HomeMy WebLinkAbout0018 BIRCH STREET - Health r
TOWN OF BARNSTABLE
L fnON ZE 13kd IT_ SEWAGE # 100
VILLAGE ASSESSOR'S MAP &LO O
INS 2ALLER'S NAME&PHONE NO. ZY -4 ob iw- .5 04';L � 22 e��p
r
SEPTIC TANK CAPACTTy I—ry a
LEACHING FACILITY: (type) 1,V 7 AI z'070-w— (size)
NO. OF BEDROOMS a
BUILDER OR OWNS
PERMTTDATE: "COMPLIANCE DATE:
Separation Distance Between the:.
Maximum Adjusted Groundwater Table and 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 r
within 300 feet of leaching facility) y Feet +,
Furnished by
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No. oo Q/ Fee
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THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: 1
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
0ppYfcation for Migaal *p5tem Cow5truction Permit
Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) P(Ilomplete System ❑Individual Components
Location Address or Lot No. ` ;r�� �— c •�� Owner's Nam kt
ess and Tel.No.
Assessor'sMap/Parcel 0p S
4
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
�S �c�vas s�� ��
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No. of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow ��� gallons per day. Calculated daily flow J�O( gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank ,60 U'�-) Type of S.A.S. t G
Description of Soil Y V 1 C oy\izw 5NN,,, D
Natur of Re airs or Alterations(Answer when applicable) /���� 15 OT C-
` 0� I=rh2(L4kkA CC(b-,ccx�5' 7 1Lcr-'VP - << Stf��
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been iss
Signed Date -®�
Application Approved by Date 1-7-7:-e_P-0
Application Disapproved for the ollowing reasons
Permit No. 0 Date Issued
No. `-'(0—O/ff Fee
� Entered in computer:
✓ `
~'- THE COMMONWEAL T�di-OF MASSACHUSETTS p
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLES MASSACHUSETTS
2pplication for Zio'Taal *pgtein Construction Permit
Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) omplete System El Individual Components
Location Address or Lot No. ` `f���Cj '— c Owner's Nam , ddress and Tel.No.
Assessor'sMap/ParceloC/
tt S
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
- Other Fixtures
Design Flow � d gallons per day. Calculated daily flow ��� gallons.
Plan Date Number of sheets '> Revision Date
Title
-Size of,Septic Tank t 60 `1)A « Type of S.A.S. (A 1—c, 1;,r.r is C,)rJ
o
Description.of Soil; If C o
Nature of Repairs ort-Alltera�t^i'ons(Answer when applicable). /� �t VA( 1 S 07i'
%01F V ,(kc �\ Cr, rY-<"rr
Date last inspected:
Agreement:-_
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions' of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been_issu b3�tls-B Eal
Signed 1 Date
Application Approved by Date / 7' Z -Vi>
Application Disapproved for the following reasjons
a
Permit No. 10~ ��� {, Date Issued
---------------------------------------
THE COMMONWEALTH OF MASSACHUSETTS
3,6
_U BARNSTABLE, MASSACHUSETTS
(Certificate of (Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( )Repaired( )Upgraded
Abandoned( )by M 1 l� S�y� i C_
at 1F5 Lj,,r_C has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. W '0/ dated /—7-- ?A'rl" .
Installer l Designer _ }, AA A
The issuance of this p t�all not a construed as a guarantee that the systemlwill function/as desigrte�d� � /�
ff
Date � I / / Inspector �c �1��!I. n b 7,1/m/u AV
it
Fee €
THE COMMONWEALTH OF MASSACHUSETTS
3 d�_Q PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS
Zi5po5ar *p5tem Construction permit
Permission is hereby granted to Construct( })Repair( )Upgrade(l,/-)Aban od n(
System located at 1 ,7
and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to
comply with Title 5 and the following local provisions or special conditions.
Provided:Construction must be completed within three years of the date of this p it.
Date: '" � Approved by 0
1/6i99
NOTICE: This Form Is To & Used For the Repair Of Failed
Septic Systems Only. -
CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL
WORKS CONSTRUCTION PERNQ (WITHOUT DESIGNED PLAYS)
, heresy c..orary that the application nor atsposal works
construction permit signed by me dated �-OCR concernins the
property located at T— [�� v. meets all of the
following criteria:
�/• The failed system is tonne✓ed to a residential dwelling only. i nere are no commercial or business
uses associated with the dwelling.
