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HomeMy WebLinkAbout0137 BRISTOL AVENUE - Health 137 Bristol Ave _ Hyannis A= 291 - 103 4 A II 0 � e V I e UNITED STATES POSTAL SERVICE First-Class Mail Postage&Fees.Paid I LISPS I Permit No.G-10 I • Sender: Please print your name, address, and ZIP+4 in this box • . I I Town of Barnstable \ P) Health Division 200 Main Street Hyannis,MA 02601 I ' I I 0000SENDER: COMPLETE THIS SECTION , AETE THIS SECTION ON DELIVERY ■ Complete items 1,2,and 3.Also complete 'J 111) I item 4 if Restricted Delivery is desired. X ❑Agent ■ Print your name and address on the reverse ❑Addressee so that we can return the card to you. B. Received by(Printed Name) D of Delivery ■ Attach this card to the back of the mailpiece, or on the front if space permits. 1. Article Addressed to: D. Is delivery address different from kem 1? ❑Yes It YES,enter delivery address below: ❑ No -H � 9 4Q�5f � ►I f- 3. Service Type ki O�] bO( ❑Certified Mail ❑Express Mail v ❑Registered ❑Return Receipt for Merchandise ❑Insured Mail ❑C.O.D. 4. Restricted Delivery?(Extra Fee) ❑Yes 2. Article Numb er,, 7;0I+0000 3524 F120l (Transfer from service label) PS Form 381.1,February 2004 Domestic Return Receipt 102595-02-M-15401 U.S. Postal ServiceTM CERTIFIED MAILTM RECEIPT (Doni6tIcT1WA Only;No Insurance Coverage Provided) For delivery information visit our website at www.usps.coma DeliveryC3 Restricted rq (Endorsement Required) _. � s : : I �• PS Form 3800,June 2002 See Reverse for Instructions Certified Mail Provides: A mailing receipt (e—eat. OOZ eunr_bose-0:J S_d ta_A unique identifier for your mailpiece ■ A record of delivery kept by the Postal Service for two years Important Reminders: o Certified Mail may ONLY be combined with First-Class Mail®or Pricrity Mello. ■ 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. • For an additional fee,a Retum Receipt maybe requested to provide proof of delivery.To obtain Return Receipt seance,please complete and attach a Return Receipt(PS Form 3811�to the article and add applicable postage to Dover the fee.Endorse mailplece Return Receipt Requested".To receive a fee waiver for a duplicate return receipt,a USPS®postmark on your Certified Mail receipt is required. s For an additional fee, delivery-may be restricted to the addressee or addressee's authorized a ent.Advise the clerk or mark the mailpiece with the endorsement"Restricted-Delivery°. ■ 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 Cerified Mail receipt is not needed,detach and affix label with postage and mail. 'IMPORTANT:Save this receipt and present It when making an Inquiry:~ Internet access to delivery Information is not available on mail •addressed to APOs and Ms. Town of Barnstable Regulatory Services Barnstable THE 1p� �P c Thomas F. Geiler,Director ;mericaiiiy Public Health Division I I I BARNSTABLE, MASS. Thomas McKean, Director 2oe7 039. A�0 200 Main Street rFD MA'S Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 S Sent Via Certified Mail: 7006 0810 0000 3524 7120 December 7, 2012 Terry T. Phan 137 Bristol Ave. Hyannis, MA 02601 As of October 1, 2006 a new rental registration ordinance was put into affect requiring all property owners of rental units to register their rental units with the Town of Barnstable Health Division. According to our records, you own the rental property at 137 Bristol Ave., Hyannis, MA. Enclosed is an application. Please use a separate application for each rental unit you own. Should you need more applications, they are available online at www.town.barnstable.ma.us. Go to the Health Division page by looking in the Department Menu. There is a link to the Rental Registration information on the Health Division page. You may print out as many as you need, and return them to the Health Division with the appropriate 2012 fees included. This must be completed within (14) fourteen days of your receipt of this letter. Failure to comply with this ordinance will result in the issuance of a non-criminal ticket citation in the amount of$100. Each day of non-compliance is considered a separate offense. Should you have any questions, please feel free to call 508-862-4644. Thank you in advance for your cooperation. Karen Herrand Division Assistant Public Health Division Direct#508-862-4072 COMMONWEALTH OF MASSACHUSETTS EXECUTWE OFFICE OF ENVIRONMENTAL AFFAIRS . DEPARTMENT OF ENVIRONMENTAL PROTECTION =E 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address:_1 3 7 � Owner's Name: nCP,-S+ �0 CA CLt.�t Owner's Address: 11-) �nt Date of Inspection: tE�l3►>c�� Name of Inspector.