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Home My WebLink About0023 WOODBURY AVENUE - Health 23 Woodbury Avenue Hyannis P A 300 048 x M SENDM-OMPLETE:THIS SECTION COMPLETE THIS SECTION ON DELIVERY ■ Complete items 1,2,and 3.Also complete A• nature item 4 if Restricted Delivery is desired. X ❑Agent ■ Print.your name and address on the reverse ❑Addressee so that we can return the card to you. B. Received by(Pd ame) C. ate of Delive ■ Attach this card to the back of the mailpiece, ar o or on-the front if space permits. A. Article Addressed to: D. Is delivery address different from item 1? ❑Yes A ., If YES,enter delivery address below: ❑No K1,,'RW_&'.CAROL SPEZZANO i r8`CANDLEWOOD DRIVE MEDWAY, MA 02053 3. Type VCtlfied Mail ❑ ress Mail ❑Registered etu p r andise ❑Insured Mall ❑C.O. e- UV, 4. Restricted Delivery?(Extra Fee Yes 2. Article Number 7 012 1010 0000 2848 12 5 4 (Transfer from service labeq PS Form 3811,February 2004 Domestic Return Receipt 102595-o2-Ma Sao I I I UNITED STATES POSTAL SERVICE First-Class Mail I = Postage&Fees Paid LISP Permit No.G-10 I • Sender: Please print your name, address, and ZIP+4 in this box • I I I Sewer Connect Public Health Division ! , y; a Town of Barnstable ; 200 Main Street Hyannis, MA 02601 I� I I I I I I I I I Ln , • .' ,- r-u ra „ - cp OFFICIAL USE -I- t:0 Postage $ rU Certified Fee P.NNIS C3 Retum Receipt Fee f1�� Pos °a OO (Endorsement Required) ri!/.� Here N Restricted Delive Fee �D p (Endorsement Required) 8�J3 p 0 Total Postage&Fees $ �4 1 rU o KEVIN & CAROL SPEZZANO I - 8 CANDLEWOOD DRIVE MEDWAY, MA 02053 Certified Mail Provides: a A mailing receipt o A unique identifier for your mailpiece a A record of delivery kept by the Postal Service for two years Important Reminders: o Certified Mail may ONLY be combined with First-Class Mail®or Priority Maile. c Certified Mail is not available for any class of international mail. n NO INSURANCE COVERAGE IS PROVIDED with Certified Mail. For valuables,please consider Insured or Registered Mail. o For an additional.fee,a Return Receipt may be requested to provide proof of delivery.To obtain Return Receipt service,please complete and attach a Return Receipt(PS Form 3811)to the article and add applicable postage to cover the fee.Endorse mailpiece"Return Receipt Requested".To receive a fee waiver for a duplicate.return receipt,a USPS®postmark on your Certified Mail receipt is required. e For an additional fee, delivery may be restricted to the addressee or addressee's authorized agent.Advise the clerk or mark the mailpiece with the endorsement"Restricted Delivery° a If a postmark on the Certified Mail receipt is desired,please present the arti- cle at the post office for postmarking. If a postmark on the Certified Meil receipt is not needed,detach and affix label with postage and mail. IMPORTANT:Save this receipt and present it when making an inquiry. PS Form 3800,August 2006(Reverse)PSN 7530-02-000-9047 t Town of Barnstable Barnstable Regulatory Services Department j edca�j IARNSTABLE, --- 9 --MASS.- g ---------- - - - ----- --- - -- 1639 Public Health Division - m-- �FD & 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Thomas F.Geiler,Director FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL#7012-1010-0000-2848 -1254 March 28, 2013 KEVIN & CAROL SPEZZANO 8 CANDLEWOOD DRIVE IMPORTANT NOTICE MEDWAY,MA 02053 Map & Parcel: 307-048 The Department of Public Works informed us that public sewer lines are now available in your neighborhood. According to our records, your property has a septic system. This letter directs you to connect your dwelling, at 23 Woodbury Ave., Hyannis, MA, to public sewer on or before 3/30/2015.. The old septic system must be either removed or filled in due to future safety concerns. This may be done by the same contractor who connects you to the sewer. Septic Abandonment Permits ($ 25) are issued at the Public Health Division, 200 Main Street, Hyannis. Failure to comply with this Board of Health Order may result in a complaint against you, in a court of law. For additional information pertaining to the sewer connection,please see the reverse side of this page. PER ORDER OF BOARD OF HEALTH omas A. McKean, S., C.H.O. _-----Agent-of-the-Board of Health_._.------.—_ _-._...._ ___ __.-----_-_ -- _ _-_..-.--------- Cc: Barbara Childs,WPC/. Roger Parsons, Town Engineering, DPW Enc. Q:ISEWER connect\Letters Stewart Creek Sewer Connects\MAILING LetA Sewer 2Pgs Merged 3-28-13 Yr2015.doc ADDITIONAL INFORMATION AND REMINDERS FROM OTHER DIVISIONS: SAVINGS AVAILABLE/GRINDER PUMP: A reminder to those of you who need a grinder pump for your connection: Department of Public Works (DPW) sent you a letter in December 2012 stating the town, for a limited time of two years, only from the receipt of the DPW letter, would provide you with the pump at no charge. (This can save you thousands of dollars.) Please note: You must pay the installation cost through.amour own contractor. Please make your contractor aware of this, if interested. Also be aware: this is a shorter deadline than the Public Health Division's deadline on the reverse side of this page. SAVINGS AVAILABLE/PERMIT FEE: The Town offers a waiver of the residential sewer connection fee of $420.00 for those properties that connect within two years of the receipt of the DPW December 2012 letter. LOANS: For loan(s) available, please see the enclosed brochure, or see the town website: http://www.town.barnstable.ma.us/cdbg (under the"CDBG Programs", see "Sewer Connection Loan Program). For loan specific questions, you may contact Kathleen Girouard, Growth Management, at 508-862-4702. CONTRACTORS: Information on Licensed Sewer Installers is available on our web site at www.town.bamstable.ma.us/PublicWorksTech/sewerinstallers. Contractors, approved to perform sewer connection work in the Town of Barnstable must obtain and file a Sewer Connection Permit with DPW-Water Pollution Control Division, 617 Bearse's Way, Hyannis—contractors,please call Dave Anderson at(508) 790-6244. FOR:-ANY-QUESTIONS Len Gobeil at the Town Manager's Office is available to provide you with direction you may need in reference to the Stewart Creek Sewer Connections. You may contact him at 508-862-4701. QASEwER connectEetters Stewart Creek Sewer Connects\MAILING LetA Sewer Up Merged 3-28-13 Yr2015.doc No. I Fee THE COMMONWEALTH OF MASSACH SETTS Entered in computer: PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Ye 01pplitation for bispo8al *pstrm Construction 3permlt Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon(YJ ❑Complete System ❑Individual Components Location Address or Lot No. Al ZOO CV-Oo" .40 E Owner's Name,Address,and Tel.No. 14VAILWlS Kc-%PQ t cAxm, SPe7zAxlo Assessor's Map/Parcel 07 Q q�g 8 cAwwLew QQj! i?- -b A A Installer's Name,Address,and Tel.No.6og-471-1_$917 Designer's Name,Address,and Tel.No. 41 C40GWc_br 4�SSE& LA-C- WA Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil • Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of on Signed Date 3 -;4 1 13 Application Approved by'-m6v' Date �} �( - / 31 Application Disapproved by Date for the following reasons f Permit No. /)( 3—Oq 2 Date Issued -- 2- � �- N 0 , o. 0 a Fee THE COMMONWEALTH OF MASSACH SETTS Entered in computer: PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Ye x ftplitatlon for Disposal 6pstem Construction permit Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon(k ❑Complete System ❑Individual Components ; Location Address or Lot No. a-b t aJopp$ogy AV E Owner's Name,Address,and Tel.No. 'Io l{Y,4xjlu1S KEvt►J t Co4XOL. SPEz2_AAJ0 ` Assessor's Map/Parcel >j .!g 8 CA�JD&ewoob Dl_> C'b(,, A%4 A Installer's Name,Address,and Tel.No.Sp�„47�_$�-17 Designer's Name,Address,and Tel.No. 15.3 c K�S v�c NIA � -- Type of Building: z, Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) r ; Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) ARAY o S EPTt C s\1,VT-M Date last inspected: Agreement: l The undersigned.agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in i accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of H Signed Date 3 —41 0 13 Application Approved by _/y1 Date 2/ / Application Disapproved by Date for the following reasons Permit No. 6 Date Issued 2- 1 THE COMMONWEALTH OF MASSACHUSETTS fJill W� BARNSTABLE,MASSACHUSETTS F l Certificate of tompliante THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( ) Upgraded( ) Abandoned(X)by dAP6WIDG E4J_1W(ISE5 !L.C-- at ?5 I^/0 O�a ctlt�fyr4 (� has been constructed in accordance ' with the provisions of Title 5 and the for Disposal System Construction Permit No. G 'Uq)dated Installer ?,A0Q-xhE EMMr kjSe' LL.C- Designer #bedrooms Approved design flow - - - gpd The issuance of this permits all n t be construed as a guarantee that the system will fu ction as/desigine ,. . Date (� 7 Inspector � `i %i �r1i !.l.r) 1� .Yii'�1 l.�lt�.fi f` ---,-------.--------------------- ---------.---------------------- ----------------- --------------------= -------- ---------------------- No.Q V V ,Z Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Misposar *pstem Construction permit Permission is hereby granted to Construct( ) Repair( ) Upgrade( ) Abandon(X) System located at 2.3 1AJ&QD8u9f Aug- My64x 06 and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this permit. Date, j �� Ij Approved by I HYANNIS FIRE DEPARTMENT 95 HIGH SCHOOL ROAD EXTENSION APR 1 8 ZO�� HYANNIS, MASS. 02601 Harold S. Brunelle BUSINESS: 775-1300 CHIEF Smoke Oeteavird Save .,dived EMERGENCY: 911 FAX: 778-6448 To t/ Town of Barnstable, Board of Health - T. McKean Town of Barnstable, Conservation Commission - From ; Fire Prevention Bureau, Hyannis Fire Department Subject ; The installation of above ground storage tanks. Date Persuant to the applicable sections of 527 CMR - Fire Prevention Regulations, this Department has inspected the following location for �above ground storage. ADDRESS OWNER/OCCUPANT " PHONE - SIZE OF TANK(S) COMMODITY STORED , PURP05B FOR STORAGE tl THIS INSTALLATION IS PRE-EXISTING A REPLACEMENT NEW This installation complies �� does not comply with the required installation regulation listed below. FIRE PREVENTION OFFICE For: HAROLD S.BRUNELLE,CHIEF HYANNIS FIRE DEPARTMENT 1 ' Commonwealth of Massachusetts Title 5 Official Inspection Form .; Subsurface Sewage Disposal System Form -Not for Voluntary Assessments a J/v .