" The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch.
t/• There are no wetlands within 100 feet of the cr000sed seutic system
v- There are no private wells within 1140 fert of the oroposea septic system
416 There is no increase in flow and/or change in use proposed
There are no variances requested or needed.
The bottom of the proposed leaching facility will not be located less than five feet above the
ma..draum adjusted groundwater table elevation. [Adjust the groundwater table swing the Frimptor
method when applicable]
If the S.A.S. will be located with 250 feet of any vegetated wetlands. the bottom of the proposed
leaching facility will not be located less than fourteen(14) feet above the maximum adjusted
groundwater table elevation.
Please complete the folIowin;;
- �e J
A) Top of Ground urface aieva[ion(coin; GIS infdrmation)
B) G.W. Elevadon (e =the -,,h G.W. Adjustment . 'r
r DIT ERENCE BETWEEN A and B
SIGNED : D ATE.
(Sketch proposed plan of system on bacc].
q:health(older yet
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1
-�
TOWN OF BARNSTABLE
LOCATION /�' J3�T/� s`% SEWAGE # �D
VILLAGE ��/d.�'�/� ASSESSOR'S MAP &LO o
INSTALLER'S NAME&PHONE NO. ,;-► �' e- L
j SEPTIC TANK CAPACITY
1
LEACHING FACILITY: (type) /,V ",/;IZV 70-S (size) S� i�✓'- �
NO.OF BEDROOMS
BUILDER OR OWNE �
PERMITDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and 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
i Furnished by
t�
X
i
TOWN OF BAMSTABLE
L _ATIbN aA� e.L SEWAGE #
VU-,LAGE.� ` ASSESSOR'S MAP & LOTS��6
INSTALLER'S NAME&PHONE NO.,,S-=ai I`YI• On�S
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) (size)
NO. OF BEDROOMS
B�OWNER J _5
PERMITDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
REAR Of HOUSE
A B
TANK O Q 1
A-1=21'
B-1=19'
D-BOX ❑2
A-2=20'
B-2=29'
S.A.S.
A•3=31'
B-3=33
YOU WISH TO OPEN A BUSINESS?
For Your Information: Business certificates(cost$40.00 for 4 years), A business certificate ONLY REGISTERS YOUR NAME in town (which you
most do by M.G.L.-it does not give you permission to operate.) You must first obtain the necessary signatures on this form at 200 Main St., Hyannis.
Take the completed form to the Town Clerk's Office, 1 st FI., 367 Main St., Hyannis, MA 02601 (Town Hall) and get the Business Certificate that is
required by law.
DATE: ^(v n please:
Fill i
APPLICANT'S YOUR NAME/S:
a` �= � " P BUSINESS YOUR HOME ADDRESS: ( Z
,,„4 A' '. �k{: 50 332 Z5 H --1C2.010'IS; WE) o
.TELEPHONE # Home Telephone Number
� -'
OR EIN #: — ''y '(I� E`HAI � � � (" � Q I n
NAME OF CORPORATION- C P1 ("1-6KMM a — F.A c—c's -
NAME OF,NEW BUSINESS TYPE OF BUSINESS 01� r)WQ T
IS THIS A HOME OCCUPATIO ? Y NO
ADDRESS OF BUSINESS. MAP/PARCEL NUMBER >✓b2(a<6 I [Assessing)
When starting a new business there are several things you must do in order to be in compliance with the rules and regulations of tha Town of
Barnstable. This form is intended to assist you in obtaining the information you may need. You MUST GO TO 200 Main St. — (corner of Yarmouth
Rd. &Main Street) to make sure you have the appropriate permits and licenses requJrred to legally operate your business in this town.