(please print). -4 -5 CompanyName: William E. Robinson Septic Service Mailing Address: P O Box 1 089 Centerville, MA Telephone Number. f 5081 775-8776- ' CERTIFICATION STATEMENT i cenify 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 tune 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 Se ction 15340 of Title 5(310 CZAR IS.000)L The system: �/Fasses • t'.oaditionally Passes K3 5 Needs Further valuation by the Local Approving Authority, z Faits Cs! Inspector's Signature: Date: &A 4.Zry '� 4 iV a The system inspector shall submit a copy of this inspection report to the Approving Authority(B- f HeaRhvr DEP)within 30 days of completing this inspection.If the system is a sham system or has a design fC of 10A0 gpd or greater,the inspector and the system owner shalt submit the report to the appropriate regional f f ice of ere 3 DEP.The original should be seat to the system owner and copies sent to the buyer,if applicable,and a apprgng r— . authority. rr) Notes and Comments ****This report only describes conditions at the time of inspection and tinder the conditions of use at that time_This inspection does not address how the system will perform in the future under the same or different conditions of use_ Title 5 Inspection Form 6/15/2000 page I 9 Page 2ofII OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued). Property Address- 17 1i5 A3� -0(NIS. Owner. V ��ee '0 CLCLt" Date of lnspeWon: e Inspection Summary: Check A,B,C,D or E!ALWAYS complete an of Section D A. Syst ty Passes: . I have not found any information which indicates that any of the failure criteria described in 310 C[v!R l S_303 or in 310 CMR !5 3Q4 exist Any Caihue criteria not evaluated are indicated below. Comments: B- System Conditionally Passes: One or more system components as described in the"Conditional pass••section need to be replaced or repaired.The system,upon completion of the replacement or repair,as aggrovid by the Board of Health,will pas,. Answer yes,no or not determined(Y,N,ND)in the for the fo explain. llowing statements_If"mot determined"please The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,tank is m substantial infltration or exfiltration or tank failure is iniminem System will pass inspection if the existing tack is replaced with a complying septic tank,as approved by the Board ofHealth •A metal septic tank will pass inspection if it is structurally sound,not leaking and'fa 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 pipes)or due to a broken,settled or un d->� on even t-t box.System will pass in if(withpp oval of Board of Health):. broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required Pumping mory than 4 tip a year due to broken or obsaL%Ud pipe(s).The system will Pass inspection if(With approval of the Board ofH=My broken pipe(s)are replaced obstruction is=WVcd ND explain: I Page 3 of 11 OFFICIAL INSPECTION FORM=NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE-SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 13� 1�7, 5-15 Awes 11p_ Owner. V\�1C�Jl�} �o cicl-CSC,t�n Date of Inspection: . o C. Further Evaluation is Required by the Board of Health: 'Aj 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 1S.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 aseptic 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. _ 'l'he system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. _ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply welt•• 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 S ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: 3 N _ Pagc 4 of t l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS ' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION.(continued) Properly Address:l3 X—ic A-o - C?w�n i S Owner: i✓1 CtACC ��+ Date of Inspection: 6 f fo a c,J D. System Failure Criteria applicable to all systems: You must indicate"-yes"or"no"to each of the following for all inspections: . Yes N>Dischargc ackup of sewage into facility,or system component due to overloaded or clogged SAS-or cesspool or ponding,of effluent to the surface of the ground or surface waters due to an overloaded or /clogged SAS or cesspool �/ Static liquid level in the distribution box above.outlet invert due to an overloaded or clogged SAS or /cesspool _ ✓ Liquid depth in cesspool is less than 6"below invert or.available volume is less than V,day flow Required pumping more than 4 tunes in'he last year NOT due to clogged or obstructed pipe(s)_Numbcr of times pumped . _ _tol"'Any portion of the SAS,cesspool or privy is below high ground water elevation. Any portion of cesspool or privy is within I OO deet of a surface water supply or tributary to a surface water supply. I I ! _ Any portion of a cesspool or privy is within a Zone 1 of a public we1L 3--Any tny portion of a cesspool or privy is within 50 feet of a private water supply well. portion of a cesspool or privy is less than 100 feet but greater than 50 fret from a private u-atcr supply well with no acceptable water quality analysis.(This system passes if the well water analysis,, performed at a DEP certified laboratory,for coliferm 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.