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Home My WebLink About0046 WOODBURY AVENUE - Health Hyannis ` JG wbG>r �( a I TOWN OF BARNSTABLE LOCATION Wes '6ry, .t ✓e S�# VILLAGE ASSESSOR'S MAP&PARCEL a3y7 8S� IDS NAME&PHONE NO. cam`*r i C/C SEPTIC TANK CAPACITY /000 \ LEACHING FACILITY.(type)��& ,r6, (size) NO.OF BEDROOMS OWNER C i0►'1 C9AJL PERMIT DATE: _%` C 000#4ANWE DATE: Separation Distance Between the: a a Maximum Adjusted Groundwat f 19ble 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 Water + Service 4. r4ii�i'��' 5::;%;%�iSit;k�i%�i�i;,ii�riiEi?%-`:;: <>:`• '�i%:i,`'•i f f I 30 23 i 45 43 1 50 No. Fee �� tz THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION- TOWN OF BARNSTABLE, MASSACHUSETTS Yes application for 33isposal 6pstem Construction Permit Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon(� ❑Complete System ❑Individual Components Location Address or Lot No. q(0 Owner's Name,Address,and Tel.No. Assessor's Map/Parcel 3C>, v to . VAKWK In taller's Name,Address,and Tel.No.5tyg-t}`�1 wIR'S,7 Designer's Name,Address,and Tel.No. k9-6►P OC C-1�1' �2�5 � NIA 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 Health. SiggovDate Application Approved by Date �i�y/Z��=,- Application Disapproved by Date for the following reasons r P Permit No. Date Issued '9 ty IJ'IS No. �lo Feev7 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 01pplitation for Misposal 6pstem Construction 3oPrmit (� Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon(h El Complete.System ❑Individual Components f i Location Address or Lot No. q b U)0O w0f Owner's Name,Address,and Tel.No. Assessor's Map/Parcel 30 6 SE"(M�� WAKA21 5; In taller's Name,Address,and Tel.No.50S�-4"n vg187 Designer's Name,Address,and Tel.No. �t 73 v��kQGW lv� c�T, 5:'Q�s�s � NIA 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) A-A40,Dos.) &-X6,<-rj0& SGn r 5) A 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 Health. 1 Sig Y Date Application Approved by Date f y Zo Application Disapproved by Date for the following reasons .�_ .. Permit No. Z�� - 7i� Date Issued Iy IY015 s' ---------------------------------------------------------------------------------------------------------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Crdifitate Of CompYiancr THIS IS TO CERTIFY,'that the On-site Sewage Disposal system Constructed( ) Repaired( ) Upgraded( ) Abandoned(X)by C,// K W Opp �y�05 U—c— at YL IA NDRQQy f'AU 6 �`YArou(S has been constructed in accordance with the provisions of Title 5 and the for Disposal SystemConstruction Permit No:0dtq' - Z%- dated Installer OAPGW(,J)� �N�e.Prlts U C Designer IV A #bedrooms Approved design flow gpd The issuance o this permits 11 not be construed as a guarantee that the system wil font)/as design Date Inspector 6UP " -------------------------------/-,-,------------------------------------------- -------------------------=----------------------- No. `7 ZI �& Fee Z u THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -BARNSTABLE, MASSACHUSETTS Disposal *pstrm Construction Vrrmit Permission is hereby granted to Construct( ) Repair( ) Upgrade( ) Abandon(XQ System located at L Au t y*Ilj&�)t< 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. i LL Provided:C7nstrpction must be completed within three years of the date of this pe { ~ Date l D/�7 Approved by �-� C9--15� W I oFt"E lAy, Town of Barnstable Barnstable Regulatory Services Department j -0 BARNSPABM ' '""SS. Public Health Division 9�s63q. ,�� m fO"" A 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Richard Scali,Director FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL# 7014 1200 0001 0358 2264 February 9, 2015 SHIRLEY A. HOLMES, TR. 51 WOODBURY AVENUE IMPORTANT NOTICE HYANNIS, MA 02601 Map & Parcel: 307-056 DEADLINE APPROACHING According to our records your dwelling at 46 Woodbury Ave., Hyannis,MA, should be connected to public sewer on or before 3/30/2015. This is a reminder that all permits need to be in place before this date to be in compliance: 1) Septic Abandonment Permits ($ 25) are issued at the Public Health Division, 200 Main Street, Hyannis. 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. 2) 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 /ASSISTANCE: 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. Thomas A. McKean, R.S., C.H.O. Agent of the Board of Health SECTIONS SECTION COMPLETE THIS ON DELIVERY ■ Complete items 1,2,and 3.Also complete A Ignature item 4 if Restricted Delivery is desired. X ❑Agent a Print your name and address on the reverse ❑Addressee so that we can return the card to you. g,� eived by(Printed N ) C. Date of Delivery a Attach this card to the back of the mailpiece, or on the front if space permits. D. Is delivery ad ss different from item 17 ❑Yes 1. Article Addressed to: If YES,enter delivery address below: ❑No rHYANNIS, IRLEY A. HOLMES, T--R. I WOODBURY AVENUE I MA 02601 ' s. see Type VCertified Mail 0 95press Mail ❑Registered WOOReturn a pt for Me e ❑Insured Mail ❑C.O. W d tr-1b 4. Restricted Delivery?(Extra Fe es 2. Article Number 7�12 1�1� 0��0 2848 1292 (transfer from service labeq BPS Form 3811,February 2004 Domestic Return Receipt 102595-02-M-1540 7 UNITED STATES POSTAL SERVICE First-Class Mail Postage&Fees Paid USPS Permit No.G-10 • Sender: Please print your name, address, and ZIP+4 in this box • Sewer Connect Public Health Division k Town of Barnstable. 