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HomeMy WebLinkAbout0062 WEST HYANNISPORT CIRCLE - Health 62 West'Fiyan�osport Cir, Myann- is- P3 A A 267 135 A - z' l' r — Commonwealth of Massachusetts. Title 5 Official In pection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ' •. 62 West H annisport Circle Property Address Roseann Hill Owner Owner's Name information is required for every Hyannis I MA 02601 10/11/13 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist.at the end of the form. Important:when filling outforms q. General Information on the computer, use only the tab. 1. Inspector: .. key to move your- - _ __ _. .. cursor-do not Matthew F.: Gilfo keY e the return Name of Inspector B&B Excavation,.Inc. � Company Name ..14 Teaberry Lane Company Address Forestdale .... .. MA:. 02644:::. City/Town State Zip Code (508)477-0653 SI-13640 Telephone Number .. . License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based-on my training and experience. in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15:340 of Title 5(31.0 CMR 15.000). The system: ® Passes. ❑ Conditionally Passes ❑ .Fails El Needs Further Evaluation by the Local:Approving Authority. 10/11/13 Inspector's Signatur Date The system;inspector shall subrnit.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 DER 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. : - - l5ins•3113 Title 5Offcial Inspection ubsurface Sewage Disposal System.•Page 1 of 17 r Commonwealth.of Massachusetts Title 5 Official Inspec ion Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 62 West H annis ort.Circle y p Property Address Roseann Hill Owner Owner's Name information.is required for eve ryHyannis MA 02601 10/11/13 Clty/Town page. - State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check :A,B,C,D:or::E/a/ways.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: El 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 ortank failure is imminent. System will pass inspection ifthe existing tank is replaced with a complying septic tank as approved bythe 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. El Y. ❑ N El (ND (Explain below) l5ins•3113 I.Title,5 Official Ins Form:Subsurface Sewage Disposal System-:Page 2 of 17 Commonwealth.of Massachusetts _ Title 5 Official Inspection : For Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 62 West H annisp ort.Circle Property Address Roseann Hill Owner Owner's Name information is required for every Hyannis MA 02601 . 10/11/13 page. City/Town. State Zip Code Date of Inspection B. Certification (con..) ❑ Pump Chamber pumps/alarms not operational.System will pass with Board of Health approval if pumps/alarms'are repaired: _B) System Conditionally Passes(cont.): ❑::.Observation of sewage backup or breakout or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will ass inspection if with p p approval of Board of Health): _. F1:.: ::. broken:pipe(s).are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): distribution box is leveled or replaced P ❑ Y El::N ❑ ND (Explain below): El The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health):... broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction.is removed ❑ Y ❑ .N ❑ ND (Explain below): C). Further Evaluation is Required by the Board of Health: _.. . .... .... El 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.: . ... ... . System will,pass unless Board of Health determines in accordance with 310 CMR 3 1 b)that the system is not functioning in a manner which will protect public health; safety and the environment: El Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt.marsh t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-.Page 3 of 17 Commonwealth_of Massachusetts F Title 5 Official Inspection Form a m Subsurface Sewage Disposal System Form - Not for Voluntary Assessments a 62 West' Hyannisport.Circle Property Address Roseann:Hill Owner Owner's Name . information is -- required for every Hyannis MA 02601 10/11/13 page. City/Town: State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier; if any) determines that the system is functioning in a manner that protects the public health, safety and environment:. The:system has a septic tank and soil absorption system (SAS)and the SAS:is within 100 feet of:a surface water supply or tributary to a surface water supply. PP.Y. ❑ 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:5:0,feet of a:private water supply well ❑ The system has,a septic tank and SAS and the SAS is Tess 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 Iaboratory, for fecal coliform.bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: _.... D) System Failure criteria Applicable to All Systems: You must indicate "Yes" or"No to each of the following for all inspections: Yes No El Backup of sewage into facility or system component due to overloaded or ® clogged.;SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters i 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^h day flow t5ins•3113 Title.5 Official Inspection Form:Subsurface Sewage,Disposal System,•Page 4 of 17 Commonwealth of Massachusetts. m W Title 5 Official In pection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °,, •`'V 62 West H annis ort.Circle y p Property Address Roseann Hill Owner Owner's Name information is required for every Hyannis MA 02601 . page. City/Town 10/11/13 State Zip Code Date of Inspection B. Certification (cont.) Yes:::: No : :::: 0.. ® 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 below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary_to a surface water supply. ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. El Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if,the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates:absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no.other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] The system is a cesspool serving a facility:with a design flow of 2000gpd-: ❑ ®.. 10,000gpd e system fails. I have determined that one or more of the above failure criteria exist as described in310 CMR 1.5.303, 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_ ....... g 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 20.0 feet of a.tributary to.a surface.drinking water supply . Elthe system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-:LWPA)or a.mapped Zone 11 of a:public water supply well If you have answered "yes"to any question in Section E the.system is:considered a significant threat,, or answered "yes" in Section D above the large,system has failed. The owner or operator of.any large system considered a significant threat under.Section E:or:failed under Section:D shall upgrade the: system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office.of the Department... t5ins-3/13 Title.5 Official Inspection Form:Subsurface Sewage Disposal System—Page 5 of 17 Commonwealth of Massachusetts - - 9 W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments w, 62 West Hyannisport.Circle Property Address Roseann Hill Owner Owner's Name - .. Information is required for every Hyannis MA 02601 . 10/11/13 _ Clty/Town page: State Zip Code: Date of Inspection C. Checklist ...Check if the following have.b.een done.:You must indicate or"no' as to each of the following: Yes: .. . No ... 0. 0:::. Pumping information was provided by the owner, occupant, or Board of Health ❑ [9 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? El 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 differentfrom owner)provided with - information on the proper maintenance of subsurface sewage disposa.I systems? The size and location of the Soil Absorption System,.(SAS) on.the site has een.determined based:on: _. .... .... .... ® ❑ Existing information. For example, a plan at the Board of Health.: ® ❑ Determined in the field(if any.of the failure criteria related to Part C is at issue _. _.approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential:Flow Conditions: Number of bedrooms(design): 3: Number.of.bedrooms (actual):.. 3 DESIGN flow based on 310 CMR 15.203(for example: 110:gpd x#of bedrooms): ._ — 330 thins•3/13 Title 5 Official Inspection Form:Subsurface Sewage;Disposal System_•Page 6 of 17 Commonwealth of Massachusetts. W Title 5 Official Insp ection. For m Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 62 West Hyannisport Circle Property Address --_- . Roseann Hill Owner Owner's Name information is required for every Hyannis MA 02601 10/11/13 page: CltylTown::. State Zip Code Date of Inspection D. System Information Description: umber of current residents. - -- - _. 0 Does residence have a garbage grinder? El Yes ® . No . Is laundry on a separate sewage system?(Include laundry system inspection information in this report.) ❑ Yes N No Laundry system inspected? ❑ Yes ® No _ Seasonal uses ❑ Yes ® No Water meter readings, if.available.(last 2 years usage(gpd)): Detail: Sump pump?. Yes ® No Last date of occupancy: Sept. 2013 Date. Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd):. Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present?. Yes: ❑ No Industrial waste holding tank present? El Yes ❑ No Non-sanitar waste discharged to the:Title 5:s tem? : .: y s: .... g y . ❑: Yes El_:No Water_meterreadings, if available: t5ins 3113 'Title Official Inspection Form:Subsurface Sewage:Disposal Systen-Page 7 of 17 Commonwealth of Massachusetts _ W Title 5 Offic.ial Inspec ion Form a A Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 62 West H annisport Circle Property Address Roseann Hill Owner Owner's Name . information is required for every Hyannis MA 02601 . 