} AV (Yes/No)The system fails_I have determined that one or more o(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. f . E. Large systems: ' To be considered a large syste the system must serve a faci!it with a design flow of 10,000 d to 15,000 Y � gP gpd- You must indicate either"ycs'or"no"to each of the following: (71te following criteria apply to large systems in addition to Ilse 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 if you have answered"yes"to any question in Seetinn E the systm is eumsidered a s"tgnifttant threat or answered "yes"in Section D above the large system bas fates The owner or operator of any Iargc system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CM 15.304.The system owner should contact the appropriate regional office of the Department. 4 Page„5 of 11 . e OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM , PART B CHECKLIST ` Property Address: t37 v r%-s�pk A'e,."1ve— Owner.Vlv\Cell+ `p [G))✓ k' Date of Inspection: tom © ' Check if the following have been done.You must indicate`des"or"no"as to each of the following: Yes No Pumping information was provided by the owner.occupant,or Board of Health / ✓ Were any of the system components pumped out in,the previous two weeks? ✓ _ Has the system received normal flows in-the previous two week period? V/ Have large volumes of water been introduced to the system recently or as part of this inspection?_ t N� Were as built plans of the system obtained and examined?(if they were not available note as NIA) ✓ _ Was the facility or dwelling inspected for signs of sewage back up? d _ Was the site inspected for signs of break out? Were all system components,excluding the SAS,located on site? v _ Were the septic tank manholes uncovered,opened.and the interior of the tank inspected for the condition of the affles or tees,material of construction,dimensions.depth of liquid,depth of sludge and depth of scum? 7_ Was the facilityowner and occupants if different from owner provided with information on the proper ( p rff fr )P P Pe 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/ J ,Existing information.For example,a plan at the Board of Health. Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)] 5 F Page 6 of t 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: �3� l�t"tS�1H.��•� Owner. V i nceirX+ ( � ^ Tl Date of Inspection: do te, FL.OW CONDITIONS RESIDENTIAL Number of bedrooms(design):.z� Number of bedrooms(actual): y DESIGN flow based on 310 CMR 15103(for example: 110 gpd x#of bedrooms): .�y� Number of current residents: 3 Does residence have a garbage grinder(yes br no): AID Is laundry on a separate sewage system(yes or nor v++0 [if yes separate inspection required) Laundry system inspected(yes or no): AilA Seasonal use:(yes or no): ? Water meter readings,if available(last 2 years usage(gpd)): Sump pump(yes or no).A40 Last date,of occupancy: �nrz..rr COMMERCLUANDUSTRIAL Type of establishment• Design flow(based on 310 CMR t5203): gpd Basis of design flow(seatslpersonsfsgkctc-): Grease trap present(yes or no): Industrial waste holding tank present(yes or no):— Non-sanitary waste discharged to the True 5 system(yes or no):_ Water meter readings,if available: Last date of occupancy/user ,. OTHER(describe):+ GENERAL INFORMATION Pumping Records Source of information: Was system pumped as pan of the inspection(yes or nor AA& If yes,volume pumped:=gallons—How was quantity.pumped determined? Reason for pumping: r-- TYPE OF SYSTEM Septic tank,distribution box,soil absorption system - / inglc 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 cmrwt operation and maintenance contract(to be obtained from system owner) _Tight tank _Attach a copy of the DEP approval _Other(describe): Approximate aQe of all components,date installed(if known)and source of information: a c,*V ye., _ Were sewage odors detected when arriving at the site(yes or no):' r' 6 ' 1'agc 7 of I I OFFICIAL INSPECTION FORfl'I—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEN'I.INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: klt(,wl e_ Owner:Vi rW-4.- - �'OCr._C.C.A�v\.k Date of Inspection: BUILDING SEWER(locate on site plan) Depth below grade. Materials of construction: %o(ist iron A40 PVC_odicr(explain): Distance Gom private realer suppl}well or suction lase: Comments(on condition of joints,venting,cvidcncc of leakage,etc"): SEPTIC TANK:J�Yj(focatc on site plan) D'cp►h below grade: / Material of construction:_cuncrete_metal fiberglass_polyethylene _othcr(explain) _ If tank is metal list age:_ Is agc confimed•by a Certiftcate uCCoinptiaree(ycs or no):_(attach a copy of certificate) Dimensions: Sludge dcptls:' Distance from top of sludge to buttons of outlet ice or barlle: Scual thickness: Distance from top of scum to top of outlet ice or baffle: Distance Gom bottom of scum to bottom of outlet ice or baffle: ' I low were dimensions determined: Comments(on pumping recommendations,inlet and outlet tee or baflle condition,strucitual integrity,liquid Iet•els as related to outlet invert,cvidcncc of icakage,ctc"): GREASE TP AI. l({vcatc on site plan) Depth below grade:— Material of construction:_concrete metal_fiberglass_polyehylene`other (explain): Dimensions: Scum tliickncss: Distance Gom top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet icc or baffle: Dalc of last pumping: Conunents(on pumping recontnundatiuns,unlet and outlet ice or baffle eonditiu:i,structuial integrity,liquid levels as ielated to outlet