ��,�, U ►�aN fir`',' l� ca BAXTER Na 224046 �STS��IOQ- 0 SURGE - 9p TOP FNu= I00.O n� yc 1 j I Nv. 97 Y / - i Yam. iCo�y.g 1000 Tv . Su$So/G— MST. INS. Gnu. Z I Ovo z- DuX 97 � IN f TANK I . ,czar LcAGu P►T INV. INV. G, ✓ wlTu I'/3/� •I%Z , WASNGD 7 6ToNE v�sc- I, �. I• 9v,y CrE R.T I F I G Q P►-o T P 1_A N /Z PRUFIL� ^/oK/ze t_oCA-TIoI,-1 BG'y wo SCALE Scp LG / :C/a SATE y/�83 p �P.t•� RE� E2ENGE S C E R'f I F Y T N AT 'T H�C�evi-?a5.�`� N�c.SNo IrYN HE REOI•l GOMFL`(5 WtTO l HE S I OEt.IW AuD SET�.GK R.6Qv►Q.EMEtJY> of TNT O F ANC 1 S �10rr j � ZUO� I��• Z� LOGP.-r D, WlTNl1.1 1a6 G�-000 PLtNM4 DATE tG 0 �u. BP.xTG V-. WI L- I N C- ► R.EG 15��26�'IAu D 5 u g-V -Tull Pt_&KI 15 N07 an5c o ob AQ oSTC -VILLE lu571R•uMaNT Suevey � -TNE nI=FSETS 5uvu43) NoT DE u5EDTo C7E7ER/�IN� �.oT ►-INE�j APPLICA T' 2�14-G ` . COMMONTV EALTH OF MASSACHUSE'I s ExEcunvE OFFICE OF EN"VIR0N1N1EiN"TAL AFFAIRS DEPARTMENT OF ENVIRONMENT AY�� C)-EC'TION 1-1 . FEB 15 2005- TOWN OF BARNSTABLE HEALTH DEPT. TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENT'S SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A � CERTIFICATION -TM---- •ARCEE _ g q 1 Property Address: OT -�- Owner's Owner's Address: Date of Inspection: 1 13 51 •w, " "� Name of Inspector:(please print) G44e t I f-f `,j, Company Name: 14 , I&CIL h✓ie6_MprdV j,%apec.-I(,w,s �: r Mailing Address: eq& - OoZ6e{/ Telephone Number: 09 CO rn CERTIFICATION STATEMENT 1 certify that I have personally inspected the sewage disposal system at this,address and that the information reported below issue,accurate and complete as of the time of the inspection.The inspection was performed based on my, and experience in the proper function and maintenance of on.site sewage ftosal systems.I am a DEP approved system inspector pursuant to Section 15340 of Title 5(310 CMR 15*0). The system: Passes . Conditionally Passes Needs Further Evaluation by the Local Approving Authority -" Fails Inspector's Signature:�c� / Date: I The system inspector shaII 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 regionat;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 Itow the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page I Page 2 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE llMOSAL`SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 4?t or► L4t&e Owner:_ a'�ris0 _ Date of Inspection: / I L,, c) Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: i _ 1 havenot 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 to be replaced or repaired.The system;upon completion of the replacement or repair,as approved by Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the follow' statements.if"not determined"please explain.. The septic tank is metal and over 20 years old*or the c tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or failure is imminent.System will pass inspection if the existing tank is replaced with a complying septic tank ved by the Board of Health. *A metal septic tank will pass inspection if it is stru y sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old' vailabie. ND explain: Observation of sewage bac or break out or High static water level in the distribution box due to broken or obstructed pipe(s)or due to a bro settled or uneven distribution box.System will pass inspection if(with approval of Board of Health): broken pipe(s)am zepLeced obsMw iw isremoved distn'liuttiod box is kneeled or replaced ND explain: The s m required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspe if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: 2 Page 3 of I I OFFICIAL. INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address:�g�grr��l_�[ La yl e (TwA_nn �S - - Owner: T— Date of Inspection: t O C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to d rmine 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 3 CMR 15.303(I)(b)that the system is not functioning in a manner which will protect public health afety 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 w and or a salt marsh 2. Svstem will fail unless the Board of Health(and P lie Water Supplier,if any)determines that the system is functioning in a manner that protects the p lie health,safety and environment: _ The system has a septic tank and soil abso 'on system(SAS)and the SAS is within. 