10/11/13 Clty/Town page. State Zip Code - Date of Inspection D. System.Information (cont.) Last date.of occupancy/use:::::- . . Date - Other.(describe.below): General Information Pumping Records: .. Source of information: Was system pumped as part of the inspection? ❑ Yes ❑ No If yes, volume pumped: gallons .. . How was quantit y y pumped determined. „ Reason for pumping: Type of System: Septic tank, distribution box, soil absorption system ❑ Single:cesspool ❑ Overflow cesspool ❑ Privy El Shared system (yes or no)(if yes, attach previous inspection records,:if.any) ❑ Innovative/Alternative technology. Attach a copy of the current operation_and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under.contract ❑ Tight tank. Attach a copy of the DEP approval... Other(describe): l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage,Disposal System-Page 8 of 17 Commonwealth.of Massachusetts _ W Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments p ° • . 62 West Hyannisport Circle Property Address Roseann Hill Owner: Owner's Name information is required for every H anni5 MA 02601 10L1.1 L13 page. Clty/Town.. State Zip Code Date o-Inspection D. System .Information (cont.) :Approximate age:of all components, date:installed (if known) and source of information: 2003 . .... Were sewage odors detected when arriving at the site? :: Yes.® No . Building Sewer(locate on site plan): Depth below grade; 32" feet Material of construction: ❑ cast iron 40 PVC _ ❑ other(explain): Distance from private water supply well or suction line: 10' feet . _._. Comments on condition of joints, venting,evidence of leakage, etc.): At time of inspection buildin sewer appears to be in working condition No sign: .of leakage Septic Tank(locate on site plan): : Depth below grade: 2"8" 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 R. No i 5'8"x5'8"x10'6" 1500 _. Dimensions:.: ( gallon) . ... Sludge depth:.. no sludge t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage:Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Fora e _. Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 62 West Hyannisport Circle Property Address oseann Hill Owner Owner's Name information is required for every Hyannis MA 02601 10/11/13 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle no sludge Scum thickness . .... no scum Distance from top of scum to top of outlet tee or baffle no scum .. Distance from bottom of scum to bottom of outlet tee or baffle no scum How were dimensions determined? scour stick Comments (or).pumping recommendations; inlet and outlet tee or.baffle condition, structural integrity, liquid levels as related:to outlet invert, evidence of leakage, etc.): At time of in septic tank appears to be structurally sound No sign of leakage. Grease Trap(locate on site plan)-.. . Depth below:grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass 9 El polyethylene El other(explain): Dimensions: Scum thickness . ... .... Distance from top of scum to.top of outlet tee or baffle istarice from. bottom of scum to bottom of outlet tee or:baffle I Date.of last pumping: - Date l5ins•3/13 Title 5.Official Inspection,Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts _ Title 5 Official Inspection Form e a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °�• 62 West H annisP ort Circle Property Address Roseann Hill Owner Owner's Name information is required for every Hyannis b MA 02601 10/1.1113 page: City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle-condition, structural integrity, liquid levels as related to outlet invert, evidence:of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan): Depth below grade: Material of construction: ❑ concrete _. . .::::. ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): ... ... ... ... Dimensions:: : Capacity: gallons Design Flow: gallons per day Alarm present: El 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. l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System.Page 11 of 17 f Commonwealth of Massachusetts ... .. Title S Official Inspection Form m Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 62 West H annisp ort.Circle Property Address Roseann Hill Owner Owner's Name information.is required for every Hyannis MA 02601 page. City/Town. . 10/1.1/13 State Zip Code Date of Inspection D. System.Information (Cont.) Distribution Box(if,present_must be opened)(locate on site=plan): ..Depth of liquid level above:outlet invert 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.): At.time of inspection d-box appears to be structurally.sound. No sign of solid carryover or leakage. _. Pump Chamber(locate on:site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: Yes. Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.j: * If pumps or alarms are not in working order; system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation .not required): If SAS not located; explain w.liy;. t5ins•3/13 Title.5-Official Inspection Form:Subsurface Sewage Disposal System.Page 12 of 17 f Commonwealth of Massachusetts.. Title 5 Official Inspection Form Sub surface Sewage Disposal System Form Not for Voluntary Assessments •'` 62.West p H annis ort.Circle y Property Address Roseann Hill Owner Owner's Name information is required for every Hyannis MA 02601 page. Cltyrrown.: 10/11/13 State Zip Code Date of Inspection D. System.Information (Cont.) Type: ❑ leaching pits number: leaching:El chambers::: - number'.. ® leaching galleries number 5 ❑ leaching trenches :number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool . P 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.): At time of inspection leaching appears to be in working order& is dry. No si ns of hydraulic failure .. Cesspools (cesspool must be pumped as part of inspection)(locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer.. Dimensions of cesspool Materials of construction ... Indication of groundwater inflow ❑: Yes ❑ No t5ins•3/1.3 ... ._.. Title 5 Official Inspection Form:Subsurface Sewage Disposal System:-Page 13 of 17 : Commonwealth of Massachusetts • f Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments `N •`'` 62 West Hyannisport Circle Property Address Roseann Hill Owner Owner's Name information is required for every Hyannis MA 02601 . page. City/Town: 10/11/13 State Zip Code Date of Inspection D. System Information (cont.) _. Comments (note condition.of soil, signs,of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on;site plan): Materials of construction: Dimensions .... Depth o solids Comments (note condition of soil, signs of hydraulic.failure, level of ponding, condition of vegetation, etc.);- ....... . . . .. t5ins•3/13 Title.5.Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth.of Massachusetts N Title 5 Official Inspection Form - Subsurface Sewage Disposal System Form - Not for Voluntary Assessments e 6.2 West H annis ort.Cimle y p _ . Property Address Roseann Hill Owner Owner's Name information is required for every Hyannis MA 02601 10/11/13 page. Clty/Town. . State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System:.Provide a view of the:sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks Locate all wells within 100 feet. Locate where. public water supply enters the:building. Check one of the boxes below: ® hand-sketch in the area below drawing attached.separately - cgrra10 A i I _B — 32 6' M- 22'0tt i5ins•3/1.3 . ._.. Title 5 Official Inspection Form:Subsurface sewage.Disposal System-Page 15 of 17 Commonwealth.of Massachusetts _ W Title 5. Official Ins pection.:Form m Subsurface Sewage Disposal System Form- Not for Voluntary Assessments a °° . 62 West Hyannisport Circle Property Address Roseann Hill Owner Owner's Name information is required for every Hyannis MA 02601 . page. City/Town 10/11/13 .::State ::Zip Code Date of Inspection _ D. System Information (cont.) Site Exam: ® Check Slope. .:Surface water - Check cellar ® Shallow wells.:::: _.Estimated depth:to high ground water: 12. feet. Please indicate:all methods used to determine the high ground water elevation: Obtained from system design plans on record If checked, date of design plan reviewed` 5/30/03 Date ❑ Observed site(abutting property/observation.hole within 150 feet of SAS) El Checked with local Board of Health -explain: El .. Checked with local excavators, installers -(attach documentation) Accessed US.GS database -explain: You must describe how you established the high ground water elevation: Before filing this Inspection Report, please see Report.Completeness Checklist:on.next page. t5ins•3/13. .. .. .. .. .. . .. .... .... Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 Commonwealth of Massachusetts N - W Tithe 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 62 West Hyannisport.Circle Property Address Roseann Hill Owner Owner's Name information is required for every Hyannis MA 02601 10/1.1/13 page. City/Town - -- - State Zip Code- - Date of Inspection E. Report Completeness Checklist ® Inspection Summary:A, B, C, D, or E checked: ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System:information Estimated depth to:high groundwater, Sketch of Sewage Disposal:System either drawn:on page 15 or attached in separate file t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 i 22:51 5084289334 EXCLUSIVE BROKERAG PAGE 14 L003 11:47 5085480796 CARMEN E SHAY ENVIRO PAGE 13 /• M i Permit Numbers Date r Completad by: HIGH QROUND-WATER LEVEL COMPUTATION i Site Location; Owner: Lot No, IS Address;_ prr,16 Contractor: Address: �I Notes: i 'i STEP 1 Measure depth to water table to nearest 1/lo ft..............................:.................. Dote / ,....._.