invcn,eridence of Ieakagr,etc_): 7 9ofII r , OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOHM PART C SYSTEM INFORl11ATION teontinued) tcrtyAddress t�7 �Jt�s'EO11i^�� -of lospcctioo: t Ib akapjr IIT or HOLDING TANK: tank must be pumped at time of inspection)(locate on site plan) th below grade: trial of construction:�concrde metal_fiberglass_polyethylene other(explain): tensions: acity: Rallons ign Flow: stations/day rm present(yes or no): rm level: Alarm in working order(yes or no):_. c of last pumping: nrncnis(condition of alanu and float switchcs,ctc_): STRIDUTION BOX:6� prescnt must be opcncd)(locate on site plan) pth of liquid level above outlet invert: nunents(note if box is Ievcl and distribution to outlets equal,any evidence of solids carryover,any evidence of kagc into or out of box,ctc.): )AIP CIIANIDER: IV of (e on site plan) imps in working order(yes or no): ' arms in working order(yes or no): — nnmcnts(note condition of pump chamber,cundition of pumps and appurtenances,etc_): Page 9 of 11 OFFICIAL INSPECTION.FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C 11SYSTEM ,, INFORMATION(continued) Property Address: (�?,�CISTU! 'L ve_ Owner: V1 N—C',✓+ COCC C Y' t Date of Inspection: n 1blo-0Grr SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation-not-required) If SAS not located explain why. Tyue, ;!' eaching pits,number. i f E�Ifo-v leaching chambers,number leaching galleries,number: leaching trenches,number,length: leaching fields.number,dimensions: overflow cesspool,number_ innovative/alternative system Type/name of technology Continents(note condition of soil,signs of hydraulic failure.level of ponding,damp soil,condition of vegetation, etc.): 0-44:PI-1-,- Af`5a"I. aF 44sr hle tr_. ,c As F.r- Lc;hr is 6'r_ G" Xem" gta4 CESSPOOLS:' IX (cesspool must be pumped as part of inspectionxlocate on site plan) Number and configuration: / Depth—top of liquid to inlet invert: 3 Depth of solids layer — Depth of scum layer. Dimensions of cesspool.- &�xC, Materials of construction: C©.tom;��c j,)cCtc Indication of groundwater inflow(yes or no):AO Comments(note condition,}of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): 5 d i�, .,�F �t y t�rr el�t {//s"1.i 2- t. ,r_+Cr- /C.,LA tom. et.10 :4 wct' A4r"4'r PRIVY:V/Al sate 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.): 9 Page 10 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION-FORM PART C SYSTEM INFORMATION(continued) Property Address: l-3 t�t`tS�u� rYrr�r1�� Owner: V 1 rce-, + :0 Cam_i t\t Date of Inspection: t. 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. t - - i lu page,I1'of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C 1 SYSTEM INFORMATION(continued) Property Address: 13� `3rkcakN Owner. v'Acp -G .C�:r•+ Date,of Inspection: bf i cif; SITE EXAM Slope Surface water Check cellar Shallow wells f _ Estimated depth to Bound water feet Please indicate(check)all methods used to determine the high Bound 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 tow you established the high ground water elevation: TOLL.,... s<• 11 \ COMMON%VEALTH OF MMSACHUSETTS TjEXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTMCATION Property Address: 137 Bristol Avenue. Hyannis Owner's Name: Vincent Procaccini Owner's Address: PO Box 2305 o —e ' o C) Date of Inspection: '7 Sean Jones Q Name of Inspector:(please prit:t) • __ _ < t Company Name: William E. Robinson Septic Service oO co Mailing Address: P O Box 1069 Centerville, MA vj Telephone Number: is 1 775-8776 w >y r-' CERTIFICATION STATEMENT —' n I certify that I have personalty inspected the sco age disposal system at this address and that the inform lion reported below is true,accurate and complete as of the time of the inspection.The inspection was per€ormed based on my training and experience in the proper function and maintenance of an site sewage disposal systems.I am a DEP approved system inspector pursuant to on 15340 of Title 5(310 CNIR MGM). The system: Passes Conditionally Passes Needs on by the Local Approving Authority fails Inspector's Signature: Date: The system inspector shall submit a copy of¢hiss 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 oviner and copses seat to da buyer.if appUcable,and the approxing authority. is 5er,.td 6/ Notes and Comments ��S9tes 14 Sn.,,l/ e:0AAyor1re (,..ell, U�lf�'!