- 23 WOODBURY AVE Property Address JEANIE ADELMANN Owner Owners Name information is HYANNIS required for every MA 02601 6/28/2010 page. Cityrrown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information on the computer, I use only the tab 1. Inspector: I L key to move your cursor- not JAMES D SEARS use the return urn key. Name of Inspector BLUEWATER HLD CORP Q Company Name 350 MAIN ST-ROUTE 28 Company Address W YARMOUTH MA City/Town State 02673 Zip Code 800-593-6449 S-1623 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP'approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: - 0 Passes ❑ Conditionally Passes ❑ ,� i'ttf►rrn,,,� ❑ Needs Further Evaluation by the Local Approving AuthorityAl o� • -� JAMES :R,=, '1 SEARS co 6/28/2010 ��.,c► o:'� spectors Signature Date C •'• •• �ptnN Sp� G��````` The system inspector shall submit a copy of this inspection report to the Approving AG �tority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. **"*This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the fu ure under the same or different conditions of use. Lb t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal s� g po Sy •Page 1 of 1 4 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 23 WOODBURY AVE Property Address JEANIE ADELMANN Owner Owner's Name information is HYANNIS required for every MA 02601 6/28/2010 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: X ❑ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined"(Y, N, ND) for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts ..............� Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 23 WOODBURY AVE Property Address JEANIE ADELMANN Owner Owner's Name information is HYANNIS required for every MA 0260.1 6/28/2010 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes(cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): . ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 23 WOODBURY AVE Property Address JEANIE ADELMANN Owner Owner's Name information is HYANNIS required for every MA 02661 6/28/2010 page. Clty/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ . The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for 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 ❑ X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ FE Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ❑NA Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ N Liquid depth in pit is less than 6" below invert or available volume is less than Y day flow j t5ins•09/08 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form S u ubsurface Sewage Disposal System Form -Not for Voluntary Assessments ............ 23 WOODBURY AVE Property Address JEANIE ADELMANN Owner Owner's Name information is HYANNIS required for every MA 02601 6/28/2010 page. Cltylrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ � Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ x❑ Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ 0 Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ❑x Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ 0 Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ Z Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ 0 The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ 0 The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is,within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑. ❑ the system is located in a nitrogen sensitive area (interim Wellhead Protection Area— IWPA)or a mapped Zone II of a public water supply well If you have answered"yes" to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•09/08 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts -- - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 23 WOODBURY AVE Property Address JEANIE ADELMANN Owner Owner's Name information is HYANNIS required for every MA 02601 6/28/2010 page. Cityfrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No N ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ 0 Were any of the system components pumped out in the previous two weeks? Ox ❑ Has the system received normal flows in the previous two week period? ❑ FS-1 Have large volumes of water been introduced to the system recently or as part of this inspection? ❑x R Were-as built plans of the system obtained and examined?(If they were not available note as N/A) ❑x ❑ - Was the facility or dwelling inspected for signs of sewage back up? ❑ Was the site inspected for signs of break out? ' ❑ Were all system components, including the SAS, located on site? El 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? R El Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size,and location of the Soil Absorption System(SAS)on the site has been determined based on: ❑ Existing information. For example, a plan at the Board of Health. ❑ R 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): NA Number of bedrooms (actual): 4 w DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 t5ins•09108 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts awl - � Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 23 WOODBURY AVE Property Address JEANIE ADELMANN Owner Owner's Name information is required for every HYANNIS MA 02601 6/28/2010 page. Cityfrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 2 Does residence have a garbage grinder? ❑Yes 0 No Is laundry on a separate sewage system?