---....... ..... .month/ v/re■r ��. STEP 4 Using Water-Level Range zone is and Index Well Map locate site and determine: � Mtt.o `� Appropriate index well.................... ...................... .. _ ® Water-tevel range zone...................... l STEP 3 Using monthly report"Current Water Resources Conditions" determine current depth to Water level for Index well........................... b mon /year - 1 -STEP 4 Using Table of Water-level Adjustments for index well(STEP 2A), current depth to water lever for index well (STEP 3), and water-level nano(STEP 28) determine water-level adjustment ............................................. z I................. i STEP 5 Estimate depth to hign water by subtracting the water• level adluatnlent(STEP 4) from measuled depth to water j level at site(STEP 1) ....................................... . ©.3 ;I ..................... ............ .......,..............._... � fr II Fi M 13.--RePmducklIe computaum fo* II , 15 �' I, i r _ 22:51 5084289334 EXCLUSIVE BROKERAG PAGE 13 03 11:47 5085480796 CARMEN E SHAY ENVIRO PAGE 12 Page 11 of l I OFFICIAL INSr ECTION-FORM—NOT FOR VOLtTNTARX A,SSESSMEN'>('S PART C I7ON suBSURFACE SEWAGE DISPOSAL SYSTEM INBPEC FORM SYSTEM INFORMA'HON(continued) AddrmR: West Avap rt Chvig Owner: Steven Emberes Date of Insp�on; 3/4/03 -- . SM ZXAM Slope swfwe water Check cellar •Yes Shallow wells—None Betimated depth to granw water 12 feet(below grade with 4ud f,) Please"cam(check)all methods used to determine the high Sound water elevation: Obtained ffmn MICM design plan an record-If checked,daft of design plan reviewed: .XX Observed site(abutting property/ob tion hole within 15o feet of SAS.) Checked with local Board of Haan-explain: Checked with focal excavators,inatalicrs-(attuh documentation) 7C^Accessed USGS database-explain: You mutt describe how you establlshed the high ground water elevation: SJtecked trltb Ovadrau k of USGS M'o-No evklen of a Lteotd in leach of f yh_ ki is 9 feet to hones hem d Per ftwoble GIs; El".of Ground-22 Feat Elev.Of GrovedwaW=8 Feet El".Of Bottom of Leack Trench-17 Feet T lemfore: 17'—8'=9 feet separation between Bottom of Leach Trench and Groundw&W. Groundwater Adjilttfeent ttsfug Index Wcll MIW29: S,$het Adjusted Groundwater Separation-8'+2.3=a0 3 teed (Refer to attached work sheet) Grade=Merv.22 fbet Leach Trench D-Box 1,000 gallon Tank Bottom of Leach TMDch Flev, 17 foot , 6.7'sepmatiOn w/4USt at. st Adj.Growtdwa w=lrlev, 10.3 Feet COMMONWEALTH OF MASSACHUSETTS F EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS d DEPARTMENT OF ENVIRONMENTAL PROTECTION RECEIVED e� MAR 1 2 2003 TOWN OF BARNSTABLE HEALTH DEPT. TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION . . MAP Property Address: #62 West Hyannisport Circle PARCEL 13� Hyannis,MA Owner's Name: Steven Gembory's LOT Owner's Address: 62 West Hyannisport Circle Hyannis,MA 02601 Date of Inspection: 2/28/03 Name of Inspector: (please print) Mr.Carmen E.Shay Company Name: Shav Environmental Services; Inc. Mailing Address: 34Thatchers Lane East Falmouth, MA 02536 Telephone Number: (508)-548-0796 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: XX Passes • . Conditionally Passes z i 1a 0 Needs Further Evaluation by the Local Approving Authority .d - y Fails `,: AR f= E. i4 Inspector's Signature: Date: 3/7/03 The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health o 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greate , ESINSF inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original shou to the system owner and copies sent to the buyer, if applicable,and the approving authority. Notes and Comments: BASED ON A DETERMINATION BY THE BARNSTABLE BOARD OF HEALTH AND BRIAN DUDLEY OF MA DEP. SYSTEM DOES NOT MEET ANY FAILURE CRITEREAREFER TO NOTES BELOW. AT THE REQUEST OF THE PROSPECTIVE BUYER&WITH PERMISSION OF THE OWNER,a determination of capacity of the septic system was performed Based on calculations of stone around and under infiltrators,THE SAS WAS DETERMINED TO BE DEFICIENT IN CAPACITY BY 30 GALLONS per DAY. No evidence of backup noted in D-Box. Excavated two areas of SAS and found no evidence of ponding,or saturated soil. Installed new observation port. Witnessed repair of tank leak at center seam. The entire center seam was re-sealed with hydraulic cement by owner. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 Page 2 of 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: #62 West Hyannisport Circle Hyannis,MA Owner:. Steven Gembory's Date of Inspection: 3/4/03 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: XX I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: AT THE REQUEST OF THE PROSPECTIVE BUYER& WITH PERMISSION OF THE OWNER a determination of capacity of the septic system was performed. Based on calculations of stone around and under infiltrators,THE SAS WAS DETERMINED TO BE DEFICIENT 1N CAPACITY BY 30 GALLONS per DAY 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 detenmined"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 distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: Page 3 of 1 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: #62 West Hyannisaort Circle Hyannis,MA Owner: Steven Gembory's Date of Inspection: 314103 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. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: T:tlo G T--t;— F,'— All v1001) 3 Page 4 of 1 l OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: #62 West Hyannisport Circle Hyannis,MA Owner: Steven Gembory's Date of Inspection: 3/4/03 D. System Failure Criteria applicable to ail systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No XX Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool XX Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool XX Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool _ XX Liquid depth in cesspool is less than 6"below invert or available volume is less than '/z day flow XX Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped _ XX Any portion of the SAS,cesspool or privy is below high ground water elevation. XX Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. XX Any portion of a cesspool or privy is within a Zone 1 of a public well. _ XX Any portion of a cesspool or privy is within 50 feet of a private water supply well. _ XX Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] NO (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd• You must indicate either"yes"or"no"to each of the following. (The following criteria apply to large systems in addition to the criteria above) yes no the system is within 400 feet of a surface drinking water supply _ 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—1 WPA)or a mapped Zone 11 of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. T;tlA ; T--ti- t7--,,, 4/1 4 Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: #62 West Hyannisport Circle Hyannis,MA Owner: Steven Gembory's Date of Inspection: 3/4/03 Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No XX Pumping information was provided by the owner,occupant,or Board of Health XX Were any of the system components pumped out in the previous two weeks ? XX Has the system received normal flows in the previous two week period XX Have large volumes of water been introduced to the system recently or as part of this inspection? XX _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) XX _ Was the facility or dwelling inspected for signs of sewage back up? XX Was the site inspected for signs of break out'? XX _ Were all system components, excluding the SAS, located on site? XX _ 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 ? XX _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: Yes no XX _ Existing information. For example,a plan at the Board of Health. XX _ 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 Page"6Qf 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: #62 West Hyannisport Circle Hyannis,MA Owner: Steven Gembory's Date of Inspection: 3/4/03 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Number of current residents: unk. Does residence have a garbage grinder(yes or no): No Is laundry on a separate sewage system(yes or no): No [if yes separate inspection required] Laundry system inspected(yes or no): N/A Seasonal use: (yes or no): unk. Water meter readings, if available(last 2 years usage(gpd)): 2002—4,488 gallons Sump pump(yes or no): No 2001 —28,424 gallons Last date of occupancy: Currently Unoccupied COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no):_ Industrial Waste holding tank present(yes or no):_ Non-sanitary waste discharged to the Title 5 system(yes or no):_ Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: None on File Was system pumped as part of the inspection(yes or no):_ If yes, volume pumped: gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM XX 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,date installed(if known)and source of information: 1998-per Board of Health&Owner Records Were sewage odors detected when arriving at the site(yes or no): No T41. 6 Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: #62 West Hyannisport Circle Hyannis,MA Owner: Steven Gembory's Date of Inspection: 3/4/03 BUILDING SEWER(locate on site plan) Depth below grade: 24" Materials of construction: XX cast iron XX 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: XX (locate on site plan) Depth below grade: 1611 Material of construction: XX concrete_metal_fiberglass_polyethylene —other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions: 5' deep x 5'wide by 10' long (1500 gallon) Sludge depth: 4. 