�w P?Y 1► I• CX r4v�,.i Qj,& "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_ i Title 5 Inspection Form 6/15/2000 page I a � Yage 2 of I i OFFICIAI.INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 137 Bristol Avenue Hyannis Owner. Vincent Procaccini Date of laspectioa: `? Inspection Su msry: Check A,B,C=D or E!ALWAYS co€rtplete all of Section D A. Sy m Passes: I have not found any information which indicates'hat arty aMe iaituze criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system,upon completion of the replacement�or repair,as approved by the Board of Health, will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements_If-not determined"please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,exhibits substantial MItration or exfilttation ortank katre is imminent_System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Hearth. -A metal septic tank will pass inspection if it is structurally sound,not leaking and if 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 nigh static water level in the distribution box flue Wbroken or obstructed pipes)or due to a broken,settled or uneven distribution box_S`ystt n I'll p�inspection if(with approval of Board of Health broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced NO explain: Y'he system required pumping more than 4 times,a year due to brvkca or obsuixud pipe(s).The system wil pass inspection if(with approval of the Board of Health): ibroken pipe(;)are=placed obstt>mdau isicmoved NU explain: 0 Zi Yage 3 of I I OFFICIAL INSPECTION FORM=NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 137 Bristol Avenue Hyannis - Owner: Vincent Procaccii -i Date of Inspection: j C. Further Evaluation is Required by the Board of Health: I 1 /1 Conditions exist which require further evaluation by the Board o Heallth 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 15JAW10)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 aseptic tank and soi!absorption systern(SAS)aad the SAS is within log feet era 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 l 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 So feet or more frodi a private water supply well** MethOd used to dC1&,rkarlastauce "I dts system passes if the well water analgsis,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 inalysis must be attached to this form. 3. Other: 3 Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 137 Bristol Avenue Hyannis Owner. Vincent Proc ccini Date of Inspection: D. System Failure Criteria applicable to all systems: You must indicate`yres"or"no"to each of the following for all inspections: Yes No� _ �+//�ackup of sewage into facility or system componetttdue to overloaded or clogged SAS or cesspool �/ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or logged 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 cquircd pumping more than Q times in the fast year NOT due to efoggcd or obstructed pipe(s). Number /of times pumped v Any portion of the SAS,cesspool or privy is below high ground water elevation. .�Any portion of cesspool or privy is within 100 Xieet of a surface water supply or tributary to a surface /water.supply. _✓ Any portion of a cesspool or privy is within a Zone 1 of a public well_ _ ; 1Any portion of a cesspool or privy is within SQ feet of a private water supply well. i/ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private umicr supply well with no acceptable unater qtWily analysis.1This system passes if the well water analysis, performed at a DEP certified laboratory,for conform 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 Tress That;S ppm,provided That no other failure criteria are triggered.A copy of the analysis must be attached to this form.l fJ (Yes/No)The system fails.l have determined that one or more o(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 systenli 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) yc� feu — _ the system is within 400 feet of a surface drinking water supply _ , the system is within 200 feet of a tributary to a sw face drinking water supply — _ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—l WPA)or a mapped Zone I l of a public hater supply well If you have answered"yes'to any question ira Section E die system is eoasidered a s'tgnWicanl tlueal,ur ansvicrcd "yes"in Section D above the large system has failed_T1te owner or operator of arty large system considered a significant threat under Section€or failed under Section:D shall upgrade the system in accordance with 310 CMR 15.304.The system o,. ncr should contact the appropriate regional office of the Department. 4 I Page 5oyII OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 1 37. Bristol Avenue Hyannis Owner: Vincent Procacc}}n Date of Inspection- Cc�A_S o Check if the following have been done.You must indicate` of or"no"as to each of the following: Yes,�No aa/ mping information was provided by the owner,occupant,or Board of Health / Were any of the system components pumped out in the previous two weeks? J Has the system received normal flows in the previous two weer period? Have large volumes of water been introduced to the system recently or as part of this inspection? NA Were as built plans of the system obtained and examined?