0� 200 Main Street Hyannis,MA 02601 r r fl +r 7 r, r ., rf„ r rr. f ,ieP1111111,111,11 t 1L�►7 li i f 1 �.l F fill 111 i � ru ■� Ir ru ._ cp F I I M � Postage $ Certified Fee 0 Postmark q M � Retum Receipt Fee «t: O (Endorsement Required) � � —+ i � Restricted Delivery Fee t3 (Endorsement Required) tC3 Total Postage&Fees $ q r� a ' SHIRLEY A. HOLMES, TR. ram- 1' 51 WOODBURY AVENUE. HYANNIS, MA 02601 Certified Mail Provides: e A mailing receipt o A unique identifier for your mailpiece o A record of delivery kept by the Postal Service for two years Important Reminders: o Certified Mail may ONLY be combined with First-Class Maile or Priority Maile. a Certified Mail is not available for any class of international mail. o NO INSURANCE COVERAGE IS PROVIDED with Certified Mail. For valuables,please consider Insured or Registered Mail. n 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 USPSe postmark on your Certified Mail receipt is required. o 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': e 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 Mail 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 'I. - - ----------- Town of Barnstable Barnstable tiAF Regulatory Services Department j'p' �c j STABS - - 9 t - - -- ��'ED MA'S a ----- -- - m-- — - —— -- 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 -1292 March 28, 2013 SHIRLEY A. HOLMES, TR. 51 WOODBURY AVENUE IMPORTANT NOTICE HYANNIS, MA 02601 Map & Parcel: 307- 056 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 46 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. P=cKean, HEALTH -----Agent-ofthe B-oard-of-Health Cc: Barbara Childs,WPC/Roger Parsons, Town Engineering, DPW Enc. QASEWER connect\Letters Stewart Creek Sewer Connects\MA1LING LetA Sewer 2Pgs Merged 3-28-13 Y0015.doc _—_—_____-Public.Health_Division—__. _.__.___—_____— _March 28,_2013___--._______ . 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 your 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: offers a waiver of the residential sewer connection fee of 420.00 for those The Town off s w $ 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.barnstable.ina.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_/ASSIS_TANCE:__ : _._ .._._..-.._ _...__._-- - _ ._-_ -----._.. ...._._. 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\MAII.ING 1.etA Sewer 2Pgs Merged 3-28-13 Y0015.doc I r CAJ VU F;lfv- oj f j / " a G I C-A � O � COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION , e� TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A 'CERTIFICATION R � Property Address: 5 Woodbury Ave AKA#60 Hyannis MA 02601 3�m Owner's Name: Option One Mortgage Co. Lo Owner's Address: 3 Ada CT ;- Irvine CA 92618 'y3.3 ' _ Date of Inspection: May 7,2007 Job#07-87 ' A o J" Name of Inspector: PATRICK M. O'CONNELL m Company Name: SEPTIC INSPECTION SERVICES CO. t� Mailing Address: 189 CAMMETT ROAD MARSTONS MILLS MA 02648 Telephone Number: 508-428-1779 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on 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 _X_ Conditionally Passes Needs her Evaluation by Local Approvi g A thority Fail Inspector's Signature ; ate: 5/7/07 The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. Notes and Comments: Septic tank is half full of solids with no liquid,tank is leaking and needs to be replaced. Leaching pit was empty at time of inspection; high stains indicate pit has never been more than half full. ****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. Page 2 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 5 Woodbury Ave AKA#60,Hyannis Owner: Option One Mortgage Co. Date of Inspection: May 7,2007 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: XX _XX_ 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. Tank is leakine and must be replaced. 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: I Page 3 of 1 I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 5 Woodbury Ave AKA#60,Hyannis Owner: Option One Mortgage Co. Date of Inspection: May 7,2007 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 I of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance "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: i I Page 4 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 5 Woodbury Ave AKA#60,Hyannis Owner: Option One Mortgage Co. Date of Inspection: May 7,2007 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No _X_ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool —X— Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool —X— Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool _X_ Liquid depth in cesspool is less than 6"below invert or available volume is less than_day flow —X— Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped X_ Any portion of the SAS,cesspool or privy is below high ground water elevation. —X— Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone I of a public well. _X_ Any portion of a cesspool or privy is within 50 feet of a private water supply well. —X— Any portion of a cesspool or privy is 