75' Distance from top of sludge to bottom of outlet tee or baffle: 3.00' Scum thickness: No significant Scum Laver Noted Distance from top of scum to top of outlet tee or baffle: scum laver was below tee initially due to tank leak which was later repaired—see notes. Distance from bottom of scum to bottom of outlet tee or baffle: See notes How were dimensions determined: Measured Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): 3' Liquid was originally observed in tank prior to repair,Structural integrity of tank was originally believed to be deficient and leaking at center seam Owner had tank seam repaired Repair work was witnessed by inspector. Entire center seam was hydraulically cemented No evidence of any other cracks leaks, or water infiltration/exfiltration after repair was performed 4" PVC Tee present and in good condition Outlet Tee also in good condition. GREASE TRAP:_(locate on site plan) Depth below grade: Material of construction:_concrete_metal_fiberglass_polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage,etc.): T;tIA G lno —t;. Pin„ All c/7MIl 7 I Page 8 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: #62 West Hyannisport Circle Hyannis,MA Owner: Steven Gembory's Date of Inspection: 3/4/03 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/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: Present (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.): No evidence of solids carryover or back-up. D-box structurally sound. One outet to SAS present PUMP CHAMBER: (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no):_ Comments(note condition of pump chamber,condition of pumps and appurtenances,etc._ Page 9 of 1 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: #62 West Hyannisport Circle Hyannis,MA Owner: Steven Gembory's Date of Inspection: 3/4/03 SOIL ABSORPTION SYSTEM(SAS): XX (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits, number:_ leaching chambers,number: leaching galleries, number: XX leaching trenches,number, length: 1 Trench—10.5' wide by 28 feet long, 1.5' deep. leaching fields, number, dimensions: overflow cesspool, number: innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): No evidence of hydraulic failure ponding damp soil or stressed vegetation. Stone was dry around SAS. Based on limited excavation and probing around SAS the system is believed to only be sized for 300 gallons per day capacity. SAS dimensions are believed to be 28' Long, 10.5'wide by 1. 5 eff. depth. New observation port installed at time of inspection 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 or 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.): Tit]. 1; Ino..—t;— 9 Page 10 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: #62 West Hyannisport Circle Hyannis,MA Owner: Steven Gembory's Date of Inspection: 3/4/03 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent Swine Ties: reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. A- Tank In—25.75' B- Tank In— 15' A-Tank Out—30.7' B -Tank Out— 17.4' A-D-Box—32.5' B-D-Box— 19.5' A—Obs. Port—37.5' B—Obs Port—28.4' Exist. House B O O Septic Tank (1500 Gal.) D-Box Leach Trench Titles G 1--ti— T n— All 4;11nn1) 10 Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: #62 West Hyannisport Circle Hyannis,MA Owner: Steven Gembory's Date of Inspection: 3/4/03 SITE EXAM Slope Surface water -None Check cellar -Yes Shallow wells—None Estimated depth to ground water 12 feet(below grade with adjustment.) 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: XX 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) XX Accessed USGS database-explain: You must describe how you established the high ground water elevation: Checked with Quadrantile of USGS Map-No evidence of any liquid in leach pit which is 9 feet to bottom from grade Per Barnstable GIS: Elev. of Ground=22 Feet Elev. Of Groundwater=8 Feet Elev. Of Bottom of Leach Trench=17 Feet Therefore: 17'—8' =9 feet separation between Bottom of Leach Trench and Groundwater. Groundwater Adjustment using Index Well MIW29: 8.8 feet •Adjusted Groundwater Separation=8' +2.3 = 10.3 feet (Refer to attached work sheet) Grade=Elev. 22 feet Leach Trench D-Box Bottom of Leach Trench=Elev. 17 feet 1,000 gallon Tank 6.7' separation w/adjustment. Adj.Groundwater=Elev. 10.3 Feet Title, G T--ot;n Pn 411 v1nnn 11 Permit Number: Date: Completed by: HIGH GROUND-WATER LEVEL COMPUTATION Site Location: (ol UVeSN -Nsp2s2t CZc_LiE Lot No. Owner: C rti,�!n� �Address: 16 Contractor: Address: Notes: STEP 1 Measure depth to water table tonearest 1/10 ft. .............................................................................. .Date CJ o month/ y/Year STEP 2 Using Water-Level Range Zone and Index Well Map locate site and determine: M%W OAppropriate index well.................................................... Z OWater-level range zone ..................................................... C STEP 3 Using monthly report "Current Water Resources Conditions" determine current depth to water level for index well 03 ` mon /Year STEP 4 Using Table of Water-level Adjustments for index well (STEP 2A), current depth to water level for index well (STEP 3), and water-level zone (STEP 2B) 2 . 3 determine water-level adjustment .......................................................................................... STEP 5 Estimate depth to high water by subtracting the water- level adjustment (STEP 4) from measured depth to.water levelat site (STEP 1) ..................................................:.......................................................... I, Figure 13.—Reproducible computation form. 15 Cape Cod Commission: USGS Well Data - February 2003 Page 1 of 2 United States Geological Survey Observation Wells As a service to Cape officials, engineers and other interested parties, the Cape Cod Commission publishes monthly groundwater data gathered by its Water Resources Office. The water level measurements shown below are taken monthly from United States Geological Survey (USGS) observation wells and compiled during the last week of each month. They are published as soon as possible thereafter. Listed below are nine out of the 61 wells measured across Cape Cod by the Commission's Water Resources Office. These nine are employed as index wells to be used with Technical Bulletin 92-001 to predict high groundwater levels. For your convenience, we've also provided links to USGS national and state data. See the last column in the table and the footnotes below. For further information, please contact Hydrologist Gabrielle Belfit at the Commission offices (508-362- 3828). February 2003 L`S(;S Site Water Record Record Departure from 'umber**'.Y Location Well No. Level* High* Low* Average** (links to [!SGS Monthly Overall national water-level database) Barnstable 230 23.4 20.5 26.6 0.0 0.3 413956070164301 Barnstable 24W 25.7 20.5 28.6 -1.0 =1.1 414154070165001 Brewster BMW 21 12.1 6.9 13.6 -1.7 -1.9 414518070020301 Chatham CGW 138 23.4 20.9 26.6 0.6 0.6 414100070011101 Mashpee MIW 29 7.4 5.6 10.0 1.0 1.1 413525070291904 Sandwich SDZ 47.2 45.9 48.2 0.2 0.1 4144180.70241601 Sandwich SDW 52.8 45.8 55.1 -2.5 -2.7 414124070265901_ 253 Truro TSW 89 11.3 10.2 13.0 0.5 0.7 420206070045901 Wellfleet WNW 17 10.2 7.3 12.8 0.2 0.2 415353069585401. http://www.capecodcommission.org/wells.htm 3/5/2003 03/07/2003 09:48 5085480796 CARMEN E SHAY ENVIRO PAGE 02 ppp COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMZNT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: #62 West Hyannisoort Circle Hyannis,MA Owner's Name: Steven Gemborv's Owner's Address:W 62 West Hvannisport Circle Hyannis,MA 02601 RECEIVED Date of inspection: 2/28M3 Name of inspector: (please print) Mr.Carmen E.Shay MAR 1 2 2003 Company Name: Shay Environnnyental Services.Inc. Mailing Address: 4 Thatchers Lilac TOWN OF BAkI,_ East Falmouth,MA_ 02536 HEALTH nFP-r Telephone Number: f5081-548-0796 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: XX Passes Conditionally Passes M; N Needs Further Evaluation by the Local Approving Authority s9 Fails . A Inspector's Signature: Date: 3/7/03 E 0 The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or great s INE inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original shou to the system owner and copies sent to the buyer, if applicable.and the approving authority. Notes and Comments: BASED ON A DETERMINATION BY THE BARNSTABLE BOARD OF HEALTH AND IAN DUDLEY OF MA DEP. SUIEM DOES NOT MEET ANY FAILURE CRITEREAREFER TO NOTES BELOW. 4 -:3h/Os AT-ME REOUES1 OF THE PROSPECTIVE BUYER&WITH PERMISSION OFT E OWNER a determination of capacity of the septic system was Performed. Based on calculations of stone around and under infiltrators THE SAS WAS DETERMINED TO BE DEFICIENT IN CAPACITY BY 30 GALLONS per DAY. No evidence of backup noted in 13-13ox. Excavated two areas of SAS and found no evidence of ponding,or saturated soil. Installed new observation port. Witnessed repair of tank leak at center seam. The entire center seem was re-sealed with hydraulic cement by owner. •••*This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page I 03/07/2003 09: 48 5085480796 CARMEN E SHAY ENVIRO PAGE 03 Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 462 West Hyannisuort Circle Hyannis.MA Owner: Steven Gemborv's Date of Inspection: 314/03 Inspection Summary: Check A,B,C,D or E/A_ LWAYS complete all of Section D A. System Passes: ,XX I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: _ AT THE REQUEST OF THE PROSPECTIVE BUYER&WITH PERMISSION OF THE OWNER a determination of gspacityof the septics as perrormed, Based on ions of stone around and under inflitrators.THE SAS WAS DETERMINED TO BE DEFICIENT IN CAPACITY B LLONS per DAY 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 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: Tiflo l..cnArtinn G..