100 feet of a surface water supply or tributary to a surface er supply_ __._ The system has a septic tank and SAS d the SAS is within a Zone i of a public water supply. _ The system has a septic tank and AS and the SAS is within 50 feet of a private water supply well. _ The system has aseptic tank d SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well".M od used to determine distance "This system passes if th ell water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile or is compounds indicates that the well is free from pollution from that facility and the presence of ammo a nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are Qered.A copy of the analysis must be attached to this form. 3. Other: f' 3 Page 4 of i 1 OFFICIAL INSPECTION FORM-NOT'FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DWOSAL SYSTEM INSPECTION FORM a PART A- CERTIFICATION(continued) Property Add ress: r¢ S L Owner: Date of Inspection: D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections_ Yes No ( Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool _ ( Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool Liquid depth in cesspool is less than 6"below invert or available volume is less than'/z day flow - Required pumping more than 4 times in the last year NOT due to clogged or obstructed pq*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. or 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 pricy is less than IOtI 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..analys* performed at a DEP certified laboratory,for coMerm bacteria and volatile organic-compaunds indicates that the well is free from'pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equat to or less than S ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] A)v (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 nVW serve fa '' a design flow of 10,000 gpd to 15,000 gPd- i You must indicate either"yes"or"no"to each of the fo g: (The following criteria apply to large systems in n to the criteria above) yes no _ the system is within 400 feet o surface drinking water supply the system is within 2 eet of a tributary to a surface drinking water supply the system is loc in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a p c water supply well If you have answe "yes"to any question in Section E the system is considered a significant threat,or answered "Yes"in Section above the large system has failed.The owner or operator of any large system considered a significant tltr under Section E or Failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.Th ystem owner should contact the appropriate regional office of the Department. 4 Page 5 of l l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSPACE SEWAGE DISPOSAL SYSTEM J NSPECTIONN FORM PART B=' CHECKLIST Property Address: 04 0.ny', Owner. OSO Date of Inspection: I I I-PTn5' Check if the following have been done.You mast indicate"yes"or"no"as to each of the following: Yes No K Pumping information was provided by the owner,occupant,or Board of Health �( Were any of the system components pumped out in the previous two weeks? Has the system received normal flows in the previous two week period _ Have large volumes of water been introduced to the system recently or as part of this inspection? _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) _ Was the facility or dwelling inspected for signs of sewage back up? _ Was the site inspected for signs of break out? _ Were all system components,excluding the SAS,located on site? _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition ofthe baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? f Was the facility owner(and occupants if different from owner)provided with information on the proper mte_nance 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)] 5 I Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address• r Owner: Date of Inspection- FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): '� Number of bedrooms(actuaI): DESIGN flow based on 310 C11� 15.203(for example: 110 gpd x#of bedrooms): .3 a Number of current residents: `r Does residence have a garbage grinder(yes or no): Is laundry on a separate sewage system(yes or no): AQif yes separate inspection required] Laundry system inspected(y s or no):�20 Seasonal use:(yes or no):Z Water meter readings,if av ilable(last 2 years usage(gpd)): :5 Sump pump(yes or no): L Last date of occupancy: COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): d Basis of design flow(seats/persons/sgftetc . Grease trap present(yes or no):_ Industrial waste holding tank pre t(yes or no):_ Non-sanitary waste discharg to the Title 5 system(yes or no): Water meter readings,i ilable: Last date of occup /use: OTHER(des be): GENERAL INFORMATION Pumping Records Source of information: Was system pumped as part of the inspection(yes or no): /l If yes,volume pumped:__gallons—How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM Septic tank,distribution box,soil absorption system Single cesspool Overflow cesspool _Privy _Shared system(yes or no)(if yes,attach previous inspection records,if any) - _Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight tank —Attach a copy of the DEP approval _Other(describe): Approximate age of all components, ate installed(if known)and source of information: ao Were sewage odors detected when arriving at the site(yes or no)-,&O 6 Page 7 of I I OFFICIATE.INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SLTBSURFACE SEWAGE IDISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address- Owner:_ fG Date of Inspection: D BUILDING SEWER(locate on site plan) . a Depth below grade: 33 C Materials of construction: cast iron _,K 40 PVC_other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: X (locate on site plan) Depth below grade: cZ Material of construction:gconcrete_metal fiberglass___polyethylene other(explain) If_tank is metal list age:__._ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions: t DOD Sludge depth: " ��. Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: e2" Distance from top of scum to top of outlet tee or baffle: 9 Distance from bottom of scum to bottom of outlet tee oaffle: ,� !�3•� How were dimensions determined: /'!E'n.S o f'4 Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): t Al GREASE TRAP:_(locate on site plan) Depth below grade:_ Material of construction:_concrete_metal egl polyethylene_other (explain): xff Dimensions: Scum thickness: Distance from top of s/endations, t tee or baffle: Distance from bottom of outlet tee or baffle: Date of last pumping: Comments(on pumpis,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invkage,etc.): 7 Page 8 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE IDISPOSAI.SYSTEM INSPECTIO N FORM PART C SYSTEM INFORMATION(continued) Property Address: v e Owner:_ v 92 _ _ Date of Inspection: 3�os TIGHT or HOLDING TANK: (tank must be p at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete fiberglass_polyethylene other(explain): Dimensions: Capacity: ons Design Flow: ons/day 5 Alarm present(yes or no): Alarm level: Al in working order(yes or no): Date of last pumping: Comments(condi • of alarm and float switches,etc.): DISTRIBUTION BOX: (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): n Z' _(z&x waS JLs^ aeec l a A c�nft+ mece.W t6 l9 PURR-P CHAMBER-/,yr ' a plan) Pumps in working ord Alarms in working ordComments(note condber,condition of pumps and appurtenances,etc.): 8 Page 9 of l l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1?q W GkA:.0VX Owner:_ Date of Inspection: SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number._ leaching chambers,number leaching galleries,number leaching trenches,number,length: V leaching fields,number,dimensions: I (is a$' X aS 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.): `t � 0►��1I1� T1,5tX a. t� e CESSPOOLS: (cesspool must be 7"s part of inspection)(locate on site plan) Number and configuration: Depth—top of liquid to inlet inverr. Depth of solids laver: Depth of scum layer. Dimensions of cesspool: Materials of construction- Indication of groundw er inflow(yes or no): Comments(note co ition 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: Continents(note co rtion of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): 9 Page l0 of 11 OFFICIAL INSPECTION FORM--NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C J SYSTEM INFORMATION(continued) Property Address: CN L&aG O P, Lgffik Owner: xz Date of Inspection.• 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. as o� Page 11 of I 1 OFFICIAL INSPECTION FORM-NOT FOR.VOL'UNI T T ARY ASSESS IETNTS SUBSURFACE SEWAGE DISPOSAL, SYSTEM INSPECTION FORM PART G SYSTEM INFORMATION(continued) Property Address: q9 U) do �—Wa t►u�...> Owner: /✓ 'pao Date of Inspection: SITE EXAM Slope Nv- Surface water 11 Check cellar i Shallow wells Estimated depth to ground waterZ 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: K 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 USES database-explain: You must describe how you established the high groupd water el vation: tL-).O q'f' ttio c -4fa a Il Permit Number: Data: Complete by:. HIGH GROUND-WATER LEVEL COMPUTATION Site Location.: J�,�-Lau! -,.k Lot NO. Owner: Add: Contractor: Address: Notes: STEP 1 Measure de{s-h to water table 0 to nearest 1/10 ft. --•--•••......................................................_.............. Date �� F month/6avPv"r # STEP 2 Using Water-Level Range Zone and Index.Well Map locate � site and determine: Appropriate index wel;..-...... •--•-----------------------------_------ � 1 $ Water-Leval range zone ..................... STEP 3 Using monthly report"Current i Waw Resources Conditions" determine m,rrer-t death to water gel for index well .................... Iv 4 t} STEP 4 Using Table 3f Water-level Adjustments for index well jSTEP 2A),current dePth t t E to water leve,t for index well (STEP U. and water=4criel zone (STEP 28) determine water-levee adiustment ......--__--- ---. STEP 5 Estimate&-ptt'-to higb-ater by subtracting the water- i leve;adjustment(STEP 4) from measured depth to water ievelat Site =STEP #) ................. ............. ._..............-•......