1. BUILDING COMMISSIONER'. FFICE —� MUST COMPLY WITH HOME OCCUPATION
This individual has been i d any pq uiremerlt .that pertain t is type of business. RULES AND REGULATIONS. FAILURE TO
tho ed Sin e**� C AY ESUj Id IP►, ,
COMMENT
2. BOARD OF HEALTH
This individual has been informed th rmit re uirements
HA
that pertain to this type of business. MUST COMPLY VVlfili ALA.=
HAZARDOUS MATERIALS REGULATIONS
Authorized Signat 'e**
COMMENTS:
3. CONSUMER AFFAIRS(LICENSING AUTHORITY)
This individual has been informed of the licensing requirements that pertain to this type of business.
Authorized Signature**
COMMENTS:
f
TOWN OF BARNSTABLE Date::�/C)�/
TOXIC AND HAZARDOUS MATERIALS REGISTRATION FORM
INAME OF BUSINESS: --dean'\nQ &xoces
BUSINESS LOCATION: I t-91�G5(1 fi2P`Ic� =niS INVENTORY
1 MAILING ADDRESS: (9) 16i F2C'n SYee-e-:t, tAuantiS t.AA 026051 TOTAL OUNT:
j TELEPHONE NUMBER: �SO
i CONTACT PERSON:
EMERGENCY CONTACT TELEPHONE NUMBER: -11 2,28 6(045 MSDS ON SITE?
TYPE OF BUSINESS: Unp nQ
INFORMATION / RECOMMENDA NS: Fire District:
Waste Transportation: Last shipment of hazardous waste:
Name of Hauler: Destination:
Waste Product: Licensed? Yes No
NOTE: Under the provisions of Ch. 111, Section 31, of the General Laws of MA, hazardous material use,
storage and disposal of 111 gallons or more a month requires a license from the Public Health Division.
LIST OF TOXIC AND HAZARDOUS MATERIALS
The Board of Health and the Public Health Division have determined that the following products exhibit toxic or
hazardous characteristics and must be registered regardless of volume.
Observed / Maximum Observed / Maximum
Antifreeze (for gasoline or coolant systems) Miscellaneous Corrosive
❑ NEW ❑ USED Cesspool cleaners
Automatic transmission fluid li Disinfectants
Engine and radiator flushes Road salts (Halite)
Hydraulic fluid (including brake fluid) Refrigerants
Motor Oils Pesticides
❑ NEW ❑ USED (insecticides, herbicides, rodenticides)
Gasoline, Jet fuel,Aviation gas
Photochemicals (Fixers)
Diesel Fuel, kerosene, #2 heating oil ❑ NEW ❑ USED
Miscellaneous petroleum products: grease,
Photochemicals (Developer)
lubricants, gear oil ❑ NEW ❑ USED
Degreasers for engines and metal Printing ink
Degreasers for driveways&garages Wood preservatives (creosote)
Caulk/Grout Swimming pool chlorine
Battery acid (electrolyte)/Batteries Lye or caustic soda
Rustproofers Miscellaneous Combustible
Car wash detergents Leather dyes
Car waxes and polishes Fertilizers
Asphalt& roofing tar PCB's
Paints, varnishes, stains, dyes Other chlorinated hydrocarbons,
Lacquer thinners (including carbon tetrachloride)
❑ NEW ❑ USED Any other products with "poison" labels
(including chloroform, formaldehyde,
Paint&varnish removers, deglossers hydrochloric acid, other acids)
Miscellaneous. Flammables Other products not listed which you feel
Floor&furniture strippers may be toxic or hazardous (please list):
nl Metal polishes
Laundry soil &stain removers
2 (including bleach)
Spot removers&cleaning fluids
3 ' (dry cleaners)
Other cleaning solvents
Bug and tar removers
K' -
Windshield wash
WHITE COPY-HEALTH DEPARTMENT I CANARY COPY-BUSINESS Applicant's Si nature Staff's Initials /
14
k
T Town of Barnstable
Regulatory Services
BMWSTASL€,
i6& 1�
prfD, a Public Health Division
Thomas Mclean, Director
200 Main Street, Hyannis, MA 02601
Office: 508-862-4644
-- Fax: 508-790-6304
Brad Sprinkle
November 13, 2013
199 Barnstable Road
Hyannis, MA 02601 I
NOTICE TO ABATE VIOLATIONS OF 105 CMR 410.000 STATE SANITARY
CODE II — MINIMUM STANDARDS OF FITNESS FOR HUMAN HABITATION AND THE TO N W OF BARNSTABLE CODE CHAPTER 170.