[if yes separate inspection required] ❑Yes 0 No Laundry system inspected? ❑Yes 0 No Seasonal use? ❑Yes 0 No Water meter readings, if available(last 2 years usage (gpd)): NA Detail: Sump pump? ❑Yes 0 No Last date of occupancy: CURRENT Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CM 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑Yes ❑ No Industrial waste holding tank present? ❑Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑Yes ❑ No Water meter readings, if available: t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;a,✓ 23 WOODBURY AVE Property Address JEANIE ADELMANN Owner Owner's Name information is HYANNIS required for every MA 02601 6/28/2010 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: NA Was system pumped as part of the inspection? []Yes x❑ No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: Septic tank, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts --- - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 23 WOODBURY AVE Property Address JEANIE ADELMANN Owner Owner's Name information is HYANNIS required for every MA 02601 6/28/2010 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: 1978 Were sewage odors detected when arriving at the site? ❑Yes ❑ No Building Sewer(locate on site plan): Depth below grade: 18" feet Material of construction: ❑cast iron FE 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage,-etc.): CAMERA LINE. CLEAN &SOLID. NO BRAKES OR ROOTS Septic Tank(locate on site plan): Depth below grade: 1' feet Material of construction: x❑concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑Yes ❑ No Dimensions: 1000 GAL PRE CAST j Sludge depth: 3" i t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 I f Commonwealth of Massachusetts Title 5 Official Inspection Form 1 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 23 WOODBURY AVE Property Address JEANIE ADELMANN Owner Owner's Name information is HYANNIS required for every MA 02601 6/28/2010 page. Cltyrrown 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 27" Scum thickness 2" Distance from top of scum to top of outlet tee or baffle 12" Distance from bottom of scum to bottom of outlet tee or baffle 16" How were dimensions determined? TAPE-SLUDGE Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): TANK IS AT WORKING LEVEL. TANK&COVERS AT 1' BELOW GRADE. INLET TEE, OUTLET BAFFLE. NO SIGN OF OVER LOADING OR LEAKAGE. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑concrete ❑ metal ❑ fiberglass ❑.polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 23 WOODBURY AVE Property Address JEANIE ADELMANN Owner Owners Name information is HYANNIS required for every MA 02601 6/28/2010 page. Cltylrown 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 El other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ` 23 WOODBURY AVE Property Address JEANIE ADELMANN Owner Owner's Name inquired for is every HYANNIS required for eve MA 02601 6/28/2010 page. City/Town 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 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box,etc.): Pump Chamber(locate on site plan): Pumps in working order: ❑Yes ❑ No Alarms in working order. ❑Yes ❑ No Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System(SAS) (locate on site plan, excavation not required): If SAS not located, explain why: 15ins•0111111 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 f Commonwealth of Massachusetts Qiij ...... ` Title 5 Official Inspection Form M' Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 23 WOODBURY AVE Property Address. JEANIE ADELMANN Owner Owner's Name information is HYANNIS required for every MA 02601 6/28/2010 page. Clty/rown State Zip Code Date of Inspection D. System Information (cont.) Type: x❑ leaching pits number: 2 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): LEACHING IS TWO 1000 GAL PRE CAST PITS WITH STONE. PIT 1 - PIT& COVER AT 20" BELOW GRADE. 1 LINE IN, 1 LINE OUT. 25"WATER IN PIT. NO SIGN OF SOLID CARRY-OVER. PIT 2-PIT&COVER AT 18". DRY WITH STAIN LINE AT 18". NO SIGN OF OVERLOADING OR SOLID CARRY OVER. UPPER WALL IS CLEAN. 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•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13of 17 , Commonwealth of Massachusetts R1 5 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments _ 23 WOODBURY AVE Property Address JEANIE ADELMANN Owner Owner's Name information is required for every HYANNIS MA 02601 6/28/2010 page. Citylrown 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.): _ Privylocate on site Ian ( P Materials of construction: Dimensions Depth of solids Comments•(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): , j t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14of 17 I- Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 23 WOODBURY AVE Property Address JEANIE ADELMANN Owner Owners Name information is required for every HYANNIS MA 02601 6/28/2010 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ❑ drawing attached separately I . I i i J I ,�- o ). 3 o / „sv r s i 3 O t5ins•09/08 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts - - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 23 WOODBURY AVE Property Address JEANIE ADELMANN Owner Owner's Name information is required for every HYANNIS MA 02601 6/28/2010 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: 0 Check Slope NONE x❑ Surface water NONE Check cellar NA O Shallow wells NONE Estimated depth to NO high ground water: 12+ feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑x Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: HAND DUG TEST HOOLE ONSITE. 12' NO WATER. TEST HOLE AT PIT 2 -4'6" BELOW BOTTOM OF PIT. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal system•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form ` Subsurface Sewage Disposal System Form -Not for Voluntary Assessments - 9 P Y 23 WOODBURY AVE Property Address JEANIE ADELMANN Owner Owner's Name information is HYANNIS required for every MA 02601 6/28/2010 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist x❑ Inspection Summary: A, B, C, D, or E checked Inspection Summary D (System Failure Criteria Applicable to All Systems)completed x❑ System Information—Estimated depth to high groundwater Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 s0 NZ�C� W f W y niA W 0 / R v � Nf � � W = o; O a H � N d ic oc Z La W O O W I V f.7 t W t W W J zip _ J LOCATION SEWAGE PERMIT NO. (ja VILLAGE I INSTA LLER4 NAME & ADDRESS BUILDER OR OWNER DATE PERMIT ISSUED Q`AT E COMPLIANCE ISSUED i rl 9� 41 �s � n � . Id Pam . No............. .... �-� ,o Fim ._............................ THE COMMONWEALTH OF MASSACHUSETTS OAR® F HE TH .....OF. Applirativaa for Biipuial Works Towi#rurtion Famit Application is hereby made for a Permit to Construct ( ) or Repair (fij""an Individual Sewage Disposal S stem at: fv�� v ,1�} iv# '.-------G_ 1or . .s----------- ----------------- - ---------------------------------------------- cation-Addrss r t No. , Gl/ao c/, -- (� T_ _Owner Address ----...-----------------•-------•-•-•---- Installer Address Type of Building Size Lot_y a_./Pd___._._Sq./f�e t U Dwelling—No. of Bedrooms______________________________________Expansion Attic ( ) Garbage Grinder A_ Other—T e of Building No. of persons____________________________ Showers — Cafeteria a' Other fixtures __________________________________ W Design Flow__________________5:�________.______gallons per person per day. Total daily flow..._...__._.___ __ ..................gallons. WSeptic Tank¢Liquid capacit� _.gallons Length................ Width................I Diameter-----........... Depth................. x Disposal Trench—No_ .................... Width_._ __._.______._.. Total Length............ Total leaching area....................sq. ft. Seepage Pit No........_....... Diameter--------� ----- Depth below inlet...... Total leaching area___y�_?t_sq. ft. z Other Distribution box Dosing tank ( ) '~ Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. I......._--------minutes per inch Depth of Test Pit.................... Depth to ground water........................ Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Ra ----•-----------------------------------•--------•••----•-••---.._..._._.._..................___-------•--------•-•---•------- _____--•••--------•---- ODescription of Soil----------------------------------....................................................---------•-•--•---•--•-•-••---•-•--••-•••----•------•-••-•---••----••-------•---- x U x ------------------------------------- •-- ------------- U Nature of Repairs WAltations—An when licabl __________ ____ IFTIF A ,19�,�-- ... /�_. — Agreement: �� The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of iITi iE p of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Sign ed , Date Application Approved BY -••••-� � ---,-------•------------•-------------•--•-------..Da te ' Application Disapproved for the following reasons_________________________________________ ._....._....._ ---------------------•-•-----•----...-----------------------------------------------------------------------•----•------------------------------•------------------------------------------------------ Date ----------------------------------- Issued---••7-----1-� Permit No......................................................... -- -------7 ------ ------------ Date 3 No.....----•- -cl-?..... FEE...... ... THE COMMONWEALTH OF MASSACHUSETTS BOARD qF HEALTH - - -------......OF...... . ...... ......--------- ...................................... Appliration for 11ispogal Workii Tonfitrnrtinn Vamit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: n-A ss or Lot No. ,... ...................................... .................................................................................................. ner Address a ................e..!...... ............................................... ...................-......................................................--...................... Installer Address QType of Buildirwl Size Lot............................Sq. fee U Dwelling No. of Bedrooms............ ..... .........•-__-____.Expansion Attic ( ) Garbage Grinder .� �+ Other—T e of Building No. of persons............................ Showers — Cafeteria Other fixtures ------------------------ W Design Flow._._.......... ........... gallons per person per day. Total daily flow...............:�_ _..-......_gallons. WSeptic Tank/-Liquid capacityl2'_..._.gallons Length................ Width................ Diameter................ Depth...._........... Disposal Trench—No..................... Width....._._ _....... Total Length........... ------ Total leaching area---------- __.___.sq. ft. Seepage Pit No ........ Diameter_______________ Depth below inlet.............:. Total leaching area.__:, . sq. ft. Z Other Distribution box (PT I Dosing tank ( ) Percolation Test Results Performed bY.......................................................................... Date........................................ aTest Pit No. I................minutes per inch Depth of Test Pit_____---...__.____-• Depth to ground water........................ Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 0 Description of Soil.................... . ti ' U ------------••---------- --•------ ------------------ •--."--....... •- . . U Nature of Repairs or Alterations—Answer when applicable______;1z -1__.� ..._. ___2__: _.�'_ �......�-�,,. ._.