•----••- I r CC)3 BO01-3139 / c7y cloy TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS vy/01 SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM BY BENNETT&O'REILLY,INC. RECEIVE P. O.Box 1667 Brewster,MA 02631 (508)896-6630 AUG 1 5 2001 PART A TOWN OF BARNSTABLE CERTIFICATION HEALTH DEPT. Property Address: 99 Wagon Lane Name of Owner: Mr.William Smith,Esq. Hyannis,MA Address of Owner: 99 Wagon Lane Date of Inspection: 7/24/01 Hyannis,MA 02601 Name of Inspector: Jane Evans Raasch,R.S. Company Name: BENNETT&O'REILLY,INC. Mailing Address: P.O.Box 1667,Brewster,MA Telephone Number: (508)896-6630 l 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 system. I am a D.E.P.approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000) The system: X Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails, ��c Inspector's Signature: G� Date:8-13-01 The System Inspectors 11 submit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this inspection. If the sy ern 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 appro riate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the uyer,if applicable and the approving authority. NOTES AND COMMENTS: ****This report only describes conditions at the time of inspection and un er 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. 1 n l 1 Property Address: 99 Wagon Lane-Hyannis,MA Client: Mr.William Smith,Esq. Date of Inspection: 7/24/01 INSPECTION SUMMARY: Check A,B,C,or D:, A)SYSTEM PASSES: X I have not found any information which indicated that the system violates any of the failure criteria as defined 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 operator has provided the system inspector with a copy of a Certificate of Compliance (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 exfiltration,or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipes(s)or due to a 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 of Health): broken pipes are replaced obstruction is removed Title 5 Inspection Form 6/15/2000 2 r -R I Property Address: 99 Wagon Lane-Hyannis,MA Client: Mr.William Smith,Esq. Date of Inspection: 7/24/01 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 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 the public water supplier,if appropriate)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 soil absorption system and is within 100 feet to a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water supply well,unless a well water analysis for 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. Method used to determine distance (approximation not valid). 3) Other Title 5 Inspection Form 6/15/2000 3 t i Property Address: 99 Wagon Lane-Hyannis,MA Client: Mr.William Smith,Esq. Date of Inspection: . 7/24/01 D)SYSTEM FAILS: You must indicate either"Yes"or"No"as to each of the following: 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 should be contacted to determine what will be necessary to correct the failure. Yes No Backup of sewage into facility or system components due to an overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6"below invert or available volume is less than%z day flow. _ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone 1 of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. 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. E)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 above: The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply _ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area(IWPA)or a mapped Zone II of a public water supply well. The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00.Please consult the local regional office of the Department for further information. t Title 5 Inspection Form 6/15/2000 4 Property Address: 99 Wagon Lane-Hyannis,MA Client: Mr.William Smith,Esq. Date of Inspection: 7/24101 Part B Checklist Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following: Yes No X _ Pumping information was requested of the owner,occupant and Board 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. Large volumes of water have not been introduced into the system recently nor 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 backup. 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,including the SAS;have been located on the site. X _ The septic tank manholes were uncovered,opened and the interior of the septic tank was inspected for conditions of baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum. The size and location of the SAS on the site has been determined based on: X _ Existing information.Ex.Plan at B.O.H. X _ Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable). [15.302(3)(b)]. X _ The facility owner(and occupants if different from owner)were provided with information on the proper maintenance of Sub-Surface Disposal system. Title 5 Inspection Form 6/15/2000 5 r Property Address: 99 Wagon Lane-Hyannis,MA Client: Mr.William Smith,Esq. Date of Inspection: 7/24/01 � 11 Part C � �9,,1•� System Information y FLOW CONDITIONS Residential: Design flow:110 g.p.d./be o�om f Number of bedrooms(desi n):4 Number of bedrooms(ac 1):3 Total DESIGN flow:462 . A - Number of