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—IWPA)or a mapped Zone 11 of a public water supply well I 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. Page 5 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 5 Woodbury Ave AKA#60,Hyannis Owner: Option One Mortgage Co. Date of Inspection: May 7,2007 Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No _X_ Pumping information was provided by the owner,occupant,or Board of Health _X_ Were any of the system components pumped out in the previous two weeks ? _X_ Has the system received normal flows in the previous two week period ? _X_ Have large volumes of water been introduced to the system recently or as part of this inspection'? _X_ _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) _X_ Was the facility or dwelling inspected for signs of sewage back up? _X_ _ Was the site inspected for signs of break out'? _X_ _ Were all system components,excluding the SAS, located on site'? _X _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? _X_ _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: Yes no _X_ _ Existing information. For example,a plan at the Board of Health. _X_ _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)] Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 5 Woodbury Ave AKA#60,Hyannis Owner: Option One Mortgage Co. Date of Inspection: May 7,2007 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 2 Number of bedrooms(actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 220 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): Seasonal use: (yes or no): No Water meter readings, if available(last 2 years usage(gpd)): 18 months total: 154,000 gal.=281 gpd. Sump pump(yes or no): No Last date of occupancy: March 2006 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: None Source of information: Was system pumped as part of the inspection(yes or no): No If yes,volume pumped: gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM _X_Septic tank,distribution box,soil absorption system _Single cesspool _Overflow cesspool _Privy _Shared system(yes or no)(if yes,attach previous inspection records, if any) _Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight tank _Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: Compliance date: 12/16/93 Were sewage odors detected when arriving at the site(yes or no): No r Page 7 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 5 Woodbury Ave AKA#60, Hyannis Owner: Option One Mortgage Co. Date of Inspection: May 7,2007 BUILDING SEWER: XX (locate on site plan) Depth below grade: V Materials of construction:_X_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: XX (locate on site plan) Depth below grade: 1' Material of construction:_X_concrete_metal_fiberglass_polyethylene —other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions: 8.5'long x 5.2' wide— 1000 gal. Sludge depth: 2' Distance from top of sludge to bottom of outlet tee or baffle: 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: How were dimensions determined: STICK WITH HINGE FLAP. Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): Tank has solids only,no liquids.Tank is Ieakin2 and needs to be replaced. GREASE TRAP: No (locate on site plan) Depth below grade:_ Material of construction:_concrete_metal_fiberglass_polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): r Page 8 of I I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 5 Woodbury Ave AKA#60,Hyannis Owner: Option One Mortgage Co. Date of Inspection: May 7,2007 TIGHT or HOLDING TANK: No (tank must be pumped at time of inspection) (locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: XX (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.): PUMP CHAMBER: No (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): Page 9 of 1 I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 5 Woodbury Ave AKA#60,Hyannis Owner: Option One Mortgage Co. Date of Inspection: May 7,2007 SOIL ABSORPTION SYSTEM(SAS): XX (locate on site plan,excavation not required) If SAS not located explain why: Type —X_leaching pits,number: One 6x6 pit. _leaching chambers,number: _leaching galleries,number: _leaching trenches,number, length: _leaching fields,number,dimensions: _overflow cesspool,number: innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation, etc.): Pit was empty at time of inspection; high stains indicate pit has never been more than half full. CESSPOOLS: No (cesspool must be pumped as part of inspection) (locate on site plan) Number and configuration: Depth—top of liquid to inlet invert:. Depth of solids layer: Depth of scum.layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): PRIVY: No (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 5 Woodbury Ave AKA#60,Hyannis Owner: Option One Mortgage Co. Date of Inspection: May 7,2007 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Woodbury A ve Water Service ...................................................................................................... ..................................................................................................... ...................................................................................................... ...................................................................................................... ..................................................................................................... ..................................................................................................... ...................................................................................................... ..................................................................................................... ...................................................................................................... ..................................................................................................... ...................................................................................................... ..................................................................................................... ...................................................................................................... ..................................................................................................... ..................................................................................................... ... _ . ...................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ...................................................................................................... ..................................................................................................... ...................................................................................................... �1 ........................................................................ .................... -. ......... ............. ............... ............... ... ............... ........ .............. ...... ...... ...... -.1...I..................11........................... ........... ......... ............--.........-......-............. ....- -l' ................ .............................. -.....11... ..... .. ....-...-....-...... ....................................-...........-........ I........... 1-1-11''...''...................I..........-...... ................... ...................................................................-.1-1-................ .......................... .....I......I........ .................. ..................- ................................. ........-..... ...... . ......... .......... ........ .........-... ................... .............. ..................... ...... ...... ...... .......... ...... ................................. ....... ............................ ................. .................................. 30 23 A 45 43 40 50 Page I 1 of 1 I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 5 Woodbury Ave AKA 060,Hyannis Owner: Option One Mortgage Co. Date of Inspection: May 7,2007 SITE EXAM Slope None Surface water None Check cellar Dry Shallow wells None Estimated depth to ground water : More than 20 feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record- If checked,date of design plan reviewed: _Observed site(abutting property/observation hole within 150 feet of SAS) _Checked with local Board of Health-explain: _Checked with local excavators, installers-(attach documentation) _X_Accessed USGS database-explain: USGS topo map and town GIS. You must describe how you established the high ground water elevation: Town groundwater contour map shows water below el. 10 and topo map shows property above el.30. No Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes 01ppYication for 33igozal *pftem Construction Vertu Application for a Permit to Construct( ) Repair Upgrade( ) Abandon( ) ❑Complete System Individual Components Location Address or Lot No.(00 woao _,, Q00.4 Owner's Name,Address,and Tel.No. Assessor's Map/Parcel Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. ("19-Co-JI,n Co 3S0 v�c�a� to&M.8 ky4 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) _sec,-L Qtp."' 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 t 's Board of He It . Sig A 0 Date (c C Application Approved by Date Application Disapproved by: Date F7�� for the following reasons Permit No. '' Date Issued No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes s .PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Application for ai,5pont *pg;tem Cott,5truction Permit Application for a Permit to Construct( ) Repair(>() Upgrade( ) Abandon( ) .,❑Complete System Q Individual Components -Location Address or Lot No. v oz_ c Owner's Name,Address,and Tel.No. Assessor'sMap/Parcel Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. SUg »S'ZBcb C o 3S 0 v,\ w ,�{�\,w0 k_kAl Type of Building: Dwelling \No.of Bedrooms Lot Size sq.ft. Garbage Grinder ( ) s Other Type of Building No.of Persons Showers( ) Cafeteria( ) w 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 a n Nature of Repairs or Alterations(Answer when applicable) L< 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 s, Compliance has been issued by this Board of Healt . Sig �y '° /JO Date (o 01 00`7 d' Application Approved by /r7 Date " Application Disapproved r by: Date for the following reasons r Permit No. �4—WK Date Issued _ 6 THE COMMONWEALTH OF MASSACHUSETTS 5 �� n t BARNSTABLE, MASSACHUSETTS A N 'N (Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed ( ) Repaired ( . Upgraded ( ) Abandoned( )by Q?,Cra\n r G at (o n i,o rone� Q v rz 2 1_� \'Ny\v S has been constr cted in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. dated Installer Designer #bedrooms Approved design flow / gpd The issuance of this permit sh 11 not be c-nstru as a guarantee that the system 'i function as designed. Date �/�/ l�0 Inspector / 7 ——————————— ------------------------ ------ No. i Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE, MASSACHUSETTS 1igo�at,6p2tem Construction Permit Permission is hereby granted to Construct ( ) Repair ( ) Upgrade ( ) Abandon ( ) System located at (00 L,.