__.: Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. rgne • •-• ---•-•..__._...••••-- ................................ iy Application Approved By.........-- = •••• -:- :.... ...._.. =7-= :._.. Date Application Disapproved for the following reasons:.................................=............................................................................ - ..................................................................................................... .................................................................................................... Date PermitNo......................................................... Issued-....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF EALTH P�!! ...OF.............,;. ... ... 0rrtif irate of Toutplitanrr TINIS IS TO CERT T e Individual Sewage Disposal System constructed ( ) or Repaired by... - - -- -- -----::-------------- --k ------- ---------------------- ---- --------... has been installed in ac rdance with the provisions of 5 of The State anitary C de as descri d in the application for Disposal Works Construction Permit N - lam- 7-- - -•- •••-----•-•-_. dated--- -- ....•-•---•. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE................................................................................ Inspector........------ -•-••- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF EALTH ... �(.......,OF............... . .... ... ............................... ? u 1 �? ... FEE...�. No..-•..... 7--.: Roposa orkii Tn tr amit Permission is hereby ranted ��n_IqAiividual M .:_.. . . ••• -• •...................•-•--••--••-•••. -"--------...................--.... Yg to Constru or Re it S.w ge D' sal System Stir as shown on the application for Disposal Works Construction Pe No._ Dated... ..1�........................ v n == .... ` .......................•..... v: Board of Health DATE- -•.............� FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS � y � f FORM 30 CAW HOBBS&WARREN TM THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HE H -mot CI OWN � '7�, a ` DEPARTMENT r ADDRESS TELEPHONE Address Occupant_ Floor Apartment No. of Occupants No.of Habitable Rooms_ No.Sleepin Rooms No. dwelling or rooming units No.Stories Name and address of owner 44-0 Remarks Reg. Vio. YARD Out Bld s.: Fences: Garbage and Rubbish Containers: Drainage 6 j Infestation Rats or other: i STRUCTURE EXT. Steps,Stairs, Porches: - - Dual Egress:and Obst'n.: IV v ❑ B ❑ F ❑ M Doors,Windows: Roof Gutters, Drains: Walls: Foundation: Chimney: BASEMENT Gen.Sanitation: Dampness: Stairs: M1 Li htin : STRUCTURE INT. Hall,Stairway: �.. Obst'n.: Hall, Floor,Wall,Ceiling: Hall Lighting: Hall Windows: HEATING Chimneys: Central ❑ Y ❑ N E ui . 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 ❑ 220 Fusing,Grnd.: AMP: Gen.Cond. Distrib. Box: Gen. Basement Wiring: DWELLING UNIT Ventil. L to . Outlets Walls Ceils. Wind. Doors Floors Locks Kitchen Bathroom Pantry Den Living Room Bedroom 1 Bedroom 2 FP Bedroom 3 Bedroom 4 Hot Water Facil. Sup.Ten.,Gas,Oil, Elect.: Stacks, FjVs,Vents, eties: Kitchen Facilities 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 IS 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. (Se- ver) "THIS INSPECTION REPORT IGNE AND CERTIFIED UNDER T PAINS AND PENALTIES OF PERJU Y." INSPECTOR TITLE P � DATE \ ® TIME M• .M. THE NEXT SCHEDULED REINSPECTION P.M. 410.750: Conditions Deemed to Endanger or Impair Health or 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 those 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 11, 105 CMR 410.100 through 410.620 state minimum requirements of fitness for human habitation, any other violation has the potential to fall within this category in any given specific situation but may not do so in every case and therefore is not included in this listing. Failure to include shall in no way be construed as a determination that other violations or conditions 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 such violation(s) pursuant to 105 CMR 410.830 through 410.833 nor shall failure to include 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 410.190 for a period of 24 hours or longer. (B) Failure to provide heat as required by 105 CMR 410.201 or improper venting or use of a space heater or water heater as prohibited by 105 CMR 410.200(B)and 410.202. (C) Shutoff and/or failure to restore electricity or gas. . (D) Failure to provide the electrical facilities required by 105 CMR 410.250(B), 410.251(A), 410.253 and the lighting in com- mon area required by 105 CMR 410.254. (E) Failure to provide a safe supply of water. (F) Failure to provide a toilet and maintain a sewage disposal system in operable condition as required by 105 CMR 410.150(A)(1)and 410,300. (G) Failure to provide adequate exits, or the obstruction of any exit, passageway or common area caused by any object, including garbage or trash, which prevents egress in case of an emergency 105 CMR 410.450, 410.451 and 410.452. (H) Failure to comply with the security requirements of 105 CMR 410.480(D). (1) Failure to comply with any provisions of 105 CMR 410.600, 410.601 or 410.602 which results in any accumulation of gar- bage, rubbish, filth or other causes of 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 Ieadbased paint on a dwelling or dwelling unit in violation of the Massachusetts Department of Public Health Regulations for Lead Poisoning Prevention and Control, 105 CMR 460.000. (See