current residents:4 Garbage grinder(yes or no):No Laundry(separate system) (yes or no):No If yes,separate inspection required. Laundry system inspected(yes or no): Seasonal use(yes or no):No Water meter readings,if available:(last two year usage(gpd): Sump pump:(yes or no):No Last date of occupancy:Present Commercial/Industrial: Type of establishment: Design flow: _gpd(Based on 15.203) Basis of design flow: Grease trap present:(yes or no): Industrial waste holding tank present:(yes or no): Non-sanitary waste discharged to the Title 5 system:(yes or no): Water meter readings,if available: Last date of occupancy: Other:(Describe): Last day of occupancy: GENERAL INFORMATION Pumping records and source of information:System was pumped in 1998 per owner. System pumped as part of Inspection?(Yes or no):No If yes,volume pumped: gallons Reason for pumping: Type of System: _X Septic Tank/distribution box/soil absorption system Single Cesspool Overflow Cesspool Privy Shared System(yes or no)(if yes,attach previous inspection records if any) I/A Technology etc'. Attach copy of up to date operation and maintenance contract? _ Tight Tank Copy of DEP Approval Other Approximate age of all components,date installed(if known)and source of information:This system was installed in 1984 per owner. The system is approximately 17 years old. Sewage odors detected when arriving at site:(yes or no):No Title 5 Inspection Form 6/15/2000 6 I Property Address: 99 Wagon Lane-Hyannis,MA Client: Mr.William Smith,Esq. Date of Inspection: 7/24/01 BUILDING SEWER: (locate on site plan) Depth below grade:Did not uncover Material of construction:_cast iron X 40 PVC_other(explain) Distance from private water supply well or suction line:Town water Diameter:4" Comments:(condition of joints,venting,evidence of leakage,etc.):No evidence of leakage SEPTIC TANK: X (locate on site plan) Depth below grade:Outlet cover is built up to deck elevation Material of construction: X Concrete _Metal _Fiberglass_Polyethylene _Other(explain) If tank is metal,list age . Is age confirmed by Certificate of Compliance_(yes/no) Dimensions: (1,000 Gallons) Sludge depth:1" Distance from top of sludge to bottom of outlet tee or baffle:23" Scum thickness:0 Distance from top of scum to top of outlet tee or baffle:6" Distance from bottom of scum to bottom of outlet tee or baffle:18" How dimensions were determined:Tape and sludge judge 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.) The outlet end of the septic tank has a precast baffle.Liquid level is at the outlet invert. No evidence of leakage. The structural integrity appears to be sound. The inlet cover is covered by a large deck. GREASE TRAP:N/A (locate on site plan) Depth below grade: Material of construction:_Concrete_Metal_Fiberglass Polyethylene_Other(explain) Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments: (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.) Title 5 Inspection Form 6/15/2000 7 r Property Address: 99 Wagon Lane-Hyannis,MA Client: Mr.William Smith,Esq. Date of Inspection: 7/24/01 TIGHT OR HOLDING TANK: N/A (Tank must be pumped prior to,or at time,of inspection): (locate on site plan) Depth below grade: Material of construction_concrete _metal _Fiberglass_Polyethylene Other(explain) Dimensions: Capacity: gallons Design Flow: gpd Alarm present Alarm level: Alarm in working order _Yes _No Date of previous pumping: Comments: (condition of inlet tee,condition of alarm and float switches,etc.): DISTRIBUTION BOX: X (locate on site plan) Depth of liquid level above outlet invert:0 Comments: (note if level and distribution is equal,evidence of solids carryover,evidence of leakage into our out of box,etc) The d-box is located under the deck. Were able to locate it with transmitter. PUMP CHAMBER: N/A (locate on site plan) Pumps in working order:(yes or no): Alarms in working order:(yes or no): Comments: (note condition of pump chamber,condition of pumps and appurtenances,etc): Title 5 Inspection Form 6/15/2000 g r Property Address: 99 Wagon Lane-Hyannis,MA Client: Mr.William Smith,Esq. Date of Inspection: 7/24/01 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,if possible. Excavation not required,but may be approximated by non-intrusive methods) If not located,explain: Type: Leaching pits,number: Leaching chambers,number: Leaching galleries,number: Leaching trenches,number,length: Leaching fields,number,dimensions:The leach field is approximately 25'x 25'as was determined by probing. Overflow cesspool,number: Alternative system: Name of technology: Comments: (Note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.)An observation hole was dug down 3'to the top of the field. The soil and stone above the field was dry. No evidence of hydraulic failure such as lush green growth, damp soil or soil staining. CESSPOOLS:_N/A_ (locate on site plan): Number and configuration: Depth of