—4/1 Q/lAnA 2 03/07/2003 09:48 5085480796 CARMEN E SHAY ENVIRO PAGE 04 Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: #62 West Hyannisport Circle HYannis,MA Owner: _ Steven Gemborv's _ Date of Inspection: 3/4/03 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. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered_A copy of the analysis must be attached to this form. 3. Other: Titln i T.�cnnM:nn r-. 4/14/1AAA 3 ,o03/05/2003 11:47 5085480796 CARMEN E SHAY ENVIRO PAGE 02 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address:_ 062 West Hyannisnort Circle _ Hyannis,MA _ Owner's Name: Steven GejQorv's Owner's Address: _._ _ 62 West Hyannisoort Circle Hyannis.MA 92§91_ Date of Inspection: 2/28/03 Name of Inspector:(please print) Mr.Carmen E.Shay Company Name: Shay Env_!umeptal Services,Inc. Mailing Address: 34 ThatShers Lane East Falmouth.MA 02146 Telephone Number: 15081-54&0796 CERTIFICATION STATEMENT 1 certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: Passes _ Conditionally Passes XX Needs F luation by the Local Approving AuthoritytN Fails T— � A Inspector's Signature: Date: 3/4/03 The system inspector shall submit a copy of this inspection report to the.Approving Authority(Board of Health h R F9 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or gre inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original s to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments: SYSTEM TECHNICALLY DOES NOT MEET ANY TITLE FAILURE CRITEREA. HOWEVER Al REQUEST OF'LOCAL'APPROVLNG AUTHORITY.FURTHER EVALUATION BY BOARD OF iHEALIH WAS REQUIRED. t AT THE REOUEST OFT F PROSPECTIVE BUYER&WITH PERMISSION OF THE OWNER,a determination of capacity of the septic system was performed, Based on calculations of stone around and under infiltrators,THE SAS WAS DETERMINED TO BE DEFICIENT IN CAPACITY BY 30 GALLONS per PAX. No evidence of backup noted in D-Box. Excavated two areas of SAS and found no evidence of ponding,or saturated soil. Installed new observation port. Witnessed repair of tank leak at center seam. The entire center seam was re-sealed with hydraulic cement by owner. '""'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 some or different conditions of use. Title 5 Inspection form 6/15/2000 page 1 "03/05/2003 11:47 5085480796 CARMEN E SHAY ENVIRO PAGE 03 �n3 Page 2 of 11 �t( OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS r Y SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM f v PART A CERTIFICATION(continued) Property Address: ##62 West Hyannisportle Hymanis,MA Owner: Steven Gemborv's Date of Inspection: 3/4/03 Inspection Summary; Check A,B,C,D or E/ALWAYS complete an or Settion 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 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: •n.i it... .. ... +. .... rsihnnn 2 `03/05/2003 11:47 5085480796 CARMEN E SHAY ENVIRO PAGE 04 Page 3 of I I SOP ti OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: #62 WiLt Hyannispoll Circle HmIIK MA Owner: Steven Gembory's Date of hapection•� / — 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. I. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone I of a public water supply. _ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is less than Ioo 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 eolifor•m bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.,A,copy of the analysis must be attached to this fbrm. 3. Other: SYSIEM TECHNICALLY DOES NOT MEETN LE V FAILURE CRITEREA,HOWEVER AT MUEST OF LOCAL APPROVING AUTHMTY,FURTHER EVALUATION BY BOARD OF HEALTH WAS REOUIRED. AT TgE.REOUEST OF THE PROSPECTIVE BUYER&WITH PERMIS31ON OF THE Owr4E!La diterminadyn of cadatift of the w0c system was 2irformed. Based Qq calculations of tMat around and under iatiltrataM THE SAS WAS DZTEELMINED TO BE DEFICIENT IN CAPACITY BY.1 GALLOIYS..ner DAY. T;+1n i T—Z—+inn T1nrm rm 4mnr#1 3 I `03/05/2003 11:47 5085480796 CARMEN E SHAY ENVIRO PAGE 05 Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR.VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: West Hyankport Circle H n A Owner: Steven GembonLla Date of]Inspection: 3/4/03 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for Al inspections: Yes No XX Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool AN Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool X.� Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool Y C Liquid depth in cesspool is less than b"below invert or available volume is less than '%;day flow XX Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped XX Any portion of the SAS,cesspool or privy is below high ground water elevation. XX Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. XX Any portion of a cesspool or privy is within a Zone 1 of a public well. XX Any portion of a cesspool or privy is within 50 feet of a private water supply well. XX 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 duality analysis.,ffbis system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this forma NO (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd- You must indicate either`yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no the system is within 400 feet of a surface drinking water supply 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—1 WPA)or a mapped Zone 11 of a public water supply well 1f 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. T'�1�Y G IMPMA/.Y�/M L'AMM��1GMAM 4 `03/05/2003 11:47 5085480796 CARMEN E SHAY ENVIRO PAGE 06 Wage 5 of l l '�X'0/ 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS � SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: "2 t Hynouisport Circle Ownis MA Date of Steven Gembory°s Date of inspection: 3/4/03 Check if the following have been done. You must indicate" es"or"no"as to each of the following: Yes No XX Pumping information was provided by the owner,occupant,or Board of Health M Were any of the system components pumped out in the previous two weeks? XX Has the system received normal flows in the previous two week period? XX 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) XX L Was the facility or dwelling inspected for signs of sewage back up? . X Was the site inspected for signs of break out ? 7U _ Were all system components,excluding the SAS,located on site? XX _ 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" XX _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no X T Existing information.For example,a plan at the Board of Health. XX _ 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)] Titlt C Tnonsrti�n R......fl1IMAM 5 `03/05/2003 11:47 5085480796 CARMEN E SHAY ENVIRO PAGE 07 Page kof 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: $062 West Hyannisport Circle _ Hyannis,MA Owner: Steven Gemborv's Date of Inspection: /4/O FLOW CONDITIONS RESIDENTIAL. Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 Number of current residents: unk. Does residence have a garbage grinder(yes or no): No Is laundry on a separate sewage system(yes or no): No (if yes separate inspection required] Laundry system inspected(yes or no): N/A Seasonal use:(yes or no): unk Water meter readings,if available(last 2 years usage(gpd)): 2002—4,488 gallons Swap pump(yes or ono):No_ 2001 —28,424 gallons Last date of occupancy: Currently Unoccupied COMMERCIALANDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no): Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION . Pumping Records Source of information: one on File Was system pumped as part of the inspection(yes or no): If yes,volume pumped:gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM _t_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,date installed(if known)mad source of information: 12M per Board of Health&Owner Records Were sewage odors detected when arriving at the site(yes or no): No R '03/05/2003 11:47 5085480796 CARMEN E SHAY ENVIRO PAGE 08 Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: #62 Wig HyannispQrt circle n' MA Owner: n G 's Date of Inspection: &"3 BUILDING SEWER(locate on site plan) Depth below grade: 24" Materials of construction:feast iron X7-40 PVC other(explain): Distance from private water supply well or suction line._ Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: XX (locate on site plan) Depth below grade: f 6"_ Material of construction: XX concrete metal_fiberglass __polyethylene _otber(explain) If tank is metal list age:— Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of certificate) Dimensions: 51 deepiEwide ft 10' 1500 llon Sludge depth: 4.751 Distance from top of sludge to bottom of outlet tee or baffle; 3.00' Scum thickness: No siguifigzat Scum JAyer Noted Distance from top of scum to top of outlet tee or baffle: scum Inver was bekw tee initially to tank Rea which was later repaired—see notes. Distance from bottom of scum to bottom of outlet tee or baffle: See notes How were dimensions determined: Measured Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): �9'Uould vas originally observed In tank prior to raWr.Singwmi iftarity of tgnk wn u1nally and baking at center amm.Owner had tank a.rm rwalmd.RID&work wet wftr *mW blf loam w W Rr_Entire center saran MathydMulically cwnented. No eyid%n o of any other cracks. !N t,.o►water 1rvfihmdonhM tration afbr nmsir wag performed. 