The property owned by you located at 18 Birch Street, Hyannis, MA, was inspected on
November 13, 2013 by Timothy B. O'Connell, R.S., Health Inspector for the Town of
Barnstable. This inspection was conducted in result of a complaint received at The
Barnstable Health Division.
The following violations of the State Sanitary Code were observed:
105 -'MR 410.100 - Kitchen Facilities Oven within said unit not working.
You are directed to correct the State Sanitary Code violations listed above within
fourteen (14) days of your receipt of this notice.
You may request a hearing before the Board of Health if written petition requesting same
is received within ten (10) days after the date the order is served.
Non-compliance will result in a fine of $100.00 per, violation. Each day's failure to
comply with an order shall constitute a separate violation. -
Should you have any questions regarding the above violations, please contact the Town
Health Division-aid ask to speak with the inspector who performed the inspection.
PER ORDER O THE BOARD OF HEALTH
I
mas A. McKean R:S., CHO
Director of Public Health
Town of Barnstable
i
I
NOV.25.2013 12:44 E087751350 Sprinkla #3753 P.00= /001
°E.
Brad S Tinkle
199 Barnstable Road• Hyannis,MA 02601 . 508 775-1778.800 244-1778•lax 508 775-1350
Ageut-Margo_sprialkic(gi;coancasLnet
November 25, 2013
Tim O'Connell
Town of Barnstable
Public Health Division
200 Main St.
Hyannis, MA 02601
Ike: 18 Birch St., Hyannis
Dear Tim,
am in receipt of your letter regarding the stove at 18 Birch St., Hyannis. We are
currently trying to find out if we just need to replace an element or if the stove
needs replacing.
It has been difficult getting technicians to respond and respectfully request an
extension until December 6, 2013.
Sincerely,
Brad Sprinkle
Landlord
8 .
Town of Barnstable
Regulatory Services
M 4
BARNSfABM
Public Health Division
Thomas McKean, Director
200 Main Street, Hyannis, MA 02601
Office: 508-862-4644 Fax: 508-790-6304
C November 13, 2013
Brad Sprinkle
199 Barnstable Road Z�
Hyannis, MA 02601 r. 9,
NOTICE TO ABATE VIOLATIONS OF 105 CMR 410.000, STATE SANITARY
CODE II — MINIMUM STANDARDS OF FITNESS FOR HUMAN HABITATION
AND THE TOWN OF BARNSTABLE CODE CHAPTER 170.
The property owned by you located at 18 Birch Street, Hyannis, MA, was inspected on
November 13, 2013 by Timothy B. O'Connell, R.S., Health Inspector for the Town of
Barnstable. This inspection was conducted in result of a complaint received at The
Barnstable Health Division.
The following violations of the State Sanitary Code were observed:
105 CMR 410.100 - Kitchen Facilities Oven within said unit not working.
You are directed to correct the State Sanitary Code violations listed above within
fourteen (14) days of your receipt of this notice.
You may request a hearing before the Board of Health if written petition requesting same
is received within ten (10) days after the date the order is served.
Non-compliance will result in a fine of $100.00 per violation. Each day's failure to
comply with an order shall constitute a separate violation.
Should you have any questions regarding the above violations, please contact the Town
Health DivisioIR
sk to speak with the inspector who performed the inspection.
PER ORDER HE BOARD OF HEALTH
ma A. McKean, :S., CHO
Director of Public Health
Town of Barnstable
�n.. Citizen Web Request Page 1 of 3
Zt
pm 71
ARN
ABLE
Logged In Citizen RequeSl Management wednesday, November 62013
TOtNN\oconnnnelt
N° �I& `'1
Route to Users Search Requests Create Requests Reports
Request Information
Request ID: 47544 Created: 10/2/2013 11:51:08 AM
Status: Assigned To Staff Assigned To: O'Connell,Timothy
Health Office
Anonymous: No Request Category: Chapter II : Housing Substandard edit
Routine work: No Estimate: No edit
Date scheduled: edit
Estimated 10/17/2013 Change Estimated Set October 2013 Nov
Completion Completion Date:
Date: Sun Mon Tue Wed Thu Fri Sat
29 30 1 2 3 4 5
6 7 8 9 10 11 12
13 14 15 16 17 18 19
20 21 22 23 24 25 26
27 28 I L91 30 131 1 2
3 4 5 6 7 8 9
Created By: Parvin, Lindsay Priority: Medium edit
Health Office
Citation Numbers: edit
Requestor Information
Requestor
Request Parcel Number 309 0
Requestor reports that the p: 1_� 1 Block: 86 �Lot: 000
Ma
basement is in "deporable condition"
and that the tenants keep food stored Parcel Lookup
down there. Requestor reports on
11/6/2013 that the walkway and
driveway need repairs, several doors
and windows are broken,the stove is
broken,the insulation issue hasn't
been repaired and the fence is
broken.