top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: .Materials of construction: Indication of groundwater inflow:(Cesspool must be pumped as part of inspection): Comments:(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY:— N/A-(Locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments: (Note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc): I Title 5 Inspection Form 6/15/2000 9 Property Address: 99 Wagon Lane-Hyannis,MA Client: Mr.William Smith,Esq. Date of Inspection: 7/24/O1 Subsurface Sewage Disposal System Inspection Form - Part C . .._. . System Information(continued) SKETCH OF SEWAGE DISPOSAL SYSTEM: Include des to at least two permanent landmarks or benchmarks. Locate all wells within 100'(locate where public water supply comes into house). 99 A �A�E DECK 0 1-AN IL 3Z n Ot',SE'2'v�AT1Ur�1 �1�:�� I..�AGH Title 5 Inspection Form 6/15/2000 10 Property Address: 99 Wagon Lane-Hyannis,MA Client: Mr.William Smith,Esq. Date of Inspection: 7/24/01 Subsurface Sewage Disposal System Inspection Form Part C System Information(continued) NRCS Report name: Soil type: Typical depth to groundwater: USGS Date website visited: Observation Wells checked: Groundwater depth: Shallow: Moderate: Deep: SITE EXAM Slope:None Surface water:None Check cellar:Yes Shallow wells:Unknown Estimated depth to groundwater: 16 Feet+/- 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 High Groundwater Elevation. Must be completed) The U.S.G.S.Quadrangle Map for Hyannis provides an elevation of 50.0 for this location. The bottom of the leach field is 4'below grade at elevation 46.0. The Cape Cod Commission's Groundwater Table Contour Map indicates that groundwater is at elevation 30.0. By subtracting elevation 30.0 from elevation 46.0,a separation of 16'is shown to exist between the bottom of the S.A.S.and groundwater. Note: The information contained herein represents our compilation of public records,our on-site inspection and third party hearsay information from the interviews conducted. No guarantees or warranties regarding the future performance of the system are expressed or implied beyond that which is represented. Title 5 Inspection Form 6/15/2000 1 1 Malone , Kathy From: Lt. Don Chase [dchase@hyannisfire.org] Sent: Friday,August 24, 2001 11:47 AM To: Maloney, Kathy Subject: Building issues Hi Kathy, 1) Voice Stream Wireless is all set for permit at Capetown Plaza. 2)199 Wagon Lane, Hyannis is_being_sold-8/30/2.0.0.1 Found illegal bedroom in basement w/o correct windows. Notified R.E. agent 3) 74 Estey Ave, Hyannis - renovations after a fire, permit #52260 Ok for final c/o. Alarm tested. Did you know there were bedrooms and a bath on the 3rd floor? The permit only says 2 floors. 4) HyannisPort Golf all set for building permit. Don 3/off I? Z JJ kc yS ., I 1 LOCA IONM SEWAGE PERMIT NO. VILLAGE p\�3-Q IS �. 1'S 1A €�E � ADDRESS I U1L_DEN OR. OWNS (j ® ATE P E R .IT OS.SO. ED DATE = G ® �P.LBAPICE ISSl1ED . O r ti �"R• y_ A,� R.R, 0 r a No ................ THE COMMONWEALTH OF MASSACHUSETTS BOARD__qF HEALTH .......... OF...... ............................ AVVftrativu for Uhipwial 1%rkii Tamitrurtiun Fa mil Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal Syst a .......... ............................................. ........... ............ ........ Addy or 0. .. ........ . . ............... 0 ne ess ....................... Address fStV, .jyst a or O'� T e f Building Size Lot.--- ....Sq. feet U Dwelling—No. of Bedrooms.........:........................_..........Expansion Attic Garbage Grinder ( ) Other—Type of Building ............................ No. of persons---------.-_---.__-_--_.--.- Showers Cafeteria ( ) Otherfixtures ---------------------------------------------------------------------------------------------------------....................................o......... Design Flow.............I.I.P....................gallons per person d -----------gallons. —Liquid capacit, rr.. ay. Total da��Iflow.......... ----------- . ....... 1:4 Septic Tank capacity_._(_.____gallons Length... .. ---- Width.... --------- Diameter.-.-..---.------ Depth..5-,V"' Disposal Trench No. .................... Width............._____._ Total Length Total leaching area----- .. .......sq. f t. Z inlet.._..........._. d...sq. ft. Seepage Pit No..ks ..... Diameter...... ........... Depth below Total leaching area.. Z Other Distribution box Dosing tank Percolation Test Results Performed by------------------------------------------ Date-:-_--..._______----io---------------- ... .... ........... W --- Test Pit No..I.../,-..2-..minutes per inch Depth of Te'st Pit... ... .............Depth to ground water..- -------- Test Pit No. 2................minutes per inch Depth of Test Pit-------.__--__-_-__- Depth to groufid water-..-----._-.-_--___----- ---------•----------- ---•-••-----•-.--------.....71......... ... .....:......... 