M.G.L. c. 111 @@ 190 through 199.) (K) Roof,foundation, or other structural defects that may expose the occupant or anyone else to fire, burns, shock, accident or other dangers or impairment to health or safety. (L) Failure to install electrical, plumbing, heating and gas-burning facilities in accordance with accepted plumbing, heating, gas-fitting and electrical wiring standards or failure to maintain such facilties as are required by 105 CMR 410.351 and 410.352, so as to expose the occupant or anyone else to fire, burns, shock, accident or other danger or impairment to health or safety. (M) Any defect in asbestos material used as insulation or covering on a pipe, boiler or furnace which may result in the release of asbestos dust or which may result in the release of powdered, crumbled or pulverized asbestos material in violation of 105 CMR 410.353. (N) Failure to provide a smoke detector required by 105 CMR 410.482. (0) Any of the following conditions which remain uncorrected for a period of five or more days following the notice to or knowledge of the owner of said condition or conditions: (1) Lack of a kitchen sink of sufficient size and capacity for washing dishes and kitchen utensils or lack of a stove and oven or any defect that renders either inoperable. (2) Failure to provide a washbasin and shower or bathtub as required in 105 CMR 410:150(A)(2)and 410.150(A)(3)or 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, gasfitting, or electrical wiring standards that do not create an immediate hazard. (4) Failure 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. (P) Any other violation of 105 CMR 410.000 not enumerated in 105 CMR 410.750(A)through (0)shall be deemed to be a con- dition 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. �' , M N � �� G� '� �' � �" � ' �� =' �� f p �� ,._�� t COMMONWEALTH OF MA SSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS + d DEPARTMENT OF ENVIRONMENTAL PROTECTION a RECEIVED o,1,M SJO 350MAIN STREET JAN 0 8 2003 WEST YARMOUTH,MA 508-775-2800 TOWN OF BARNSTABLE HEALTH DEPT. TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION ? 1 MAP 307 PAR 048 Property Address: 23 WOODBURY AVENUE HYANNIS,MA 02601 Owner's Name: BELFANTI,PAUL Owner's Address: 675 CLIFTON AVENUE NEWARK,NJ 07104 Date of Inspection DECEMBER 16,2002 Name of Inspector:(please print) :JAMES D.SEARS Company Name: A&B Canco Mailing Address: 350 Main Street West Yarmouth,MA 02673 Telephone Number: 508-775-2800 CERTIFICATION STATEMENT I certify that[have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. 1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ./ Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority ails Inspector's Signature: S9, Date: ,�� -�� a� The system inspector shall suPrnitay of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent tot he buyer,if applicable,and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 1 Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 23 WOODBURY AVENUE HYANNIS,MA 02601 Owner: BELFANTI,PAUL Date of Inspection: DECEMBER 16,2002 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: ✓ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: N/A 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 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: Title 5 Inspection Form 6/15/2000 2 Page 3 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(CONTINUED) Property Address: 23 WOODBURY AVENUE HYANNIS,MA 02601 Owner: BELFANTI,PAUL Date of Inspection: DECEMBER 16,2002 C. Further Evaluation is Required by the Board of Health: N/A 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 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 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: Title 5 Inspection Form 6/15/2000 3 Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(CONTINUED) Property Address: 23 WOODBURY AVENUE HYANNIS,MA 02601 Owner: BELFANTI,PAUL Date of Inspection: DECEMBER 16,2002 D. System Failure Criteria applicable to all systems: N/A You must indicate"yes"or"no"to each of the following for all inspections: Yes No ✓ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ✓ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool N/A Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ✓ Liquid depth in pits is less than 6"below invert or available volume is less than`/2 day flow ✓ Required pu nping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped ✓ Any portion of the SAS,cesspool or privy is below high ground water elevation N/A Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply N/A Any portion of a cesspool or privy is within a Zone 1 of a public well N/A Any portion of a cesspool or privy is within 50 feet of a private water supply well N/A 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 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. 1 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: N/A To be considered a large system the system must service 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—I WPA)or a mapped Zone II of a public water supply well. If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes"in Section D above the large system is 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. Title 5 Inspection Form 6/15/2000 4 Page 5 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 23 WOODBURY AVENUE HYANNIS,MA 02601 Owner: BELFANTI,PAUL Date of Inspection: DECEMBER 16,2002 Check if the following have been done. You must indicate"yes"or"no"as to each of the following Yes No ✓ Pumping information was provided by the owner,occupant,or Board of Health ✓ Were any of the system components pumped out in the previous two weeks? ✓ Has the system received nonnal flows in the previous two week period? J Have large volumes of water been introduced to the system recently or as part of this inspection? N/A Were as built plans of the system obtained and examined?