Email:
http://issgl2/intemalwrs/WRequest.aspx?ID=47544 11/6/2013
Citizen Web Request Page 2 of 3
Edit Requestor Information
Track Request Progress
Request Work History: Internal Note History:
Entered on 10/3/2013 8:17:58 AM System entry on 10/2/2013 11:51:08 AM:
by O'Connell,Timothy
Assigned to Parziale,Jim
On 10-2-13 went to said property and met with
occupant. I did observe missing insulation in some System entry on 10/2/2013 1:07:15 PM:
areas between the floor joist. Occupant said that oil
deliver man said oil tank is ready to fail. I then had Assigned to O'Connell,Timothy
Lt. Cosmo meet me at home. He stated that he did
have some concerns about tank but could not deem System entry on 11/6/2013 8:16:36 AM:
it structurally unsound. I will oder owner to replace
insulation and talk to him about replacing tank. I can Request Closed by oconnelt
not order replacement of tank because I did not - -
observe it leaking. System entry on 11/6/2013 8:16:43 AM:
update delete
Request Reopened by oconnelt
Entered on 11/6/2013 8:16:36 AM Entered on 11/6/2013 11:39:44 AM
by O'Connell,Timothy by Parvin, Lindsay
Owner called stating work has been completed. Tim, he came in with additional complaints
Above number not working. and gave a new phone number.
update delete
Enter work progress: Enter internal note:
(Viewed by everybody) (Viewed internally only)
`J k
............::.mod i''
Spell Check � SpelllCheck ;;'
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Current Links:
Time worked on request: 1 00 Response time: 1.00
http://issgl2/intemalwrs/WRequest.aspx?ID=47544 11/6/2013
ISENDER::COMPLETE THIS SECTION • • • DELIVERY
e Complete items 1,2,and 3.Also complete A. Signature
item 4 if Restricted Delivery is desired. X Agent
C E Print your name and address on the reverse ❑Addressee
so that we can return the card to you. B. Received by Prin Name) Date of D livery
■ Attach this card to the back of the mailpiece, . to of Ii
or on the front if space permits.
D. Is delivery address different from item 1? ❑Yes
1. Article Addressed to: If YES,enter delivery address below: ❑No
Brad Sprinkle
�
C 199 Barnstable.Road •A
r Hyanr%is, MA 02601 3. Service Type
Vertified Mail ❑Express Mail
` ❑Registered ❑Return Receipt for Merchandise
❑Insured Mail ❑C.O.D.
4. Restricted.Delivery?(Extra Fee) ❑Y�es
2. AMcle N-vMber ( r `
' - (Transfer from service label) 7 12 1010 '0 0 0 0 2 8 5D 815 9
N PS Form 3811,February 2004 Domestic Return Receipt 102595-02-M-1540
UNITED STAT09'RQ!V%,A'C!-8—
?6si'
he'
•
arm,
Sender: Please print your name, address, and ZIP+4 in this box •
Town of Barnstable
Health Division
200 Main Street
Hyannis, MA 02601
111111111"10111//IIIq JIIII /fill I/Id I III d)111111
Certified Mail#7012,1010 0000 2850 8159
Town of Barnstable
Regulatory Services
RARNSCABLE,
1NASS.
fD ,�a Public Health Division
Thomas McKean, Director
200 Main Street, Hyannis, MA 02601
Office: 508-862-4644 Fax: 508-790-6304
October 8, 2013 I
Brad Sprinkle
199 Barnstable Road
Hyannis, MA 02601
NOTICE TO ABATE VIOLATIONS OF 105 CMR 410.000, STATE SANITARY
CODE II — MINIMUM STANDARDS OF FITNESS FOR HUMAN HABITATION
AND THE TOWN OF BARNSTABLE CODE CHAPTER 170.