4"PVC TM present and In good aga tton. Outlet Tee also In good eontlitlon. GREASE TRAP:—(locate on site plan) Depth below grade:— Material of construction:—concrete—metal— fiberglass_polyethylene—otter (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): 7 .03/05/2003 11:47 5085460796 CARMEN E SHAY ENVIRO PAGE 09 Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:_ #6x West Hyannisnort Circle Hyannis. Owner: Steven Gemboals Date of Inspection:.. 3/4/03 TIGHT or HOLDING TANK: (tank must be pumped at time of inspectionXiocate on site plan) Depth below grade: Material of construction: concrete metal fiberglass,_polyethylene other(explain): Dimensions: Capacity: --__gallons Design Flow: Gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc_): DISTWBUTION BOX:. Present (if present must be openedXlocate 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.): No evidence of solids cirryover or back-un. D-box structurahv sound. One outet to SAS present PUMP CHAMBER: _ (locate one 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,etch 8 .03/05/2003 11:47 5085480796 CARMEN E SHAY ENVIRO PAGE 10 Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: #62 West lRyannisportCircle fta"is,MA Owner: Sleven Gemborylls Date of Inspection: 3/"3 SOU.ABSORPTION SYSTEM(SAS):-XX _(locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number:_ leaching chambers,number: leaching galleries,number: X leaching trenches,number,length: 1 Trench-10.51 wide by 28 feet ion deep. leaching fields,number,dimensions: overflow cesspool,number: innovativetalternative system 'type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): No evidence of hydraulic failure,000ding damp soil or stressed vegetation Stone was dry around SAS. Bond on limftsd excavatio-n-n-ad-2robing around SAS,the system is ieved to only be sir&d for 300 gallons r day caipacity. SAS dimensions are k1lieved to be ZS'Lm 10.51wid by 1.5 cft,depth. New observatign wort installed at time of inspection, CESSPOOLS:—(cesspool must be pumped as part of inspeetionxlocate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer.• Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: (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.): T:eta S «n«sne:n«V^—1./1GMnAA 9 ,03/05/2003 11:47 5085480796 CARMEN E SHAY ENVIRO PAGE 11 Page 10 of l 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: "2 Wcst H.Vannisport Circle is MA Owner: _ Steven Gembo , 's Date of Inspection:_ 3/4/03 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent Swing Tom: reference landmarks or benchtnaft,Locate all wells within 100 feet.Locate where public water supply enters the building. A- Tank In—25.75' B- Tank In—15' A-Tank Out—30.7' B-Tank Out— 17.4' A-D-Box—32.5' B-D-Box— 19.5' A—Obs.Port—37.5' B—Obs Port—28,4' Exist. House B Septic Tank (1500 Gal.) D-Box Leach Trench . . .....,,,,.. 10 -03/05/2003 11:47 5085480796 CARMEN E SHAY ENVIRO PAGE 12 Page I I of 1 I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: #62 Wed Hyannisportcle Bxmnni&M Owner; Steven bo 's Date of Inspection: SITE EXAM Slope Surface water -None Check cellar -Yes Shallow wells—None Estimated depth to ground water 12 feet(below grade with adjustment) 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 playa reviewed: XX Observed site(abutting property/observation hole within 150 fleet of SAS) Checked with local Board of Health-explain: Checked with local excavators,installers-(attach documentation) XX Accessed USGS database-explain: You must describe how you established the high ground water elevation: Checked with Ouadrangle of USGS Map-No evidence of any liquid in leach pit which is 9 feet to bottom from Grade. Per Barnstable GIS• Elev.of Ground-22 Feet Elev.Of Groundwater=8 Feet Elev.Of Bottom of Leach Trench=17 Feet Therefore: 17'—8'=9 feet separation between Bottom of Leach Trench and Groundwater. Groundwater Adjustment using Index Well MIMI: 8.8 fat Adjusted Groundwater Separation=8'+2.3=10.3 feet (Refer to attached work sheet) Grade=Elev.22 feet Leach Trench D-Box Bottom of leach Trench=Elev. 17 feet 1,000 gallon Tan1c 6.7'separation I w/adjustment. Adj.Groundwater=Elev_ 10.3 Feet •03/05/2003 11:47 5085480796 CARMEN E SHAY ENVIRO PAGE 13 R Permit Number: Date: Completed by: HIGH GROUNDVATER LEVEL COMPUTATION Site Location: (01 West ��n��p_p�� CIQ_ Lot No, Qwnev: _. ?__C:i -C �.�„c„�is Address: Contractor: .`."•'� Address: Notes: STEP 1 Measure depth to water table to nearest 1/10 ft. .............................................................................. .Date month/ y/year STEP 2 Using Water-Level Range Zone and Index Well Map locate site and determine: Ms� G) Appropriate index well.................................................. Z t"S� Water-level range zone ..................................................... STEP 3 Using monthly report"Current Water Resources Conditions" determine current expel to M , water level for index well ........................... -•�' mon /year STEP 4 Using Table of Water-level Adjustments for index well (STEP 2A),current depth to water level for index well (STEP 3), and water-level zone (STEP 28) determine water-level adjustment ..............................................:........................................... 2.3 STEP 5 Estimate depth to high water by subtracting the water- level adjustment (STEP 4) from measured depth to.water 1�• levelat site (STEP 1) ..................................................;.,...,..........................,.,.,..................... / J; Pjljiure 11--Reproducble computation form, 15 '03/05/2003 11:47 5085480796 CARMEN E SHAY ENVIRO PAGE 14 `Cape Cod Commission: USGS Well Data-February 2003 Page 1 of 2 United States Geological Survey Observation Wells As a service to Cape officials,engineers and other interested parties,the Cape Cod Commission publishes monthly groundwater data gathered by its Water Resources Office. The water level measurements shown below are taken monthly from.United States Geological Survey (USGS)observation wells and compiled during the last week of each month. They are published as soon as possible thereafter. Listed below are nine out of the 61 wells measured across Cape Cod by the Commission's Water Resources Office. These nine are employed as index wells to be used with Technical Bulletin 92-001 to predict high groundwater levels. For your convenience,we've also provided links to USGS national and state data. See the last column in the table and the footnotes below. For further information,please contact Holoogist Gabrielle Belfit at the Commission offices(508-362- 3828). 7HMlItlM W IN4tlh�lpyLyLpqp{11pmM12:1111mwgIN1111N:7B1A411MhmmLif/61M.N�Ny1LLILpqLwmdkLLlJNLx(�LyNlggpiA{{NINIMtlkyLL7L February 2003 USGS Site WaterDeparture from Number**** Level Location Well No. Level* Record Record Average" (links to USGS High Lp�' Monthly Overall national water-level database) Barnstable 23U 23.4 20.5 26.6 0.0 0.3 413956070164301 Bar�astable 24W 25.7 20.5 28.6 -1.0 -1.1 414154070165001 Brewster IiMW 21 12.1 6.9 13.6 -1.7 -1.9 414518070020301 Chatham CGW138 23.4 2Q.9 26.6 0.6 0.6 4141000700111.01 Mashpee M1W 29 7.4 5.6 10.0 1.0 1.1 413525070291904 Sandwich D� 47.2 45.9 48.2 0.2 0.1 4144180702.4_.1.6_01.. Sandwich SD3 52.8 45.8 55.1 -2.5 -2.7 414124070265 01. Truro TSW 89 11.3 10.2 13.0 0.5 0.7 4202060700455201 Wellfleet WNW 17 10.2 7.3 12.8 0.2 0.2 4� 5.3 3062585401 httlD://www.camcodwmmission.org/wells.htm 3/5/2003 TO OF BARNSTABLE V S s� LOCATION w t/Ge.6 c1 eSEWAGE # - ®®�`o !II.LAGE aV N t ASSESSOR'S MAP & LO INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY. S�® LEACHING FACILITY: pe) A S (size) NO. OF BEDROOMS tie BUILDER OR OWNER /� + S +, ® rf 0 5 PERMITDATE: ® t COMPLIANCE DATE: m Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet I 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 ' f l C�_ � � �`, � _ i �� � ( N r/' �- �� _ ������ .. C� � Q �' � $ �� � r► ►; y, ►� 1� „ �.�. �, �-���. �� -. ;ty � a � � _ i� Ll No. 2003' � � Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS ZippYication for Migonl 6peum Congtruction Permit Application for a Permit to Construct( )Repair( )Upgrade(✓f Abandon( ) El Complete System KIndividual Components Location Address or Lot No. Owner's Name,Address and Tel.No. &-2- ICJ. n'lce, Ci e--G� L-K--A L-yONLS � A7) Assessor's Map/Parcel l3� ✓►1¢a rJv�� `�O �7� Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. lz_rt H CDY,s-A_ruX-+i csrl U t-�,A GCS Sa-� cis ab�s ve-) Type of Building: Dwelling No.of Bedrooms 5 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow �� gallons per day. Calculated daily flow gallons. Plan Date M atA 03 Number of sheets Revision Date Title Size of Septic Tank 1,500 Type of S.A.S. J. 11YV i•f'7-4- Dy]� G %5fby - Description of Soil I'1' c&'A� Nature of Repairs or Alterations(Answer when applicable) cep c-^ oj N' tom, f+M.foY i`{k S a ' _<kVfY_1 orl CL.— 4. fl;ne+4& sue. Ul � •�o `',� Ism I i„�, x Date last inspected: -F26 2.i5l o 2, Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Envir ovnental Code and not to place the system in operation until a ertifi- cate of Compliance has been iss th. Signed Date 0 Application Approved by J& S Date 6M 1 3 Application Disapproved for the following reasons Permit No. w o 3-- Date Issued 3 --------------------------------------- r t Fee t, THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS • Ytcai'owfdF.Di!5paa1 *p6tem Construction Permit Application for a Permit to Construct( )Repair( )Upgrade(VfAbandon( ) ❑Complete System WrIndividual Components Location Address or Lot No. Owner's Name,Address and Tel.No. ' Cot W. rti��c���- :r cl+z._ L1 L_ycvnl5 �Gna� Assessor's Map/Parcel 2s� -1 i ) ` i✓r�z�- �t7g 1�p Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Type of Building: ; ( ` Dwelling No.of; edrooms 't 5, Lot Size sq.ft. Garbage Grinder( ) Other. Type of-�Buil&4 .' No.of Persons Showers( ) Cafeteria( ) Other Fixtures ` Design Flow + 3 + gallons per day. Calculated daily flow gallons. Plan Date M&A "._?;0, l b3't Number of sheets Revision Date Title Size of Septic Tank A 'C o a -Z Type of S.A.S. 5 !