(If they were not available note as N/A) J Was the facility or dwelling inspected for signs of sewage back up? ✓ Was the site inspected for signs of break out? ✓ Were all system components,excluding the SAS,located on site? ✓ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum ✓ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)has been determined based on: Yes No ✓ Existing information. For example,a plan at the Board of Health. ✓ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CM 15.302(3)(b)] Title 5 Inspection Form 6/15/2000 5 Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 23 WOODBURY AVENUE HYANNIS,MA 02601 Owner: BELFANTI,PAUL Date of Inspection: DECEMBER 16,2002 FLOW CONDITIONS RESIDENTIAL Number of Bedrooms(design): 4 Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203(for example: 1 10 gpd x#of bedrooms: 440 Number of current residents: 0 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): YES Seasonal use(yes or no): YES Water meter readings,if available(last 2 years usage(gpd)): N/A Sump pump(yes or no) NO Last date of occupancy: UNKNOWN COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CM 15.203): Basis of design flow(seats/persons/sqft,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: N/A Was system pumped as part of the inspection(yes or no): NO If yes,volume pumped: gallons—How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM ✓ Septic tank, 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 copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: UNKNOWN Were sewage odors detected when arriving at the site(yes or no): NO Title 5 Inspection Form 6/15/2000 6 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 23 WOODBURY AVENUE HYANNIS,MA 02601 Owner: BELFANTI,PAUL Date of Inspection: DECEMBER 16,2002 BUILDING SEWER(locate on site plan): ✓ Depth below grade: 10" Materials of construction: Cast iron _ 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(locate onsite plan): ✓ Depth below grade: I Material of construction: ✓ 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: 1,000 GALLON PRE CAST Sludge depth: 4" Distance from top of sludge to the bottom of outlet tee or baffle: 26" Scum thickness: 2" Distance from top of scum to top of outlet tee or baffle: 8" Distance from bottom of scum to bottom of outlet tee or baffle: 20" How were dimensions determined: ASBUILT AND TAPE Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): MAIN TANK AT WORKING LEVEL.TANK AND COVERS I' BELOW GRADE.INLET TEE,OUTLET BAFFLE.NO SIGN OF OVERLOADING SEEN IN TANK. GREASE TRAP(located on site plan) N/A 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.): Title 5 Inspection Form 6/15/2000 7 Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 23 WOODBURY AVENUE HYANNIS,MA 02601 Owner: BELFANTI,PAUL Date of Inspection: DECEMBER 16,2002 TIGHT or HOLDING TANK: N/A (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: N/A (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.,): PUMP CHAMBER: N/A (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): Title 5 Inspection Form 6/15/2000 8 Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 23 WOODBURY AVENUE HYANNIS,MA 02601 Owner: BELFANTI,PAUL Date of Inspection: DECEMBER 16,2002 SOIL ABSORPTION SYSTEM(SAS): ./ (locate on site plan,excavation not required) If SAS not located explain why: Type ./ leaching pits,number: 2 leaching chambers,number: leaching galleries,number leaching trenches,number,length leaching fields,number,dimensions: overflow cesspool,number: innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.) LEACHING IS TWO 1,000 GALLON PRE CAST PITS.PIT(1)PIT AND COVER 20"BELOW GRADE.PIT DRY,STAIN LINE AT OUTLET LINE. PIT(2)PIT AND COVER 18"BELOW GRADE,DRY,STAIN LINE AT 18".WALL CLEAN.NO SIGN OF OVERLOADING OR SOLID CARRY OVER. CESSPOOLS: N/A (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: N/A (locate on site plan) Materials of Construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) Title 5 Inspection Form 6/15/2000 9 Page 9 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 23 WOODBURY AVENUE HYANNIS,MA 02601 Owner: BELFANTI,PAUL Date of Inspection: DECEMBER 16..2002 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two pennanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. AJ i r ' O xx/ /45) 3 O i O Title 5 Inspection Form 6/15/2000 10 Page I 1 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 23 WOODBURY AVENUE HYANNIS,MA 02601 Owner: BELFANTI,PAUL Date of Inspection: DECEMBER 16,2002 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to no groundwater 12 feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observation site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with local excavators,installers-(attach documentation Accessed USGS database-explain: You must describe how you established the high ground water elevation: HAND DUG TEST HOLE 12'NO WATER. TEST HOLE 4'6"BELOW BOTTOM OF PIT(2). 7/1- ;acT,h 1 Title 5 Inspection Form 6/15/2000 11