�O OrQQ-,0_�1 Q 33 , A and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title S and the following local provisions or special conditions. Provided: Cons7�) do _mmu be completed within three years of the date of this p rinit. Date / / Approved by6/ ,.. Lum- . N OF ARNSTABLE LOCATIO SEWAGE # 7, 9-6 VILLAGE //i/ A"A p S ASSESSOR'S MAP LOT 3o1 6,61, 7 INSTALLER'S NAME & PHONE NO. A & B CANCO 775-6264 .SEPTIC TANK CAPACITY 000 LEACHING FACILITY:(type) % -oo 1,eAr- (size) J AA NO.OF BEDROOMS PRIVATE WELL--OR PUBLIC WATER BUILDER OR OWNER • /% everY DATE PERMIT ISSUED: ,) � ) - g"L025 . DATE COMPLIANCE ISSUED VARIANCE GRANTED: Yes No `� fi ' a -71 GY P 3v'7 NO..... ... Fics..---...��o......... ;niav 0 DCpCMfttMTHE COMMONWEALTH OF MASSACHUSETTS —/ j�q OARD OF HEALTH TOWN OF BARNSTABLE Appliratiutt for Diripw3al l ur1w Towitrurtiun Permit WLUA15 Application is hereby made for a Permit to Cortst uct�( ) or Repair (--ran Individual Sewage Disposal System at: ... o * ....._ = ............. . --------•••-......--•-••-----..... ------------•----••................. ao, t an-_\ddress .L Or Lot I� 9 •. -.. Owner y l ° Atc Installer Address UType of Building Size Lot............................Sq. feet �..� DwellingNo. of Bedrooms.-------___-a---_-_ -Ex Expansion Attic a —; __._ pz ( ), Garbage Grinder ( ) pi Other—Type of Building ---------------------------- No. of persons.--__---_--__--_--_---.--- Showers ( ) — Cafeteria ( ) a' Other fixtures ------------------------------- - - W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No. .................... Width.................... Total Length.---.--_-___--_.__-- Total leaching area....................sq. ft. 3 Seepage Pit No--------------------- Diameter----------.--------- Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit-------------------- Depth to ground water........................ L% Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water........................ a •..••-•-----------------------------------•--••--•-----------•-------•-•••-• ...............-----........................................................... 0 Description of Soil........................................................................................................................................................................ x U ••••-•--------••------------•............................•-----•---------•---------••--•.......---••-----••----------------------•-•----•------•-•-._...------------...........---•--•-----.....---•---- � ..................................................... --•--•-----------------------------------••---------•--•---------....----•---•----•---•------•----•---•-••--•-----•--•-----.......-•-------...... U Nature of Repairs or Alterations—Answer when applicable--.rh S -//------/--.Ioigp....��4 j,---.-S��y4I-(t.�._...1. ...Ln......kp.... ----`s-,.(--ak % . . Qn -------------------------- -------- ----•-•. -------- ---..... -------• -••-•••. •--........ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code —The undersigned further agrees not to place the system in operation until a Certificate of Compliance h ben is ued b e board of health. Signed ........... �------------ .....1.�.' t. ..... .3.... Dare Application Approved By ....... .. . ............... .............. e------ . .. --- - ... ....... ........................ ...................�[e..-...------------ Application Disapproved for the following reafo : ........................................................................................ ............................................. .......... ............. ......................... .......-- ............................. ..... f/] .. t/ . Permit No. .. -------------- l/............ Issued ,l . . .1✓ ..... .... ........ _ Dce �,�,5.,, .::.�^".'"„"'w..r•_--�.�..-....r...-�+--'*...-..s'••--------4"y..-..e�....•�.�..-..�..�„��-.-�-o...:tl.�ay''�"c" ,rs..-...-...�w..�� ...��r` �"�,�•,.,-yr_...r- --.,_.._.,t. rII/lJ p .. 3 Ul%7 Par U5 No _... FEB. ..... .... THE COMMONWEALTH OF MASSACHUSETTS .rBOARD OF HEALTH TOWN OF BARNSTABLE Apphration for Diripngttl Vorlw C owitrurtiun Famit f�r��r�Ap Application is hereby made for a Permit to Construct or lte air an Individual Se a Disposal PP Y �( ) P. (-�` � P System at: ` / .................•--......---•.....--•- Leealion-Address or Lot No. --......... n owner Address )(-C�--------•-•---------•-•-------------------••. ...--.. ------ G` a ........................ .......... Installer Address UType of Building Size Lot............................Sq. feet .., Dwelling—No. of Bedrooms------------�------------------------Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) dOther fixtures -_--------------------- ------- ....................----------•-------------------........---------•-•----------------------...-•-•--•---•----•---- W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity------------gallons Length--.---_--_-- Width---------------- Diameter--- ............ Depth................ x 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 ( ) Dosing tank ( ) 04 Percolation Test Results Performed by.......................................................................... Date........................................ W Test Pit No. I................minutes per inch Depth of Test Pit-------------------- Depth to ground water........................ 44 Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water........................ a ...-••----••----------------•-•--....•••--•-•-•---•-••---•-..._....--••-•-•---.......---..._....•---......................................................... 0 Description of Soil..................................................................................... --------•---------...-----------------•-----------------.........•...........-•--• -------------•----- -------------• ------.-----------•-------- -----------------------•---------------------------------- --M --- ----------------••-----•.------••-••------------ U Nature of Repairs or Alterations—Answer when applicable..__ _ _��-____-7...1_d/2n.___�_,�_1...__._:<'/41`.,_c......?w c...... A ii .....1 a _............. ........................................ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by, :he board of health. Signed ...................... ....... ..�. /�, t - ................... .....1..(.....�.�..'..9...'��.... �). �.........`�:-'LV may+............... Dare Application Approved B _ -� �_/ . �.._� ►1.r-... ..... ..P................ PP PP Y .................. � .................. �/ � ✓ / "'_ 8i / ��CN (/•' I t/7i ��... Dare Application Disapproved for the following rea.rosvr: -. j/ ................................................................................................................... ...... .................n..... ./ >- ... {..............................--.. - ---------- ----------- ( j ,�[ —Date Permit No. .3./.. ......,,.. Issued ................. a e ..... ..�.-..�.....--. / THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE C'IEr#tfirate of Compliance THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( c,)"- by .................. ......_.-�/�Q rl.�.«._...... .. ........................................_....-------_-----...................................................... ............................ 1 l 1nsr.J lcr at .. n.f..............!f,.,/...h..0..d:.�`1�L:`. ..1f...._...___ .n. _................._.. 'T.rl,..l. ....._..........................._..............................................: has been installed in accordance with the provisions of TITLE 5 of e State F nv onmental Code as described in the application for Disposal Works Construction Permit No- ------------ .n dated THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE------------........1.. _~ �.. ...... -------- Inspector ... ........ .... •................. .. .............. .... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH No. `�.�� TOWN OF BARNSTABLE FEE...... o . ... _........II ........ .•.. liiipniittl Vorkii Tunstrurtion "Vrrntit Permissionis hereby granted...........A.?.-(52----------- --------------------------------------------------------------------•------..---.-.-.- to Construct ( ) or Repair ( &,)—an Individual Sewage Disposal System atNo...... —0....-•••••... >D 4.!.t,` ......4AJ'J�--_--------------------------- ------- o-•-----/ •-------.------... street as shown on the application for Disposal Works Construction 'ermit No Mated..�...................�.�............ r v Boar of Hcea`lth DATE. �/� ----� --- FORM 36508 HOBBS Q WARREN.INC..PUBLISHERS n ; I;0MMONWLAI;1 II Oh MASSnCIIUSI;'I"I'� OF]WE O[' I:,NVIIt.ONMI;N'I'AL, Arrnrrzs ++_— I)f;1.1Alt'1'M_I',N'l' Or ENVI.R0NM1,,N'1'AI, 1'TtO'l'EG'VION t =- /,•?. ONI; WIN'rFI?.STIZFF,'I', ROS'T'ON MA 02109 (617) 292-550o WPC r } TI?UDY c:OXG Berl-r,I.nl'y 350 MAIN STREET ARG,FO PAU1, ct;1,11,UC(A WF_ST YARMOUTH, MA DAVID 11. S'FRIIIIS Governor r t� 508-775-2800 Cnmroissi„n�r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION MAP 307 PAR 056 PROPERTY ADDRESS: 60 WOODBURY RD, HYANNIS ADDRESS OF OWNER: DATE OF INSPECTION: OCTOBER 22, 1999 CAROL STEWART NAME OF INSPECTOR : JAMES D.SEARS I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 9310 CMR 15.000) COMPANY NAME: A&B Canco MAILING ADDRESS: 350 Main Street,West Yarmouth,MA.02673 TELEPHONE NUMBER: (508 7) 7)-7-800 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: X PASSES CONDITIONALLY PASSES NEEDS FURTHER EVALUATION BY THE LOCAL APPROVING AUTHORITY FAILS INSPECTORS SIGNATURE: _ DATE: 7 The system Inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP) within thirty(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 Depadnienl of Environmental Protection. The original should be sent to the system owner,and copies sent to the buyer,if applicable and the approving authority. NOTES AND COMMENTS: SITE OVER ALL PASSES,INSPECTION OF SYST EM IS BASED ON CONDITION OF SYSTEM AT THE TIME OF THE INSPECTION.THERE IS NO GUARANTEE ON THE LIFE OF.THE IE SYSTEM. 