%►IR I+rx*n r- -� Description of Soil �rV &,,W � . Nature' of Repairs or Alterations(Answer when applicable) ojlrvl ,c,,'' Oj ku'C'Q o,-A YA fur WTi'k I ' 4 y CM `--� on 3rd C.Ln—. o-W -iQ Iso !iroc, J•box. Date last inspected: 'FLL6 28q o 3 Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Envirorental Code and not to place the system in operation until a ertifi- cate of Compliance has been issued-by this Bo o e4th. Signed Cati.��s�"'"° - Date Application Approved by S Date F Application Disapproved for the following reasons Permit No. 2003_ Date Issued (d 3 3 T�E COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of (Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired (�Upgraded( ) Abandoned( )by at 2 tIInc te, has been constructed n * cordance with the provisions of Titi 5 and the for Disposal System Construction Permit No. la)3—Z'-1-'/dated ° Installer + Designer i / r" The issuance#of thin ertnit shall not be construed as a guarantee that the syste 1;1'�cti m (�,gn4 DateP Inspector � � No. 2co J 2Ll Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE} MASSACHUSETTS Mizpooar *p5tem Construction Permit Permission is hereby granted to C•nstru t( )Repair O U grade( )Abandon( ) System located at r � F LfQ,ryl SDo�-� ` r If and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Co nst cti d n must be completed within three years of the date of this permit. Date:_ �) Approved by FORM3o HOBBS&WARREN,INC. THE COMMONWEALTH OF MASSACHUSETTS �Jl W i B D F EAJ = W rly LIM. AA EPA N /MA #DFrES§ GSM SvO y`e�I. r A iL v r - ® TELEPHO Address OcYAn Floor Apartment'No. No.of Occupants No.of Habitable Rooms No.Sleeping Rooms No.dwelling or rooming.unit tor' e Name and address of owner Remarld Reg. Vio. YARD Out Bld s.: Fences: _ Garbage and Rubbish' Containers: a' Infestation Rats or othe : STRUCTURE EXT. Steps,Stairs, Porches: Dual E ress:and Obst'n.: ❑ B ❑ F ❑ M Doors,)Ni do s Roof IA Gutters, Drains: 0- 11 ;Ono III Walls: Foundation: Chimney:_ BASEMENT Gen.Sanitation: Dampness: Stairs: Li htin STRUCTURE INT. Hall,Stairwa Obst'n.: a c Hall, Floor,Wall,Ceiling: Hall Lighting: Hall Windows: v HEATING Chimneys: Central ❑Y ❑ N Equip. Repair TYPE: . Stacks, Flues,Vents: PLUMBING: Supply Line: ❑ MS ❑ ST ❑ P Waste Line: , H.W:Tanks Safety and Vent(s) ELECTRICAL Panels,Meters,Cir.: ❑ 110 11220 Fusing,Grnd.: AMP: Gen.Cond. Distrib. Box: Gen. Basement Wiring: DWELLING UNIT Ventil. L to . Outlets -Walls Ceils. Wind.gDoorsoors. Locks Kitchen- - Bathroom Pant n Den V Living Room Bedroom 1 � . Bedroom 2 Bedroom 3 Bedroom 4 Hot Water Facil. Sup.Ten.,Gas,Oil, Elect.. Stacks,Flues,Vents,Safeties: Lk Alld)VIVI Kitchen Facilities Sink Stove' o o Bathing,Toilet Facil. Vent., Plumb.,Sanit'n:: Wash Basin,Shower or Tub: Infestation Rats, Mice, Roaches or Other: Egress Dual and Obst'n: General Building Posted Locks on Doors:ONE OR MORE OF THE VIOLATIONS CHECKED ABOVE &A CONDITION WHICH MAY MATERIALLY IMPAIR THE HEALTH OR SAFETY AND WELL—BEING OF THE OCCUPANT AS DETERMINED BY 105CMR 410.750 OF THE CODE 'OR THE AUTHORIZED INSPECTOR.(See Over) "THIS INSP CTION REPORT SIGNED-AND CERTIFI UNDER TH PAINS AND PENALTI PERJURY." g INSPECTOR /'�, L A.M. DATE TIME' C� P.M. THE NEXT SCHEDULED REINSPECTION A�V���, 6- ) A.M. P.M. 410.750: Conditions Deemed .to-Endanger or.Impair Health=Safety The following conditions,.when•found to exist in residential premises, , shall be deemed conditions which may endanger or impair the health, or safety and well-being of -a Person or-persons occupying the premises. This listing' is composed of these items which are deemed to always have the potential to endanger or materially impair the,health.or safety, .and well-being of the +., occupants or the public. Because Chapter II, 105 CMR -410.000 through 410.499 ' . state minimum requirements of fitnessifor human habitation, any violation has the potential to fall within' this caiegory•in•any given situation but may not do so in every case 'and therefoie�cannot be included.•,in this listing. ' Failure to include shall in no way be construed as.a'determination that other violations may not be found to fall within this category. Nor shall. failure to include affect the duty of the local health official to order repair or correction of the violations) pursuant to, 410 CMR 410.830 through 410.833 nor shall'it affect the legal obligation of the person,to whom the order is issued to comply with such order. (A) Failure to provide a supply of water sufficient in quantity, pressure and temperature-,both'hot and cold, to meet the ordinary needs of the occupant In. accordance with'105. CMR '410.180 and-410.•l90 for a period of 24 hours•or ^.longer. _ (B) ^Failure',to-providel.heit)as required by 105 OIR 410.201 or improper 3 ( venting or use of, a;space he v r.(orr water heater as prohibited by 105 CMR 4.10.200(B) and.410.202 i t :(C) Shut-off and/orrfailure,to restore electricity or gas. (D) Failure• to supply the electrical facilities required by 105 CMR 410.250(B), 410.251(A),-410.253(A), 410.253(B) and the lighting in common area required by 105 CMR 410.254. r '(8) Failure to provide a safe supply of water. �(F) . Failure to provide a toilet and maintain a sewage system in operable -�.. 11 .:condition.,as,required by 105 CMR 410.150(A)(1) and 440.300. :(G) - Failure to provide adequate exits, or the obstruction of any exit, passageway or common area caused by ran object; including garbage or trash, - which prevents egress in case� of an emergency 105 CMR 410.450 and ,410.451. (H) -Failure-to comply with the-security requirements of 105 CMR 4110.480(D). Failure to comply with any provisions of 105-CMR 410.600 through 410.602 :.:Alch.results-in.any accumulation of garbage, rubbish, filth-or other causes ' lid sickness which-may provide a food source .or harborage for rodents, insects .or other pests or otherwise contribute to accidents or .to the creation or :spread of disease. (J) The presence of lead-based paint on a dwelling or dwelling unit in .violation of the Massachusetts Department of Public Health Regualtions for Lead-Poisoning Prevention and Control 105 CMR 460.006. ' ;(S) 'xoof,'foundation, or-other structural-defects that may expose the oc"pant.or•anyone• else to fire, burns, shock, accident or other dangers or impair6nt to health =or dafety.j' Failure to install<electrical, plumbing, heating and gas-burning faciliiiisiin accordance with,accepted-plumbing, heating, .gas-fitting and electrical wiring standards or ,failure. to maintain such facilities as ' are requireNbq 105 CMR•410:351-and 410.352 so as to expose the occupant anyone-else to fire, burns, shock, accident' or other danger or impairment _ ._`to:health or safety. (M) Any of the•folloving�condiciona which remain uncorrected for a period i of five or more dagsyfollowing the notice-to or knowledge of the owner ' of said condition or conditions: (i)'``lack of a kitchen sink of sufficient size and capacity for washing dishes and kitchen utensils or lack 'of a.stove and oven _; t C or any defect that renders)either.bperable. (2) failure to provide 'a"washbasin and a shower or bathtub as required in 105 CMR 410.150(A)(2) and 410.150(A)(3) and •any defect which renders them inoperable. (3) . any defect in the electrical, plumbing;' or heating system which makes such.system or any, part `thereof in violation of generally accepted plumbing heating,• gas-fitting, or electrical wiring standards that do not create an immediate hazard. ;,(r)_ �,faiiure to maintain a safe handrail or .protective railing for every stairway, porch balcony, roof or similar place as required by 105 CMR 410.503(A) and 410.503(B). (5) failure to -eliminate rodents, cockroaches, insect infestations and other pests as required by 105 CMR 410.550. (N) Amy other violation of Chapter II not enumerated in 105 CMR 410.750(A) through .(M) shall be deemed, to be a condition which may endanger or materially impair the health or safety and well-being of an occupant upon the failure of the .owner to remedy said condition within the time.so ordered•by the board of health.. TOWN OF BARNSTABLE V bOCATION I VN �-�s SEWAGE # 7 V"--LAGE U ''^ - ASSESSOR'S MAP & LOT D A 7- /3,5J ' INSTALLER'S NAME&PHONE NO ' ��. s f' SEPTIC TANK CAPACITY' ' ,500 I:EAC &FACILITY: (type) �`/ 04I Mh4o/L5 (size) � II NO.OF BEDROOMS BUII DER�OR OWNER w PERMIT DATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility, (If any wells exist on site or within 200 feet of leaching facility) Feet Edge.of Wetland and Leaching Facility(If any wetlands exist . within 300 feet of leaching facility). Feet '4; Furnished by i II ED DID ,1 •' v No. ,�tL—�r _ Fee _ THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS ZIpphration for 3Bi_4po!5a1 *pgtem Congtruction Permit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) >:Complete System O Individual Components Location Address or Lot No. Owner's Name,Address and Tel.No. Assessor's Map/Parcel J� _ —, F_Y\A Z 0 PLY Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow �� gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank 1 � CRC CLk j Type of S.A.S. cc,,o Description of Soil Nature of Repairs or Alterations(Answer when applicable) S`'f 0, v OT 5 T` tl Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 the E7He ' ' en Code and not to place the system in operation until a Certifi- cate of Compliance has bee ' u d by � Signed_ Date Application Approved by Date f —?1r Application Disapproved for the foll ing reasons Permit No. 7// Date Issued ..