0 Description of Soil. 0..L.2- 17 2- , co I E *........................... ............. ----------­-- .......... ....................................................................................... U --- .... ... ........._ ............... ---------------------------------------------------------------------- -_------------------------I-------------------------------------------------------------------------------- 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 T IT LE 5 of the State Sanitary Code— The undersigned further agrees not,to place4he system in operation until a Certificate of Compliance has be-, issued by the board of health. Compliance has be' Issue"by ------------- Date 0 s ....................---------- ------------ ........... Application Approved By- -------- .. .............. ........................................... ----------- ---- ------ .... ....... Date Application Disapproved for e fol wing reasons:................................................................................................................ ...................................................................................................................................................................................................... Date PermitNo........................................................ Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 0 ............................ TH 0 TrFY, That, the Individual Sewage Disposal �- em constructed�_�) or Repaired .. . ............ b ......... .. ......... ... .. . ................ ........................ ...... ------ ................................................................. y -- -------- ------------------ ... ....... ......... ---- ------- at.................... ------------ ....... ------ ------------------------­--------------------- has been installed in cordance with the prov is of '11'T of The S od s d in the _tate Sanitary _j/ r . .... ..... -- ------- application for Disposal Works Constructi7permi - -- ---- -------- 2-- -------- dated.. .. .... --- ­1... ........ THE ISSUANCE 9F THIS CER FICAT . SHALL NOT BE CON�S�UED AS A GUAR NTEE THAT THE SYSTEM'WILL IN N SATISFA Y. DATE.....)2,- Inspector . .. ......................................................................... ...... ........................................................ THE COMMONWEALTH OF MASSACHUSETTS BOAR or ;HE AI-TH "T .............OF......... . ........................ .......................... No...................... FEE.....(�.. 4W ....... Umpoloal . or Famit. Permiss.ibn:'is hereby r.. . ted.... .P....o.r.... � . .. ................. ....... to Construct r it an n i dual Sewag ispoS St6n atNo,....... .. . .................................................................................................. .... Street as shown ono the catio for Disposal Works Construction Permit No................ ­ D . ....... .......... .............. -- -------- ...................................... .......... ..........................................I........... Bo of Health DATE................... ...... ................................................. FORM 125 HOBBS & WARREN. INC., PUBLISHERS ,� ��1►�G?LC-. FAMt�Y - B�ORooM `,. o GARBAGE 62JWDER I�Mviati- Flow z t10 x 3 = 7-,306,PP it SEPT G TAtiK = 33oxt5o% ','49i6-PQ (I y51= I 000 GAL. o%5Po5AL P►'T v5E too GAL. �7v t5o 5.t= x �•5 - 3?5 G.Po 98t'4_ 97 /G _ 12.1 goTToM AREA= 0..6.F. o S.F 5a �►x t. o �• G.P o II -ToTA� �E.S1C�N = q25 G.PD. fir (� 'TOTAL pA I L-( FL-ov! - 33o G,Po 9 j, PE2GOLAT1o�! RATE ; 1 N 2MIN oR.L�55 Q 98, a RICHARD IL AN 4 qu BMTF.A j �im 24046 I t • rin. I II �Q�STB��QQ• a . 1 "1 5 II TE`�T �� _ 9�•U 7v5'7 1oo.0 ,. ^ / T /, ,Co fy I( 0 o INV. DUST. INS. GAL. �iEP'rIC. 97 Z i z I ovo INV. DuX 97 TANK y I' star LEAC. INV. INV. G. ✓� P IT WIT" I� I'/3A,-I Vi WASUGD 7 6To N t~ �2TIF•tGD PLOT PLAN PRoPIL I ►.t0 SCALE ScAt_G /��l�p �AT � y/�e3 1 CERTIFY 'T N AT T µ E PR-c��bx� k{�c.SNo IrYN _ - NERE011 GOMPL`(5 WtTN THE 'S t t>f J E-- ��T Ag 16, SETe4GK R.6Ru1R.EMEN7'> oF -tµE- -To W N CD F 13A2NS`r43� At-A-D 1 S I.I� ' /��'• LOcp.T P WtTNt�1 NE FLOOD PLAIN a DAT{r tG ( �u- BAxTEQ WYE INC- -Tuts PLar.t 1`5 WaT f3n5r n o'° AQ OSTE2VILLE - MASS 1 IW5TR.UMENT' Sv2VeY 'i' NE n1=FSETS No'T DE U5EDTo �ETEW�IN� �.o'r INES APPLICANT Sl /nlC SYSTEM PROFILE ALL MKE�D WITHCMAGNETICTTAP SHALL BE NOTES Route 28 1 COMPARABLE MEANS FOR FUTURE LOCATION. NOT TO SCALE) PROVIDE IF NECESSARY 1. DATUM IS APPROX. NGVD (GIS SPOT EL.) �o ACCESS COVERS TO WITHIN 6" OF FIN. GRADE C.I. COVERS TO GRADE H-�0 2. MUNICIPAL WATER IS EXISTING s o \ TOP FOUND. EL. 54.8' 2" PEASTONE OR GEOTEXTILE FILTER FABRIC OVER STONE 2% SLOPE REQUIRED OVER SYSTEM 53.0' 3. MINIMUM PIPE PITCH TO BE 1/8" PER FOOT. MINIMUM .75 OF COVER OVER PRECAST o PRECAST N-to 4. DESIGN LOADING FOR ALL PROPOSED PRECAST r a RISERS (�•) _Zo 4"0SCH40 PVC N MORT R1 ALL UNITS TO BE AASHO H-2Q Q Locus o°, ..;- 52.1. ��px PIPES LEVEL 1ST 2' 4' COMPONENTS I V' 1' 4' 5. PIPE JOINTS TO BE MADE WATERTIGHT. > tr et MID.) o EXISTING .9zNss Z r ENDS SIDES 49.61 s 10" 1000 GAL H-10 14" ➢000a0000 o° v6N CONSTRUCTION DETAILS TO BE IN ACCORDANCE � rteven TEE SEPTIC TANK TEE ���� �C]0® ���0 -���� '°°°°°°°° Mitehells > > o 0 0 0 > o 0 0 0 �- (RE-USE) °°°°°°°° OO�H >°°°°°°°° 310 CMR 15.000 (TITLE V.) ## o 0 0 0 0 0 0 0 0 0 0 0 0 o U O °°°°°°°°°°°° '00000000 a®oaoaoa000 aaoaa000000 ;°°°°°°°° N GAS BAFFLE '?o°°°°°o°o? N 'O°°°O°O° '>°o°o°o°o ��0����0@, Oooaaa000ao ,00000000 7. THIS PLAN IS FOR PROPOSED WORK ONLY AND 48.9' 48.73' 46.61 NOT TO BE USED FOR LOT LINE STAKING OR ANY OTHER PURPOSE. m Main " L H-20 500 GAL LEACHING CHAMBER BY ACME PRECAST OR EQUAL. 