The property owned by you located at 18 Birch Street, Hyannis, MA, was inspected on
October 2, 2013 by Timothy B. O'Connell, R.S., Health Inspector for the Town of
Barnstable. This inspection was conducted in result of a complaint received at The
Barnstable Health Division.
The following violations of the State Sanitary Code were observed:
105 CMR 410.500—Owner's Responsibility to Maintain Structural Elements
Insulation in basement area is falling down and missing from between floor joist.
You are directed to correct the State Sanitary Code violations listed above within
thirty (30) days of your receipt of this notice.
You may request a hearing before the Board of Health if written petition requesting same
is received within ten(10) days after the date the order is served.
Non-compliance will result in a fine of $100.00 per violation. Each day's failure to
comply with an order shall constitute a separate violation.
Should you have any questions regarding the above violations, please contact the Town
Health Division and ask to speak with the inspector who performed the inspection.
PER ORDER OF THE BOARD OF HEALTH
as A. McKean, R.S., CHO
Director of Public Health
Town of Barnstable
I
P.1
COLO��, *
**ME HEATl1�G► **
11/22/2013
Re:Integrity of Oil Tank
18 Birch Street
Hyannis,MA
Dear 1&. O'Connell:
Upon inspection of the oil tank located at the above property it was found to have
substantial visible rust covering the exterior surface,as well as the legs which are the
support for the tank.
Based on these findings it is in our opinion that the oil tank be removed and replaced.
C)
Sincerely,
i
C�
Richard G.Mahoney
President
P.O.Box242-West Barnstable,MA02668.500-640-1807 508-428-1807 508-224-2255 Fax 508-362-1513
Commonwealth Of Massachusetts
Executive Office Of Environmental Affairs
Department Of Environmental Protection
TITLE 5
Official Inspection Form -Not.For Voluntary Assessments
Subsurface Sewage Disposal System Form
Part A
Certification
Property Address: 18 Birch St.Hyannis Ma.02601
Owners Name:Eric Ellis
Owners Address: 18 Birch St.Hyannis Ma.02601
�.n
Date of Inspection:4/1/2006
Name of Inspector(please print)Sean M.Jones N'
Company Name:S.M.Jones Title V Septic Inspectors `5
Mailing Address:74 Beldan Ln. M: x
Centerville Ma.02632
Telephone Number:508-778-4597 -
CS'e i`T 1
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:
X Passes
Conditionally Passes
Needs further evaluation by the Local Approving Authority
Fails
Inspectors Signature Date: L /1,)eo
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:
****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 1
In elVj
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(cowmxD)
Property Address: 18 Birch St.Hyannis Ma.02601
Owner:Eric Ellis
Date of Inspection:4/l/2006
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: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 the 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 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:
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(cola mmp)
Property Address: 18 Birch St.Hyannis Ma.02601
Owner:Eric Ellis
Date of Inspection:4/1/2006
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 310CMR 15.303(1)(b)that the
System functioning in a manner that protects the public health,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 supplyor 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 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:
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(coNTuv m)
Property Address: 18 Birch St.Hyannis Ma.02601
Owner:Eric Ellis
Date of Inspection:4/1/2006
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 '/2 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 cesspool or privy is within Zone 1 of a public well.
X Any portion of cesspool or privy is within 50 feet of a private water supply well.
Any portion of 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 pp,provided that no other failure criteria
are triggered.A copy of the analysis must be attached to this form.]
X (Yes/No)The system fails.I have determined that one or more of the above 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 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:
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
If you 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
CM15.304.The system owner should contact the appropriate regional office of the Department.
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 18 Birch St.Hyannis Ma.02601
Owner:Eric Ellis
Date of Inspection:4/1/2006
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 system components pumped out in the previous two weeks?
X _ Has the system received normal flows in the previous two week period?