«..�+^` _.-y. .P•�ar.w .... ab�,;.v*f��'`sw..t�". "'A't,Y✓f`#�Y✓dY'�'i .-*n'. _ No. / fl >•� _...`• Fees"o `1 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION,-.TOWN OF BARNSTABLE., MASSACHUSETTS 01pprication,lor Mi-4potal *potent Construction Permit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) Complete System ❑Individual Components Location Address or Lot No. Oj-t�-S—T' c.,v*.P 6 PoQ( Owner's Name,Address and Tel..No. Assessor's Map/Parcel C V\AB O 2Y Installer's Name,Address,and Tel.No. ' Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ), Other Type of Building No.of Persons Showers( )t;Cafeteria( ) Other Fixtures ` 'i Design Flow gallons per day. Calculated daily flow gallons. Date Plan D Number of sheets Revision Date Y a Title if Size of Septic Tank 1 � C,Lk j Type of S.A.S• _.�N Cc a( t`1' Description of Soil &�515 x Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system. in accordance with the provisions of title 5 f theme E�vineen ode and not to place thesystem in operation until a Certifi- cate'of Compliance has beenissued by iaar of He Si ne ` Date g`9p-) Application Approved by Q Date I(- �4 9K Application Disapproved for the foll ing reasons f, �y Permit No. - -7// Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY},tth�at the On-site Sewage Disposal System Constructed( )Repaired( )Upgraded Abandoned( )by CERTIFY, \t -'G�1� S CPI L at --( v Gi'✓rUe Chas been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. M- ?a dated Installer Designer The issuance of this permit shall not be construed as a guarantee that the system will u`nction as designed. Date f r L) - '` Inspector l � I --......_. _ k`:....= ...............--,---. _. .------------ .-, --. .. No. 7 :7 Fee '�t7 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS Mfi6pool *pg;tem Cots trurtion Permit Permission is hereby granted to Construct( )Repair( )Upgrade 0-/-)Abandon( ) System located at to,-4- u_)e_<_T- Gc, c S 49/o Ct'✓c�. . l.L S.i a L✓2. F and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided: Construction must be completed within three years of the date of this permit. Date: t f- 4- Approved by ��� 1ON/97 f a NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT ENGINEERED PLANS) { 1, � , hereby certify that the application for disposal works construction permit signed by me dated �J— 7 ��1� - concerning the property located at LC�V'.V (Dt' CA(-Je , meets all of the ' I following criteria: i Ll There are no wetlands located within 100 feet of the proposed leaching facility i There are no private wells within 150 feet of the proposed septic system There is no increase in flow and/or change in use proposed There are no variances requested or needed. ...�.._:.,._ /I f the proposed leaching facility will be located within 250 feet of any wetlands,the bottom of the proposed leaching facility will p4.t be located less than fourteen(14) feet above the maximum adjusted groundwater table elevation. Please complete the following: 1 '( A)Top of Ground Elevation(according to the Engineering Division G.LS. map) B)Observed Groundwater Table Elevation(according to Health Division well map) SIGNED: DATE: Lf f: LICENSED SEP4 SYSTEM INSTALLER 1N THE TOWN OF BARNSTABLE NUMBER j I t (Attach a sketch plan of the proposed system. Also if the licensed installer posesses a certified plot plan, this plan should be submitted]. I —_q:health folder;ew ` ��� .f r :� p �e .�. �© 0 ; � _ _ _ TOWN OF BA.RNSTABLE 1 LOCATION >9 W 1 � SEWAGE.# VILLAGE � 's'� ✓�� ASSESSOR'S MAP & LOT : In 7- /:3,5 INSTALLER'S NAME&PHONE NO. � SEPTIC TANK CAPACITY -/S-00 LEACHING.FACILITY: (type) L/ l/Iwh4alkizS (size)' NO.OF BEDROOMS BUILDER OR OWNER j PERMTTDATE: - - COMPLIANCE DATE: 1/ 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 nl Arl I d I Jy ypEtHETO� The Town of Barnstable Besa9TSBLs Department of Health, Safety and Environmental Services o 9 k,�� Public Health Division 367 Main Street,Hyannis,MA 02601 Office 508-790-6265 Thomas A.McKean FAX 508-775-3344 Director of Public Health May 5, 1998 To Whom This May Concern: As a result of my inspection on May 4, 1998 at 62 W. Hyannisportport Circle,Hyannis it has been deemed unfit for human habitation due to the failed hot water heater and possible septic failure. This home is occupied by Mr. James Cormier and his son,Andrew. There are large holes in the bathroom ceiling and roof making the house open to the weather. There are no operable smoke detectors in the house. The bedroom ceiling is open to the outside. There is excessive mold due to chronic dampness in the bathrooms and upstairs bedroom. Upstairs you must duck your head to walk in order to avoid many, many cobwebs. You cannot walk upstairs or in the basement or in the garage due to overflowing debris. Half the basement is wet with standing water from the failed hot water heater. This house is a health and a fire hazard. Si jelly, q 0 Donna Z. Miorandi Health Inspector n ;TO OF B�,RNSSTABLEcc , 'r LOCATION (XJ V4�� SEWAGE# C. 00 mo'�`t VILLAGE a> c ASSESSOR'S MAP & LO i INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) i NO. OF BEDROOMS BUILDER OR OWNER PERMITDATE: ",� — 02 COMPLIANCE DATE: 6 m (7 J Separation Distance Between the: I Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet. j Private Water Supply Well and Leaching Facility .(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by � i x.•.- ` �� 3r^y".:..-, .r^a��3._r,.�.�„`Y'y..w.w'v T�r..ryb v1c y RF^,h;S'nY+nrm..y+-. PY'--*ra2 G:.y++v...4•-.-....rP •r�,•w�we[f`y.y`^^"'•K"�'*'..;# . TOWN OF BARNSTABLE BAR=W � . 3680 Ordinance or Regulation WARNING NOTICE �' + Name of Offender/Manager . # VCAJ , ' Address ,of Offender' { ' /_r per(1j L�MV/MB Reg.* Village/State/Zip Business Name /pm� ,on . 14 G ;11X20 Business Address 1 Signature of Enforcing Officer Village/State/Zip . Location of Offense W(% ' / �4 Enforcing Depyt/Division 0 f f e n s.e /-V AN.t / Facts .r` Leo Ems/ R, Kfiff)��_ 'a ON) This will serve ,,only as jaa wa"rning. At this time' no legal action has been taken. It is the goal of Town agencies to achieve voluntary compliance of Town Ordinances, Rules and Regulations. Education efforts and warning notices are attempts to gain voluntary compliance. Subsequent. violations will result in appropriate legal action by the Town. WHITE-,OFFENDER CANARY-ORD./REG.-PROG. PINK-ENFORCING OFFICER GOLD-ENFORCING,DEPT. _-,., .,>o';:... :; .: >:e� -^w.�n^ t,�z .av-�^'"^•'"'!t-',,',�..'N. t,r--:=`.T'.�T "''�,�`<+f z^ �-. ;,� ^� ,r,.�. ,.. .�^s .R:r �'-'-' TOWN OF BARNSTABLE~ BAR-W 3680 Ordinance or Regulation � 1. WARNING NOTICE Name of Off ender/Manager �j ray 1 Address of Offender '� � &L—J),ICI-Irr k.. . MV/MB Reg.# r Village/State/Zip P MAIM Oe-9' ,I& � Business Name --.�" amt/pm; on2Q Business Address % :"i~ :1 � ,.;; ., x Signature of Enforcing Officer Village/State/Zip � Location of Offense ! 't 4 /J Enforcing Dept/Division Offense � 1' . +�s � y� t4„ .,., a �t Facts TV This will serve ;only as /a' warning. At this time' no legal action has been taken. It is the goal of Town agencies to achieve voluntary compliance ' of Town Ordinances, Rules and Regulations. Education efforts and warning notices are attempts to gain voluntary compliance. Subsequent violations will result in appropriate legal action by the Town. WHITE-OFFENDER CANARY-ORD./REG.-PROG. PINK-ENFORCING OFFICER GOLD-ENFORCING DEPT. I17'LOG L E--",,7 HO ASSESSORS MAP 7 TEST I:VARCEL, ;T5 ..... HE INSTALLATION MUST BE IN SUBST'AN'T-I'A'L"C'O'M' PLIA.NCE- WITH§ACHU§JETT§"":TITLE:` SOIL2, EVALUATOR: &-TA0 1P-�� WITNESS : BOARD OF'HEkLTHRE'G'U IS FLOOD ZONE; ,;: REFERENCE. MAY 26 4 2) 7:'THE,�`.INSTALLER VERIFY.:.,THE LOCATION PIFIC 4 ! `,"COMPONEN1 ISE RCOLATION'.R IPE NSTALLATIC�3) t SE- ­ , .1�1, .: , �,1. �o!� ,H 2 LL 13 U D FOR SEPTIC.SYSTEM INSTALLATION' TH I THIS PLAN S 0 ONLY, ,, AND SHALL, NOT BE , USED FOR PROPERTY, -LINE -DETERMINATION.2! LoAP4%/ tA*4?> iUNLESS 4) ,'ALL PIPING TO BE 47.SCHEDULE .40 @ 1/8 FOOT.-Ip-opm SPECIFIED OTHERWISE)LOCATION MAP THE DESIGN OF THIS SYSTEM DOES NOT ALLOW' FOR THE USE OF A'�GARBAGE DISPOSAL.Flg'5rr f;LcDl?- F&O 12-(mm"iSOW SAY�T' 6) SEPTIC TANKS AND DISTRIBUTION BOXES ,(WHEN INSTALLED) MUST BE PLACED ON A MECHANICALLY COMPACTED BASE OR ON'A BASE OF 6"OF CRUSHED STONE. .7) NEW DISTRIBUTION LINE TO BE INSTALLED TO THE F'7 5 OlURTH CHAMBER., SPEED LEVELERS TO BE INSTALLED.;8 GROUNDWATER WAS DETERMINED BY CARMEN SHAY WHO INSPECTED HE SYSTEM FEBRUARY 28,,2003,BY USING USGS SEPT I MA C PS. AN ADJUSTMENT OF 2.3' WAS,APPLIED USING MONITORING WELL M I W 29. (COPY OF REPORT ATTACHED)I 9), TOP OF SAS TO BE NO GREATER THAN 3 FEET FROM GRADE.21- BEDROOMSAT 110 GAL/DAY/BEDROOM 350GAL/DAY, GAL loo USE GALLON SEPTIC TANK ..........4 141 -CAP LUC.ADPlWG I GAP-A&C- Bm S I DE AREA: x .74 117.5 BOT 0 e.,4-75 (7-215 x 13-133)X.74 4 7-4�SEPTIC '-SYSTEM SECTION f lop cr--rou&z.q1t 0 AT WW4149AI� GRADE=ELEV.21.5'r PEASTONE TOP OF SAS. ELEVA 8.5 TO I lr2'CLEAN 314 D_,BOx I 5m GAL OUB EWAS HED STONE 7' ELEV.Ir 8.83W x 6.25L + 10.83W 25 GROUNDWATER SEPARAT)ON 6.7" ,ADJ.GROUNDWATER ELEV.lo..T T1 t,4 C_;­ (SEE NOTE#8)HI CAP INFILTRATOR G JAI S I TE AND SEWAGE PLAN LOCATION 62 W. :44YANtll_SP0j2_-r l p _e FOR : L_Ye�ti s IWE5-r HYA N1 W SCALE: I.: 10 LISA C. G0RDON DATE 612, W. HYANNISPORT CIRCLE 4IS,�MA W u T E /D 1-13 0 X S ro"-ME'A 0 ;'o 4E 7'=HEALTH. AGENT 790-9270