8• PIPE FOR SEPTIC SYSTEM TO SCH. 40-4" PVC. West Main St. St. DEPTH OF FLOW = 4' 3/4"-1-1/2 DOUBLE WASHED STONE (2) UNITS REQUIRED ae� TEE SIZES: 6" CRUSHED STONE OVERALL DIMENSIONS TO OUTSIDE OF STONE: 25' X 12.83' 9. COMPONENTS NOT TO BE BACKFILLED OR ONE OR MECHANICAL 5 P e COMPACTION. (1 .221 (2]) 24't CONCEALED WITHOUT INSPECTION BY BOARD OF INLET DEPTH = 10„ HEALTH AND PERMISSION OBTAINED FROM BOARD OUTLET DEPTH = 14" **THE INSTALLER SHALL VERIFY THE SEPTIC TANK SIZE AS MIN. OF HEALTH, nraD I=NGm15r_TL. 1000 GALLON AND ITS SUITABILITY FOR RE-USE. REPLACE 10. CONTRACTOR SHALL BE RESPONSIBLE FOR LOCUS MAP WITH 1500 GALLON H-10 IF FOUND UNSUITABLE. BOTTOM _ CALLING DIGSAFE (1-888-344-7233) AND 1.5% SLOPE 1 NO GROUNDWATER FOUND VERIFYING THE LOCATION OF ALL UNDERGROUND & % SLOPE ' ( ( ) SCALE 1 -2000 f OVERHEAD UTILITIES PRIOR TO COMMENCEMENT OF LEACHING (GROUNDWATER EXPECTED AT EL. 22'1) WORK. FOUNDATION EXIST. SEPTIC TANK 120' D' BOX 14' FACILITY 11. ANY UNSUITABLE MATERIAL ENCOUNTERED ASSESSORS MAP 270 PARCEL 197 SHALL BE REMOVED 5' BENEATH AND AROUND THE WP DISTRICT *THE INSTALLER SHALL VERIFY THE LOCATIONS OF ALL PROPOSED LEACHING FACILITY. UTILITIES AND ALL BUILDING SEWER OUTLETS AND ELEVATIONS PRIOR TO INSTALLING ANY PORTION OF SEPTIC SYSTEM 12. EXISTING LEACHING FACILITY SHALL BE PUMPED LEGEND AND REMOVED OR PUMPED AND FILLED WITH CLEAN SAND. 99- EXISTING CONTOUR X 99•1 EXIST. SPOT ELEV. 01 SYSTEM DESIGN. / 99 PROPOSED CONTOUR 3.66 RAISED 198•4] PROPOSED SPOT EL 'GARDEN GARBAGE DISPOSER IS NOT ALLOWED 52.46 TH1 53 DESIGN FLOW: 3 BEDROOMS ® 110 GPD = 330 GPD 4.07 TEST HOLE USE A 330 GPD DESIGN FLOW + .76 05 G 3.83 3. 2% SLOPE OF GROUND DGEy 9 AWN 53.5 } 82 >>6, SEPTIC TANK: 330 GPD (2) 660 UTILITY POLE 3.56 _ **RE-USE EXISTING 1000 GAL. SEPTIC TANK FIRE HYDRANT I 3.64 3. 3.84' i NOTE NOT ALL SYMBOLS MAY APPEAR IN DRAWING 3.48 LEACHING: 51.79 ti 52.3 -BOX/DECK �P 54 47ST�- 53.68 OH W 96t53.66 SIDES: 2 (25 + 12.83) 2 (.74) = 112 GPD +52')0 53.79 3.68 / BOTTOM 25 x 12.83 (.74) = 237 GPD TEST HOLE LOGS 3.64 / 3.06 TOP FNDN / TOTAL: 472 S.F. 349 GPD 'c EL.=54.8' ii ENGINEER: DAVID FLAHERTY, R.S., SE2755 FIELD?? EXIST. LOT 168 // USE (2) 500 GAL. LEACHING CHAMBERS (ACME OR EQU L) 192 i DECK DWELLING 10,093 SFt =j WITH 4' STONE ALL AROUND WITNESS: DONNA MIORANDI, IRS 2.84 53.97Q- DATE- JULY 14, 2008 �� SHED < 2 MIN INCH PERC. RATE - CLASS I SOILS P# 12278 x ® 4 \ W---E�3 S / �Q' MA 3.44 GAs 3.29 APPROVED DATE BOARD OF HEALTH 5 .9' GARAGE / \ 3 49METER / PROVIDE APPROX. 27' OF 40 MIL LINER ELEV. ELEV. 85 / 6 AT 5 OF SAS IN AREA SHOWN. TOP „ 4 , X N 2.53 -�����` Y �� / AT EL. 49.6', BOTTOM AT EL. 45.6' TITLE 5 SITE PLAN p 53.0 p 53.0 k J3 +2_3.30 / OCkADX ENCf A- // g H1 DRIVEL Cqs C pF f� \ 0--�52.83 ��//__55 i 5 4 FILL FILL 5 52.$(T2.85 TH 52.87 s" s" / / 99 WAGON LANE 4-151 HYANNIS B B BENCHMARK: NAIL SET 95 p3 "� -+' /0- LS LS IN FENCE AT EL. 53.5' S2.68 / PREPARED FOR 10YR 5/6 p 75, 10YR 5/6 27" 30" 50.5' / PROP. VENT WITH CHARCOAL FILTER { 52 51 AND BUGSCREEN (FINAL PLACEMENT BY B & B EXCAV. CONTRACTOR WITH HOMEOWNER CONSULTATION) DULY 14, 2008 C C PERC Scale: 1 20' MS MS VARIANCES FOR SEPTIC SYSTEM REPAIRS WHICH MAY BE IMMEDIATELY GRANTED BY THE BOARD OF HEALTH AGENT OR 0 10 20 30 40 50 FEET BY HEALTH INSPECTOR PAPERWORK AND HEARING REDUCTION PROPOSALS APPROVED 1OYR 7/4 10YR 7/4 BY THE BOARD OF HEALTH REVISED DURING A PUBLIC �titt1oFM�ss ��HOFAgSs off 508-362-4541 HEARING HELD ON NOVEMBER 15, 2005 �y qo fax 508-362-9880 2) FAILED SYSTEMS ONLY: SEPTIC.SYSTEM COMPONENT TO ��o� DANIEL yGfi ��� DANIELA. tiG�� I downcape.com FOUNDATION SETBACK, IF AN IMPERVIOUS LINER IS DESIGNED o A. o OJALA AND INSTALLED. " OJALA " CIVIL codown cope engineering, MC. 3 FAILED SYSTEMS ONLY : SOIL ABSORPTION SYSTEM 4t3980 N°.46502 120" 43.0' 126" 42.5' ) �� civil engineers INSTALLATIONS PROPOSED MORE THAN THREE FEET BELOW r ° Fsso°� °� `� rsT NO GROUNDWATER ENCOUNTERED GRADE WITH PROPER VENTING (PIPED TO THE ATMOSPHERE) 7�ly�� qy sulzvE�° L G, / Ian surveyors AND WITH H-20 LOADING, BUT IN NO CASE SHALL THE SAS / 939 Main Street ( Rte 6A) BE LOCATED MORE THAN FIVE FEET BELOW GRADE. DATE DANIEL A. OJALA, P.E., P.L.S. YARMOUTHPORT MA 02675 08- 15 >