9 r'999 { d, 912/98 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A • CERTIFICATION(continued) Property Address: 60 WOODBURY ROAD, HYANNIS Owner: CAROL STEWART Date of Inspection: OCTOBER 22, 1999 INSPECTION SUMMARY: Check A, B, C, orD: A] SYSTEM PASSES: YES I have not fount any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. COMMENTS: B SYSTEM CONDITIONALLY PASSES: 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. Indicate yes,no,or not determined(Y,N,or ND). Describe basis of determination in all instances. If"not determined",explain why not) The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate Of Compliance(attached)indicating that the tank was installed within twenty(20) years prior to the date of the inspection;or the septic tank,whether or not metal,is cracked,structurally unsound,shows substantial infiltration or exfiltration,or tank is failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. The system will pa pass inspection if(with approval of the Board of Health). broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed revised 9/2/98 2 ; SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 60 WOODBURY ROAD, HYANNIS Owner: CAROL STEWART Date of Inspection: OCTOBER 22, 1999 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 the public health,safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 15.303 (1)(b)THT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER,IF ANY) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and 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 soil absorption system and the SAS is within a Zone 1 of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well,unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen and is equal to or less than S ppm. Method used to determine distance (approximation not valid). 3) OTHER i revised' 9/2/98 3 } • F t s SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 60 WOODBURY ROAD, HYANNIS Owner: CAROL STEWART Date of Inspection: OCTOBER 22, 1999 D] SYSTEM FAILS: N/A You must indicate either"Yes"or"No" to each of the following: I have determined that one or more of the following failure conditions exist as described in 310 CMR 16.303. The basis for this determination is identified below. The Board of Health should be contacted to Determine what will be necessary to correct the failure. Yes No Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an over- loaded or clogged SAS or cesspool. Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6"below invert or available volume is less than%day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s) Number of times pumped Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic compounds,ammonia nitrogen and nitrate nitrogen. E) LARGE SYSTEM'FAILS: N/A You must indicate either"Yes"or"No"as to each of the following: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or mapped Zone II of a public water supply well) The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional office of the Department for further information. I 1 revised 9/2/98 e. s. 4 w Al SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 60 WOODBURY ROAD, HYANNIS Owner: CAROL STEWART Date of Inspection: OCTOBER 22, 1999 Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following: Yes No X Pumping information was provided by the owner,occupant,or Board of Health. X None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. X As built plans have been obtained and examined. Note if they are not available with N/A. X The facility or dwelling was inspected for signs of sewage back-up. X The system does not receive non-sanitary or industrial waste flow. X The site was inspected for signs of breakout. X All system components,including the Soil Absorption System,have been located on the site. X The septic tank manholes were uncovered,opened,and the interior of the septic tank was inspected for condition of baffles or tees,material of construction,dimensions,depth of liquid depth of sludge,depth of scum. The size and location of the Soil Absorption System on the site Has been determined based on: X Existing information.Ex.Plan at B.O.H. X Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable)[I5.302(3)(b)] X The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of Sub-Surface Disposal System. 5 revised 9/2/98 F SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address:. 