(If they were not available note as NtA) Was the facility or dwelling inspected for signs of sewage back up? _ Was the site signs inspected for of break out P Were all system components,excluding the SAS,located on site? C'essq t Were theieptic-tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? t he size and location of the Soil Absorption System(SAS)on the site has been determined based on Yes no,,G� � ,�' Existing information.For example,a plan at the Board of Health. I — _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)) 5 G' ^0 gage b of t OFFICIAL.INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM-INFORMATION Property Address: 137 Bristol Avenue yann1s Owner. Vincent Procaccini Date of Inspection: !a 5` a LOW CONDITIONS RESIDENTIAL Number of bedrooms(design):. Number of bedrooms(actual): Y f��,� DESIGN flow based on 310 CM15-203(for example:110 gpd x#t of bedrooms): ( �' Number of current residents: a Does residence have a garbage grinder(yea or no): i Is laundry on a separate sewage system(yes or no):s [if yes separate inspeWon required] Laundry system inspected(yes or no):_2,jAA Seasonal use:(yes or no): )w Water meter readings,if available(last 2 years usage(gpd)): 2 0 0 6 — 3 9,0 0 0 Sump pump(yes or no): — 41,250 Last date of occupancy: C"Pec-t' COMMERCIALANDUSTRIAL IVI A Type of establishment: Design flow(based on 310 CMR 15203): xPd Basis of design flow(seats/persons/sgketc_): 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): �3 If yes,volume pumped: ]_gallons--How was quantity pumped determined? .74- c,/-' (f4& ,,j Reason for pumping: 6l.;S!0v,l TYPE OF SYSTEM _Septic tank,distribution box,soil absorption system gle 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 currcat 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: Were sewage odors detected when arriving at the site(yes or no): :'� i 6 �I'agc 7auf I I OFFICIAL INSPECTION FORM-NOT F0R\IQL:UmTAjty ASSLSSNi INTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C S YSTEM II`#F ORA ATIOn(corrtirtued) Property Address: 137 Bristol Avenue Hyannis Owner: Vincent Procaccini Date of Inspection: UUiLUING SEWER(locate on site plan) Depdi below grade: Materials of construction:_ ast ison .✓d4 YVC ot4ici ttexplaut): Distance from private seater supply ttclt or suction line: Comments(on condition of juuRs,venting,evidence of leakage, etc.): �C,,fix a SEPTIC TANK (locate on site plait) Depth below grade: Material of construction:_concrete rectal Fiberglass_polyctl►ylene _othcr(cxplain) _ —' If tank is metal list age;_ is age cnnEet!y} a Cr.:�£rcate of`6tnnt(ance(Yes or nu):_(attach a copy of certificate) Dimensions: Sludge depth: Distance fsontt top of sludge►u bottom of outlet tee or baffle: Scunt thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scup►to bottom of outlet tec or baflle: I low were dimensions detcrruincd: Comments(on pumping recommendations,inlet and outlet tee or baffle eonditien,structural urtcgrity, liquid levels as related to outlet inverl,evidence of leakage,etc.): GREASE TRAP.I' _(facarc on silt plan) Depth below grade:Material of constructi— on: concrete metal ftbetglasi_�}tal�ctlt�lctse anises (captain): — — — Dimensions: Scum thickness: Distance Gan top of scum to top of outlet tee or bafllc: Distance from bottom of stunt to buttalt of outlet(cc or baffle: Date of last pumping: COHMIcnts(on pumping tcconttstcusiatiutiS,it►1ct attsl vdazi it c ut W-51t:cuttdilio:n,slruclul a1 imcgrity,liquid lcvcls as related to outlet invert,et•idencc of icakagc,etc.): r :aofii OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTUN1 INSPECTION FORM I'AHT C SYSTEM INFOR ATION(continuct!) perty Address: 137 Bristol Avenue Hyannis ner: Vincent Procaccini e of Inspection: ' MT or HOLDING TANK: N/ (La'tk must be pumped at time of inspection)(locate on site plan) nth below grade: serial of construction:_concrete metal fiberglass_pulyetltylene olher(explaut): ncnsions: mcity:_ Qalluns sign Flow: gallonslday um present(yes or no): u1n level: Alann in %votkutg order(yes or no): is of last pumping: nuncnts(condition of alamt and float switcltcs,ctc•): isTluuuTlof`! BOX: )� ,o Etf present must be opencd)(loeate on site plan) :pth of liquid level above outlet irtvcrt: munents(note if box is level and distribution to outlets equal,aetj-evidence of solids eatT}over,arty eviJcucc uC ikagc into or out of box,ctc.): JA1P CRANIUM- (locate on site plan) mlps in working order(yes or no):_ larncs in working order(yes or no): _ onuuen►s(note condition of pump cltautlrer,cuttdttton of pumps and appurtenances.etc_): i Page 9 of I 1 � . • OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFOR ATTONicontinuzed) Property Address: 137 Bristol Avenue Hyannis owner: Vincent Procacc/ini Date of Inspection: SOIL ABSORPTION SYSTEM(SAS): (locate oo site plan,excavation not required) If SAS not located explain why: TypK _ :L// leaching pits,number: leaching chambers,number: leaching galleries,number: teaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number. innovativelalternative system Type/name of technology: Comments(note condition of soil,signs ofhyrltaulic failure,level ofgoadiag,damp soil,condition of vegeta(ion, etc.): CJJtt,t�bow Pl- / 1.� 5 Pi'I•}r,�..+.a .y,;, �{"Ji��[c b tc? c�.'�'y a• C n�S' l'G y d b4lS 4A 1+8 !�- ✓l.G�t2�'6 4L� t ."- e CESSPOOLS: `' (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: / Depth—top of liquid to inlet invert: > Depth of solids layer: Depth of scum layer, to Dimensions of cesspool: z-X g Materials of construction: eC06teae Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs ofhydraufie failure,fevel of ponding,condition of vegetation,etc.): �t :�+% S: h• sv.'