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 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 tee,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. s-Built
_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)]
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: IS Birch St.Hyannis Ma.02601
Owner:Eric Ellis
Date of Inspection:4/1/2006
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design):-3— Number of bedrooms(actual):_3_
DESIGN flow based on 310 CMR 15.203(for example): 110 gpd x#of bedrooms): 330 GPD
Number of current residents:-3—
Does residence have a garbage grinder(yes or no): No
Is laundry on a separate sewage system(yes or no)_No [if yes separate report required]
Laundry system inspected(yes or no):_N/A
Seasonal use:(yes or no) No
Water meter readings,if available(last 2 years usage(gpd): � ¢ aooS ' J S S aSU �4/1u�s
Sump pump(yes or no): No a l r.
Last date of occupancy/use: Current
COMMERCIAL/INDUSTRIAL:N/A
Type of establishment:
Design flow(based on 310 CMR 15.203): gpd
Basis of design flow(seats/persons/sgft,etc.):
Grease trap present(yes or no):
Industrial waste holding tank present(yes or no):
Non-sanitary waste discharged to the Title 5 system(yes or no):
Water meter readings,if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping records
Source of information:
Was system pumped as part of the inspection(yes or no): No
If yes,volume pumped: gallons--How was this 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 the 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: 2000-
Were sewerage odors detected when arriving at the site(yes or no): No
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 18 Birch St.Hyannis Ma.02601
Owner:Eric Ellis.
Date of Inspection:4/1/2006
BUILDING SEWER(locate on site plan)
Depth below grade: 18"
Materials of construction:_X_cast iron_X 40 PVC other(explain):
Distance from private water supply well or suction line:
Comments(on condition of joints,venting,evidence of leakage,etc.):
Joints were in good condition,no evidence of leakage.
SEPTIC TANK:_Xrt(locate on site plan)
Depth below grade:_12"_
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: 1500 Gallons
Sludge depth: 24
Distance from top of sludge to bottom of outlet tee or baffle: 2`
Scum thickness: 8"
Distance from top of scum to top of outlet tee or baffle:_3"
Distance from bottom of scum to bottom of outlet tee or baffle: 9"
How were dimensions determined: Opened covers and took measurements
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
As related to outlet invert,evidence of leakage,etc.):
Inlet and outlet tees were intact ad in good condition.Tank was structurally sound.Tank was not leaking_Liquid
levels were good.Tank is due for a cleaning
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(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
As related to outlet invert,evidence of leakage,etc.):
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 18 Birch St.Hyannis Ma.02601
Owner:Eric Ellis.
Date of Inspection:4/l/2006
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_X_(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.):
D-Box was level and in good condition. No evidence of solids carryover. Box was not leaking;
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.):
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 18 Birch St.Hyannis Ma.02601
Owner:Eric Ellis
Date of Inspection:4/l/2006
SOIL ABSORPTION SYSTEM(SAS)_X (locate on site plan,excavation not required)
If SAS not located explain why:
Type
Leaching pits.Number:
Leaching chambers,number:
Leaching galleries,number:
X Leaching trenches,number,length: 4 Infiltrators I FX 25`
leaching fields,number,dimensions:
overflow cesspool,number:
innovative/alternitave system Type/name of technology:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
_Soil was .,no sign of hydraulic failure.Vegetation was normal.
CESSPOOLS: N/A (cesspools 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.):
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 18 Birch St.Hyannis Ma.02601
Owner:Eric Ellis
Date of Inspection:4/1/2006
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water 5+ feet
Please indicate(check)methods used to determine the high ground water elevation:
Obtained from system design plans on record-If checked,date of design plan reviewed:
Observed site(abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health-explain:
Checked with local excavators,installers-(attach documentation)
Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
High Groundwater was determined by accessing Town Of Barnstable Groundwater Contour Map.
I
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 18 Birch St.Hyannis Ma.02601
Owner:Eric Ellis
Date of Inspection:4/l/2006
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent referencelandmarks or
Benchmarks.Locate all wells within 100 feet.Locate where water supply enters the building
REAR OF HOUSE
A B
TANK 0 1
A-1=21'
B-1=19'
D-BOX ❑ 2
A-2=20'
B-2=29'
S.A.S.A-3=31'
B-3=33'