60 WOODBURY ROAD, HYANNIS Owner: CAROL STEWART Date of Inspection: OCTOBER 22, 1999 FLOW CONDITIONS RESIDENTIAL: YES A Design flow: 220 g.p.d./bedroom for S.A.S. Number of bedrooms(design) 2 Number of bedrooms(actual): 2 Total DESIGN flow Number of current residents: 1 Garbage grinder(yes or no): NO Laundry(separate system) (yes or no): NO If yes,separate inspection required Laundry system inspected(yes or no): YES Seasonal use(yes or no) NO Water meter readings,if available(last two(2)year usage(gpd): N/A Sump Pump(yes or no): NO Last date of occupancy: N/A COMMERCIAL/INDUSTRIAL: N/A Type of establishment: Design flow: Gpd(Based on 16.203) Basis of design flow Grease trap present:(yes or no): Industrial Waste Holding Tank present:(yes or no) Non-sanitary waste discharged to the Title 5 system:(yes or no) Water meter readings,if available: Last date of occupancy: OTHER:(Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: NIA System pumped as part of inspection:(yes or no) NO If yes,volume pumped: gallons Reason for pumping TYPE OF SYSTEM X Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no)(if yes,attach previous inspection records,if any) I/A Technology etc.Attach copy of up to date operation and maintenance contract. Tight Tank Copy of DEP Approval Other APPROXIMATE AGE of all components, date installed (if known) and source of information: INSTALLED 1993 PERMIT#93-620 Sewage odors detected when arriving at the site:(yes or no) NO revised 9/2/98 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 60 WOODBURY ROAD, HYANNIS Owner: CAROL STEWART Date of Inspection: OCTOBER 22, 1999 BUILDING SEWER: N/A (Locate on site plan) A Depth below grade: Material of construction _ cast iron _ 40 PVC. other(explain) Distance from private water supply well or suction line Diameter Comments:(condition of joints,venting,evidence of leakage,etc.) SEPTIC TANK: YES (Locate on site plan) Depth below grade: 101, Material of construction X concrete _ metal _ Fiberglass _ Polyethylene _ other(explain) If tank is metal,list age Is age confirmed by Certificate of Compliance - (Yes/No) Dimensions: 1,000 GALLON PRE CAST Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle: 28" Scum thickness: 0" 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: 18" How dimensions were determined TAPE&AS BUILT Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage,etc.) TANK AT WORKING LEVEL,TANK AND COVER 10"BELOW GRADE OUTLET BAFFLE,INLET HAS TWO TEES GREASE TRAP: N/A (locate on site plan) Depth below grade: Material of construction _ concrete _ metal _ Fiberglass _ Polyethylene _ other(explain) Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle.- Date of last pumping: Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage,etc.) revised 9/2/98 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 60 WOODBURY ROAD, HYANNIS Owner: CAROL STEWART Date of Inspection: OCTOBER 22, 1999 TIGHT OR HOLDING TANK:N/A (Tank must be pumped prior to,or at time,of Inspection) (Locate on site plan) Depth below grade: Material of construction _ concrete _ metal Fiberglass _ Polyethylene _ other(explain) r Dimensions: Capacity: Gallons Design flow: gallons/day Alarm present Alarm level: Alarm in working order Yes; No Date of previous pumping: Comments: (condition of inlet tee,condition of alarm and float switches,etc.) DISTRIBUTION BOX: YES (locate on site plan) Depth of liquid level above outlet invert: 0 Comments: (note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc,) D BOX IS 16"X 16",22"BELOW GRADE ONE LINE IN,ONE LINE OUT BOX IS CLEAN,LEVEL AND SOLID 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.) revised 9/2/98 8 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 60 WOODBURY ROAD, HYANNIS Owner: CAROL STEWART Date of Inspection: OCTOBER 22, 1999 SOIL ABSORPTION SYSTEM (SAS): YES (locate on site plan,if possible;excavation not required,but may be approximated by non-intrusive methods) A If not located, explain: Type: Leaching pits,number: 1 Leaching chambers,number: Leaching galleries,number: Leaching trenches,number,length: Leaching fields,number,dimensions: Overflow cesspool,number, Alternative system: Name of Technology: Comments: (note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.) ONE 1,000 GALLON PRE CAST PIT PIT AND COVER Z BELOW GRADE PIT DRY,WALLS CLEAN CESSPOOLS: N/A (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(cesspool must be pumped as part of inspection) Comments:: (note condition of soil,signs of hydraulic failure,,level of ponding,condition of vegetation,etc.) J 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.) revised 9/2/98 9 I z SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 60 WOODBURY ROAD, HYANNIS Owner: CAROL STEWART Date of Inspection: OCTOBER 22, 1999 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to a6east two permanent references landmarks or benchmarks locate all wells within 100'(locate where public water supply comes into house) W ,}0, _ ys' 0 So� 7— revised 9/2/98 10 �I v . SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 60 WOODBURY ROAD, HYANNIS Owner: CAROL STEWART Date of Inspection: OCTOBER 22, 1999 NRCS Report name Soil Type Typical depth to groundwater USGS Date website visited Observation Wells checked Ground water depth: Shallow Moderate Deep SITE EXAM Slope Surface water Check Cellar Shallow wells Estimated Depth to no groundwater 12 Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record X Observation of Site-observation hole Determine it from local conditions Check with local Board of health Check FEMA Maps Check pumping records Check local excavators,installers Use USGS Data Describe in your own words how you established the High Groundwater Elevation.(Must be completed) NOTE: HAND DUG TEST HOLE TEST HOLE NOTED ON PAGE 10 TEST HOLE 4' BELOW BOTTOM OF PIT -.revised 9/2/98 11 F