- }+ C�fJ . .:se.. e� Z o. /►.e�awl - 'ems a a� o•�r1 4 - b-,i'I.s. -!- PRIVY: (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation, etc.): 9 Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION-FORM PART C SYSTEM INFORMATION(continued) Property Address: 137 Bristol Avenue Hyannis Owner: Vincent Pro a Cini Date of Inspection: !o a 3a�-�? SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building. A^I ► f i3 �- ac �o I PageA I of R OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 137 Bristol Avenue Hyannis Owner. Vincent rocaccini Date of Inspection: T SITE EXAM Slope Surface water Check cellar Shallow wells fi Estimated depth to ground water feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-if checked,slate 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 dorumeautlon) Accessed USGS database-explain: rou musta tribe how you established the high ground water elevation: c n ti �e s No...... ......... r✓ — FE........ 5..00 THE COMMONWEALTH OF MASSACHUSETTS r BOARD OF HEALTH _ 04:1�1ro� .............Town................oF.........Barnstable................................................ Appliratiun -fur 43hipu,ial Vjarkfi Tunutrnrtiun Vrrni t Application is hereby'made for a Permit to Construct ( " ) or Repair ( X) an Individual Sewage Disposal System at: ._Av..enue_........t.. �tv.s.-- •--------•--. --------•--•----------•-------------------•---•-•-•------•-----•------ Lo ation-Address or Lot No. ...Phi 11 ip Hi....Cho e r e r..................................... ..........H�!ann i s Owner Address W ...Jos_e_ph...2......Mae.Qmber---- ............. .............. -en.toy yi.1.1e..................................................... Installer ' Address UType of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms---------3................................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Other fixtures ........................................: W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. P4 Septic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................ Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No..................... Diameter-------------------- Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. I................minutes per inch Depth of "Pest Pit.................... Depth to ground water........................ G4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 9 ------•-------------------------------------------------------------------------------------------------•.................................................. O Description of Soil--.__Sand---&--- rayel.............................. U ----------•-•-••---•-----------•...•-••-•••-----------•--••-•••••••••----•--•--•••---•-•------•-•--•-•-••-•--••---••-•------•. ----------------------•--------•----------------------------------------------------------------------------. --.......:.:-----------------•-------•------•--------------..... ------------------------ U Nature of Repairs or Alterations—Answer when applicable.....1--1JOJ gallon Overflow-••�pit�---------- ._..----•-... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System id accordance with the provisions.of Article XI of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has be issued by the hoar o health. Signed . --•-.....f'-!....................... ----- /< Date ApplicationApproved By....... -----•--•- ----•----•--------•••••----•••-•-•-•----•-......-•--•-----•---•-••--•-- Date Application Disapproved for the following reasons:---•---•........................•--•-------------------...........------._._.........----=--------•-....-----... ..............................••---.......-•-----------••--•----..__......------•-•---.........------.......---......-------------•-•-•---•-•---•--....---•-•------...__.......------........------------ Date Permit No------Z'/!L•----------------------•---............ Issued.-----`' /*t------.._..----------- r Date N........4n? ...... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..............Town...............OF..........T$Arnstable ... .. A ......................................................................... Appliration -for Dispaiial 10orkii Tutuitrurtion Vrrnift Application is hereby made for"a Permit to Construct or Repair ( X) an Individual Sewage Disposal System at: ................................................... ................................................................................................. ion-Address or Lot No Phillip Hirs-Alverger If ................. Phillip........................................................................... ..............yRapis ........................ Owner Address ......... ..............GexitervfUle..................................................... Installer Address Type of Building Size Lot....... --------------------Sq. feet Dwelling—No. of Bedrooms.......... ................................Expansion Attic Garbage Grinder Other—Type of Building -_------------------------ No. of persons_---_----.-------------- Showers Cafeteria Otherfixtures -------------------------------------------------------:------------------------------------------------------------------------------------------ Design Flow............................................gallons per person per day. Total daily flow............................................gallons. Septic Tank—Liquid capacity............gallons Length---------------- Width..---........... Diameter........._..... Depth......_........ Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area.................---sq. f t. Seepage Pit No..................... Diameter....._-------------- Depth below inlet_.._..._-_-_-._...-. Total leaching area------------------scl. f t. Other Distribution box Dosing tank Percolation Test Results Performed by-------- --------------------•-----•--•----...............-------•----.... Date........................------------.... Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to -round water....----................ Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ ------------------------------------------*----------------------------------------------•---------------------------------*----------------------- 0 Description of Soil...._-qa:iij &---Gra.ye_l ............................................................................................................................. ... ........ ...... U ---------------------------------m....................................................................................................................................................................... ... ................................................................................................................................................................................................... U Nature of Repairs or Alterations—Answer when applicable.....!-;LQQQ---E-41lon overflow (pit)........... . .............................................. ........................................................................................................................................................................................................ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been,issued by the board ofi health. Signed...��I-i /" lVd(_ lt�$" ............I------------------III-1-V-------------------------------*-------- ------------Date-------------------- ApplicationApproved By........ ................. -------------------------------------------------------------------- ............................ ........... Date Application Disapproved for the following reasons:................................................................................................................ ................................................................................. ....................................................................................................................... Date ................. ......................................... Permit No.......1/1 -------------------- Issued......... Z4. Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH /I Town Barnstable ...................................OF....................................................................................... QgWrtifiratr of 10111nijiliatta THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed or Repaired (X by------J9.5-9ph P. Macobber & Son Inc. Centerville . .... ...............................................P..................................................................................................................... Installer at...13.7...Brtstol Avenue yannis Hirschberger . .............................. ............Ell............................................................................................................................. has been installed in accordance with-the provisions of Article XI of The State Sanitary Code as described in the application for Disposal Works Construction Permit No------------------------------------------ dated................................................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. j DATE--------- Inspector.-_,"I --- -----7---------------------------------------- y--- --- ------------------------------------------ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH qn .....To...............................OF......Barnstable ................................................................. N ......... ............. 00. FEE.... .................. Bi-spotial Mork-q Tlomitru' dion ramit Permission is hereby granted_Joseph P. .'.Ma.c.omber...&...S_oP_,__...Inc........................................................ Joseph ....... ------- ----- ------- to Construct or Repair ( X) an Individual Sewage Disposal S stem at No...�37 �rlstol Avenue, Hyannis stem ... ................................................Hyannis... as show,'."n. n.. Street ---4-If........ Dated_ ............... the application for Disposal Works Construction Permit No -----------------------------al. .............................................. Board K Health FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS