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Home My WebLink About9-19 CAPTAIN COOK LANE - HYANNIS CONDOS 9-19 CAPT. COOK 1LAII,N''E, GRNMWnM �4y BLD.2 a nn�S MUM Y�NIM�,W ROSANO DAVIS 9 ROCKY LANE COHASSET MA 02025 (781)383-1234 (781)545-2800 (781)749-6178 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address 9- 19 Captain Cool:Lane Building 2 Center Village, Hyannis,MA 1533 n Owner's Name Multiple Owners S J (f Owner's Address Huntingest Property Management 40 Industry Road—P.O. Box 340 M_arstons Mills, MA 02648 Date of Inspection 01/22/09 Name of Inspector Paul W. Davis Company Name Rosano Davis Sanitary Pumping Inc Mailing Address 9 Rocky Lane Cohasset,MA 02025 Telephone Number 781-383-1234 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 ❑Conditionally Passes ❑Needs Further Evaluation by,the Local Approving Authority ❑Fails Inspector's Signature: Date:01/30/09 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 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. VA 1 z�oj Title 5 Inspection Form 6/15/2000 ROSANO DAVIS 9 ROCKY LANE COHASSET MA 02025 (617)383-1234 (617)545-2800 (617) 749-6178 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION(Continued) Property:9- 19 Captain Cook Lane/Building 2 Center Village, Hvannis: MA Owner: Multiple Owners Date: 01/22/09 INSPECTION SUMMARY: Check A,B, C,D or E/ALWAYS complete all of section D: A] SYSTEM PASSES: X l have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 or in 310 CMR 15.: 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. Indicate 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 breakout or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. The system will pass inspection if(with approval of the 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: 2 Title 5 Inspection Form 6/15/2000 R®SAN® DAVIS 9 ROCKY LANE COHASSET MA 02025 (617)383-1234 (617)545-2800 (617)749-6178 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION(Continued) Property:9-.19 Captain Cook Lane/ Building 2 Center Villne,.Hvannis, MA Owner: Multiple Owners Date: 01/22/09 C Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board or 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)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 Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet of more from a private water supply well**. Method use 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: 3 Title 5 Inspection Form 6/15/2000 ROSAN® DAVIS 9 ROCKY LANE COHASSET MA 02025 (617)383-1234 (617)545-2800 (617)749-6178 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION(Continued) Property: 9- 19 Captain Cook Lane/ Building 2 Center Village, Hyannis, MA Owner: Multiple Owners Date: 01/22/09 D System Failure Criteria applicable to all systems: You must indicate either"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 than 1/2 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 the high groundwater elevation. X Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. _ X Any portion of a cesspool or privy is within a Zone 1 of a public well. 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. [The 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 I have determined that one of more of the following failure criteria exist as described in 310 CMR 15.303, fails. 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) 4 Title 5 Inspection Form 6/15/2000 R®SAN® DAVIS 9 ROCKY LANE COHASSET MA 02025 (617)383-1234 (617)545-2800 (617)749-6178 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION(Continued) Property:9- 19 Captain Cook Lane/ Building 2 Center Village, Hvannis. MA Owner: Multiple Owners Date: 01/22/09 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 with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. ®s age ®mmtentionally left blank 5 Title 5 Inspection Form 6/15/2000 R®SAN® DAVIS 9 ROCKY LANE COHASSET MA 02025 (617)383-1234 (617)545-2800 (617)749-6178 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART B CHECKLIST Property:9- 19 Captain Cook Lane/Building 2 Center Village. Hvannis. MA. Owner: Multiple Owners Date: 01/22/09 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 prevous 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 the septic tank manholes were uncovered,opened,and the interior of the septic tank inspected for condition of baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge,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 on the site has been determined based on: Yes No X _ Existing information.For example, 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) [15.302(3)(b)] 6 Title 5 Inspection Form 6/15/2000 R®SANO DAVIS 9 ROCKY LANE COHASSET MA 02025 (617)383-1234 (617)545-2800 (617) 749-6178 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART C SYSTEM INFORMATION Property:9- 19 Captain Cook Lane/Building 2 Center Village. Hvannis, MA Owner: Multiple Owners Date: 01/22/09 FLOW CONDITIONS RESIDENTIAL: Number of bedrooms(design): Number of bedrooms(actual): 12 units. DESIGN flow based on 310 CMR 15.203 (for example: l 10 gpd x 4 of bedrooms): Number of current residents: Number varies but tvpically 15 on average. 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 two(2)year usage(gpd)): Water usage records were not available at time of inspection. Sump Pump(yes or no): No Last date of occupancy: 01/22/09—Units were still occupied at time of inspection. COMMERCIAL/INDUSTRIAL: Type of establishment: Design flow(based on 310 CMR 15.203): gpd. Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no): _ Industrial Waste Holding Tank present(yes or no): Non-sanitary waste discharged to the Title 5 system(yes or no): _ Water meter readings,if available: Last date of occupancy/use: OTHER: (Describe) GENERAL INFORMATION PUMPING RECORDS Source of information: Property currently under regular maintenance schedule.Tank was pumped on 11/17/08. 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 No 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) No Tight Tank. Attach a copy of the DEP Approval Other(describe) Approximate age of all components, date installed(if known)and source of information: 36 years per previous inspection. Were sewage orders detected when arriving at the site(yes or no): No 7 Title 5 Inspection Form 6/15/2000 R®SAN® DAVIS 9 ROCKY LANE COHASSET MA 02025 (617)383-1234 (617)545-2800 (617)749-6178 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART C SYSTEM INFORMATION(Continued) Property:9- 19 Captain Cook Lane/ Building 2 Center Village. Hyannis. MA Owner: Multiple Owners Date: 01/22/09 This page tatentionally left blank 8 Title 5 Inspection Form 6/15/2000 ROSAN® DAVIS 9 ROCKY LANE COHASSET MA 02025 (617)383-1234 (617)545-2800 (617) 749-6178 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART C SYSTEM INFORMATION(Continued) Property:9- 19 Captain Cook Lane/ Building 2 Center Village, Hvannis. MA . Owner: Multiple Owners Date: 01/22/09 BUILDING SEWER(locate on site plan) Depth below grade: 21". Material of construction: X cast iron 40 PVC other(explain) 4" cast iron inlet pipe. Distance from private water supply well or suction line: No known wells in immediate area. Comments:(on condition of joints,venting,evidence of leakage,etc.) All piping appeared to be clean and flowing freely. No evidence of leakage. SEPTIC TANK: YES(locate on site plan) Depth below grade: 17". Material of construction: X concrete metal Fiberglass Polyethylene other(explain)2,000-gallon precast concrete septic tank. If tank is metal, list age Is age confirmed by Certificate of Compliance(Yes or No):_(Attach a copy of certificate) Dimensions: 5' deep X 6' wide X 11.5' long. Sludge Depth: 2". Distance from top of sludge to bottom of outlet tee or baffle: Zabel filter in place. Scum thickness: 0". Distance from top of scum to top of outlet tee or baffle: Zabel filter in place. Distance from bottom of scum to bottom of outlet tee or baffle: Zabel filter in place. How dimensions were determined: Measured with a tape. Comments:(on pumping recommendations,inlet and outlet tees or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.) Septic tank was pumped at time of inspection.Cast iron inlet tee and A-100 Zabel filter on outlet pipe in place.Tank is structurally sound and water tight and all effluent levels were at an appropriate height.There are no repairs recommended at this time. 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 tees or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.) 9 Title 5 Inspection Form 6/15/2000 • ROSANO DAVIS 9 ROCKY LANE COHASSET MA 02025 (617)383-1234 (617)545-2800 (617)749-6178 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART C SYSTEM INFORMATION(Continued) Property:9- 19 Captain Cook Lane/Building 2 Center Village, Hyannis. MA Owner: Multiple Owners Date: 01/22/09 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/No) Date of last pumping: Comments:(condition of alarm and float switches,etc.) DISTRIBUTION BOX: YES.(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.) Box was structurally sound and water tight and providing even distribution of effluent due to speed levellers being in place. Carryover was moderate. There are no repairs recommended at this time. 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.) 10 Title 5 Inspection Form 6/15/2000 • ROSAN® DAVIS 9 ROCKY LANE COHASSET MA 02025 (617)383-1234 (617)545-2800 (617)749-6478 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART C SYSTEM INFORMATION(Continued) Property:9- 19 Captain Cook Lane/ Building 2 Center Village, Hvannis, MA Owner: Multiple Owners Date: 01/22/09 SOIL ABSORPTION SYSTEM (SAS): YES.(locate on site plan,excavation not required) If SAS not located,explain why: Type: X leaching pits,number: 3—leaching pits. 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.): There was no surface wetness, breakout or signs of hydraulic failure observed. Pit "E"way dry; in pit "F" the effluent level was 10" below the overflow pipe to pit "G". Leaching appears to be in good working condition.There are no repairs recommended at this time. 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.) 11 Title 5 Inspection Form 6/15/2000 ROSANO DAVIS 9 ROCKY LANE COHASSET MA 02025 (617)383-1234 (617)545-2800 (617)749-6178 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART C SYSTEM INFORMATION(Continued) Property: 9- 19 Captain Cook Lane/ Building 2 Center Village. Hyannis, MA Owner: Multiple Owners Date: 01/22/09 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. 1� I9 O rwjr C \ C i^ 34 ' 0 r9 - c = 30 , r> - F = 3 O C 10"below /A - n = I 4 " %1 - � - 46 ' over .-Flow . i3 - 0 - 33 ' - 0� y� 0 _ E - �•3 /Val JD ouildt" a 12 Title 5 Inspection Form 6/15/2000 i • ROSAN® DAVIS 9 ROCKY LANE COHASSET MA 02025 (617)383-1234 (617)545-2800 (617) 749-6178 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART C SYSTEM INFORMATION(Continued) Property:9- 19 Captain Cook Lane/ Building 2 Center Village, Hvannis; MA Owner: Multiple Owners Date: 01/22/09 SITE EXAM Slope Surface water Check Cellar Shallow wells Estimated Depth to groundwater: Greater than 21 feet Please indicate(check)all methods used to determine the high groundwater elevation: _ Obtained from system design plans on record. If checked,date of design plan reviewed: X Observed site(abutting property/observation hole within 150 feet of SAS) X Checked with local Board of Health-explain: Previous Title 5 Inspections. Check local excavators, installers-(attach documentation). Accessed USGS database-explain: You MUST describe how you established the High Groundwater Elevation: During previous inspections the high groundwater was indicated to be 21' 7" below grade.Clearly there is separation from the bottom of the SAS to the high groundwater elevation. It was by this non-intrusive method that it was estimated that separation exists from the bottom of the SAS and the high groundwater. 13 Title 5 Inspection Form 6/15/2000 Town of Barnstable Regulatory Services Barnstable c Thomas F. Geiler,Director A*#WmiraMy ' Public Health Division 1 ' F • � � snxtvsrnat.e, MASS. Thomas McKean,Director 2on� 039. 200 Main Street Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 June 3, 2008 Charmaine Norman 17 Captain Cook Lane Centerville, 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 17 Captain Cook Lane, Centerville 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.bamstab.le.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 2008 fees included. 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. Timothy B. O'Connell Health Inspector Health Division Direct#508-862-4646 SENDER: COMPLETE THIS SECTION COMPLETE THIS SECTION ON DELIVERY ■ Complete Items 1,2,and 3.Also complete A. Signature Item 4 if Restricted Delivery Is desired. [3Agent ■ Print your name and address on the reverse X ❑Addressee so that we can return the card to you. B. Received by(Printed Name) C. Date of Delivery ■ Attach this card to the back of the mallplece, or on the front if space permits. 1. Article Addressed to: D. Is delivery address different from Rem 1? ❑Yes If YES,enter delivery address below: ❑No 3. Se oe Type El Certified Mail 13 4press Mail 13 Registered [Ketum Receipt for Merchandise ❑Insured Mall ❑C.O.D. 4. ResMcted Delivery?Pft Fee) ❑Yes 2. Article(nans rftmNumb 7006 2150 0002 1041 8924 (0 (Oansfer Irom service/atleq PS Form 3811,February 2004 Domestic Return Receipt 102595•02-W1540 I 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 • Town of Barnstable a Health Division 200 Main Street Hyannis, MA 02601 � FOR MAIL-IN REQUESTS Please mail the completed application form to the address below. Also, please include the required fee amount (see fees at bottom of this page). Make check payable to: Town of Barnstable. Our mailing address is: Town of Barnstable Public Health Division 200 Main Street Hyannis, MA 02601 To get a rental registration application form, click here. To be able to access this form, your computer must have Acrobat Reader. Most computers have Acrobat Reader, and it will usually activate itself automatically. If your computer does not have Acrobat Reader, you can download a copy of it by going to the Adobe website. FEES Fee: $90.00 Per Unit plus $25 for each additional rental unit on the same property, with the same owner For further assistance on any item above, call (508) 862-4644 ROSANO DAVIS 9 ROCKY LANE COHASSET MA 02025 (781)383-1234 (781)545-2800 (781)749.6 118�E C e I C. OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address 9- 19 Captain Cook Lane Building 2 Center Village,Hyannis,MA Owner's Name Multiple Owners Owner's Address Huntineest Property Manaeement 33�� 0 40 Industry Road^-P.O. Box 340 ✓ / Marstons Mills,MA 02648 Date of Inspection Completed 1/19/06 Name of Inspector Jeffrey F.O'Connell Company Name Rosano Davis Sanitary Pumpine.Inc. Mailing Address 9 Rocky Lane Cohasset, MA 02025 Telephone Number 781-383-1234 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 ❑Conditionally Passes ❑Needs Further Evaluation by the Local Approving Authority ❑Fails Inspector's Signature: Date: 02/02/06 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 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. 1 Title 5 Inspection Form 6/15/2000 ROSANO DAVIS 9 ROCKY LANE COHASSET MA 02025 (617)383-1234 (617)545-2800 (617)749-6178 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION(Continued) Property: 9- 19 Captain Cook Lane/Building 2 Center Village,Hyannis,MA Owner: Multiple Owners Date: Completed 1/19/06 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 conditions described in 310 CMR 15.303 or in 310 CMR 15.3( 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. Indicate 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 breakout or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. The system will pass inspection if(with approval of the 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: 2 Title 5 Inspection Form 6/15/2000 ROSANO DAVIS 9 ROCKY LANE COHASSET MA 02025 (617)383-1234 (617)545-2800 (617)749-6178 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION(Continued) Property: 9- 19 Captain Cook Lane/Building 2 Center Villaee,Hyannis,MA Owner: Multiple Owners Date: Completed 1/19/06 C Further Evaluation is Required by the Board of Health: _ Conditions exist which require further evaluation by the Board or 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 15303(l)(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 Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet of more from a private water supply well*'". Method use 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: 3 Title 5 Inspection Form 6/15/2000 ROSANO DAVIS 9 ROCKY LANE COHASSET MA 02025 (617)383-1234 (617)545-2800 (617)749-6178 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION(Continued) Property:9- 19 Captain Cook Lane/Building 2 Center Village,Hyannis,MA Owner: Multiple Owners Date: Completed 1/19/06 D System Failure Criteria applicable to all systems: You must indicate either"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 than 1/2 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 the high groundwater elevation. _ X Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone 1 of a public well. _ 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. [The 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 I have determined that one of more of the following failure criteria exist as described in 310 CMR 15.303, fails. 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) 4 Title 5 Inspection Form 6/15/2000 ROSANO DAVIS 9 ROCKY LANE COHASSET MA 02025 (617)383-1234 (617)545-2800 (617)749-6178 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION(Continued) Property: 9- 19 Captain Cook Lane/Building 2 Center Village,Hyannis,MA Owner: Multiple Owners Date: Completed 1/19/06 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 with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. This page intentionally left blank 5 Title 5 Inspection Form 6/15/2000 ROSANO DAVIS 9 ROCKY LANE COHASSET MA 02025 (617)383-1234 (617)545-2800 (617)749-6178 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART B CHECKLIST Property: 9-19 Captain Cook Lane/Building 2 Center Village,Hyannis,MA. Owner: Multiple Owners Date: Completed 1/19/06 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 prevous 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 the septic tank manholes were uncovered,opened,and the interior of the septic tank inspected for condition of baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge,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 on the site has been determined based on: Yes No X _ Existing information.For example, 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) (15.302(3)(b)] 6 Title 5 Inspection Form 6/15/2000 ROSANO DAVIS 9 ROCKY LANE COHASSET MA 02025 (617)383-1234 (617)545-2800 (617)749-6178 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART C SYSTEM INFORMATION Property: 9- 19 Captain Cook Lane/Building 2 Center Village,Hyannis,MA Owner: Multiple Owners Date: Completed 1/19/06 FLOW CONDITIONS RESIDENTIAL: Number of bedrooms(design): Number of bedrooms(actual): 12 units. DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): Number of current residents: Number varies but typically 15 on average. 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 two(2)year usage(gpd)): Water usage records were not available at time of inspection. Sump Pump(yes or no): No Last date of occupancy: 01/19/06—Units were still occupied at time of inspection. COMMERCIAL/INDUSTRIAL: Type of establishment: Design flow(based on 310 CMR 15.203): gpd. Basis of design flow(seats/persons/sqk 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:Property currently under regular maintenance schedule. Was system pumped as part of the inspection(yes or no): Yes If yes,volume pumped: 2,000 gallons-how was quantity pumped determined?Sight glass on vacuum truck. Reason for pumping: To determine structural integrity and water tightness of septic tank. TYPE OF SYSTEM X Septic tank,distribution box,soil absorption system _ Single cesspool _ Overflow cesspool Privy No 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) No Tight Tank. Attach a copy of the DEP Approval _ Other(describe) Approximate age of all components,date installed(if known)and source of information: 36 years per previous inspection. Were sewage orders detected when arriving at the site(yes or no): No 7 Title 5 Inspection Form 6/15/2000 ROSANO DAVIS 9 ROCKY LANE COHASSET MA 02025 (617)383-1234 (617)545-2800 (617)749-6178 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART C SYSTEM INFORMATION(Continued) Property: 9-19 Captain Cook Lane/Building 2 Center Village,Hyannis,MA Owner: Multiple Owners Date: Completed 1/19/06 This page intentionally left blank 8 Title 5 Inspection Form 6/15/2000 ROSANO DAVIS 9 ROCKY LANE COHASSET MA 02025 (617)383-1234 (617)545-2800 (617)749-6178 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART C SYSTEM INFORMATION(Continued) Property: 9- 19 Captain Cook Lane/Building 2 Center Village,Hyannis,MA Owner: Multiple Owners Date: Completed 1/19/06 BUILDING SEWER(locate on site plan) Depth below grade: 27". Material of construction: X cast iron 40 PVC other(explain) Cast iron inlet pipe. Distance from private water supply well or suction line: No known wells in immediate area. Comments:(on condition of joints,venting,evidence of leakage,etc.) All piping appeared to be clean and flowing freely.No evidence of leakage. SEPTIC TANK: YES(locate on site plan) Depth below grade: 17". Material of construction: X concrete metal Fiberglass Polyethylene other(explain)2,000-gallon precast concrete septic tank. If tank is metal, list age Is age confirmed by Certificate of Compliance(Yes or No):_(Attach a copy of certificate) Dimensions:6'deep X 4' wide X 12' long. Sludge Depth: 4_'. Distance from top of sludge to bottom of outlet tee or baffle: 31". Scum thickness: 0". Distance from top of scum to top of outlet tee or baffle: 6". Distance from bottom of scum to bottom of outlet tee or baffle: 14". How dimensions were determined: Measured with a tape. Comments:(on pumping recommendations,inlet and outlet tees or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.) Septic tank was pumped at time of inspection.Inlet tee and outlet tees in place as reuuired.Tank is structurally sound and water tieht and all effluent levels were at an appropriate height.There are no repairs recommended at this time. 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 tees or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.) 9 Title 5 Inspection Form 6/15/2000 ROSANO DAVIS 9 ROCKY LANE COHASSET MA 02025 (617)383-1234 (617)545-2800 (617)749-6178 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART C SYSTEM INFORMATION(Continued) Property: 9- 19 Captain Cook Lane/Building 2 Center Village,Hyannis,MA Owner: Multiple Owners Date: Completed 1/19/06 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/No) Date of last pumping: Comments:(condition of alarm and float switches,etc.) DISTRIBUTION BOX: YES.(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.) Box was structurally sound and water tight and providing even distribution of effluent.Carryover was moderate.There are no repairs recommended at this time. 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.) 10 Title 5 Inspection Form 6/15/2000 ROSANO DAVIS 9 ROCKY LANE COHASSET MA 02025 (617)383-1234 (617)545-2800 (617)749-6178 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART C SYSTEM INFORMATION(Continued) Property:9- 19 Captain Cook.Lane/Building 2 Center Village,Hyannis,MA Owner: Multiple Owners Date: Completed 1/19/06 SOIL ABSORPTION SYSTEM(SAS): YES.(locate on site plan,excavation not required) If SAS not located,explain why: Type: X leaching pits,number: 3—6' X 6' leaching nits. 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.): There was no surface wetness,breakout or signs of hydraulic failure observed.Leaching appears to be in good working condition. There are no repairs recommended at this time. 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.) 11 Title 5 Inspection Form 6/15/2000 ROSANO DAVIS 9 ROCKY LANE COHASSET MA 02025 (617)383-1234 (617)545-2800 (617)749-6178 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART C , SYSTEM INFORMATION(Continued) Property: 9-19 Captain Cook Lane/Building 2 Center Village,Hyannis,MA Owner: Multiple Owners Date: Completed 1/19/06 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. � 19 A a rear �--� A - C - 12 ' A _ F - 34' C = '30 ` a - F = 36 ' A - d = I4 A - 0 = 4 ' A - E = 3Z 0 - E- = 43 ` NO-1 JD Scale Bvi l drr�� 12 Title 5 Inspection Form 6/15/2000 ROSANO DAVIS 9 ROCKY LANE COHASSET MA 02025 (617)383-1234 (617)545-2800 (617)749-6178 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART C SYSTEM INFORMATION(Continued) Property:9-19 Captain Cook Lane/Building 2 Center Village,Hyannis,MA Owner: Multiple Owners Date: Completed 1/19/06 SITE EXAM Slope Surface water Check Cellar Shallow wells Estimated Depth to groundwater: Greater than 21 feet Please indicate(check)all methods used to determine the high groundwater elevation: Obtained from system design plans on record. If checked,date of design plan reviewed: X Observed site(abutting property/observation hole within 150 feet of SAS) X Checked with local Board of Health-explain: Previous Title 5 Inspection dated 03/29/03. Check local excavators,installers-(attach documentation). Accessed USGS database-explain: You MUST describe how you established the High Groundwater Elevation: During a previous inspection on 03/29/03 the high groundwater was indicated to be 21' 7" below grade.Clearly there is separation from the bottom of the SAS to the high groundwater elevation.It was by this non-intrusive method that it was estimated that separation exists from the bottom of the SAS and the high groundwater. 13 Title 5 Inspection Form 6/15/2000 COMMONWEALTH OF MASSACHUSETTS 1'1 Z4g ID EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS a DEPARTMENT OF ENVIRONMENTAL PRO=Y1 � <tl 03 TOWN OF BARNSTABLE HEALTH DEPT. TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 9-19(odds)Captain Cook Lane,Bldg 2,Center Village MAP PARCEL ; D 4- Owner's Name: c/o Huntingest Management Owner's Address:Unit C,40 Industry Rd.Marstons Mills,MA 02648 LOT Date of Inspection: 03/29/03 Name of Inspector: Michael Bisienere Company Name: A&K Septic Systems Plus Mailing Address: 565 Carriage Shop Road East Falmouth,MA 02536 Telephone Number: 508-540-6706 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 Inspector's Signature: / / Ya.e.-04/11/03 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: System functioning fine. There is no evidence of failure criteria. System consists of 2000 gallon tank with d-box and 3 leaching pits. ""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 l 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 9-19(odds)Captain Cook Lane,Bldg#2 Center Village Owner: c/o Huntingest Management Date of Inspection: 03-29-03 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: X I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. 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: Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address:9-19(odds)Captain Cook Lane,Center Village,Bldg 2 Owner: c/o Huntingest Management Date of Inspection: 03/29/03 C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(l)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: _ Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. _ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. _ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance "This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 9-19(odds)Captain Cook Lane,Bldg 2,Center Village Owner: c/o Huntingest Management Date of Inspection: 03/29/03 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 Yz 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 1 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.] (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 II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes"in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional of-Tice of the Department. Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 9-19(odds)Captain Cook Lane,Bldg 2,Center Village Owner:c/o Huntingest Management Date of Inspection:03/29/03 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? 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 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: 9-19(odds)Captain Cook Lane,Bldg 2,Center Village Owner: c/o Huntingest Management Date of Inspection: 03/29/03 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 12 Number of bedrooms(actual) : 12 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 1320 Number of current residents: 15 Does residence have a garbage grinder(yes or no): no Is laundry on a separate sewage system(yes or no): no [if yes sepafate,,inspection required] Laundry system inspected(yes or no):NO Seasonal use: (yes or no): no Water meter readings, if available(last 2 years usage(gpd)): NA Sump pump(yes or no): no Last date of occupancy: current COMMERCIALANDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no):_ Non:sanitary waste discharged to the Title 5 system(yes or no): Water meter readings, if available: Last date of occupancy/use: . OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: system on regular maintenance schedule 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: 33 years, management co. Were sewage odors detected when arriving at the site(yes or no): NO Page 7 of 1 l OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 9-19(odds)Captain Cook Lane,Bldg 2,Center Village Owner: c/o Huntingest Management Date of Inspection: 03/29/03 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction: _cast iron _40 PVC other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: x (locate on site plan) Depth below grade: 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: standard 2000 gallon tank Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle: 38" Scum thickness: 2" Distance from top of scum to top of outlet tee or baffle: 8" Distance from bottom of scum to bottom of outlet tee or baffle: 5" How were dimensions determined:Field instruments Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): Recommend pumping every two years. Condition of tees and liquid levels are fine. There is no evidence of leakage. Structural integrity is fine. GREASE TRAP:_(locate on site plan) Depth below grade:_ Material of construction:_concrete_metal_fiberglass_polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): Page 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 9-19(odds)Captain Cook Lane,Bldg 2,Center Village Owner: c/o Huntingest Management Date of Inspection: 03/29/03 TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass_polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: x (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.):Distribution is equal. There is no evidence of solids carryover or any evidence of leakage. PUMP CHAMBER: (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 9-19(odds)Captain Cook Lane,Bldg 2,Center Village Owner: c/o Huntingest Management Date of Inspection: 03/29/03 SOIL ABSORPTION SYSTEM(SAS): x (locate on site plan,excavation not required) If SAS not located explain why: Type X leaching pits,number: 3 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.): No signs of hydraulic failure. Condition of vegetation and soil is fine. CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth—top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): i 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.): Page 10 of l 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 9-19(odds)Captain Cook Lane,Bldg 2,Center Village Owner:c/o Huntingest Management Date of Inspection: 03/29/03 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. O O 15 2 ,A % � 19 1-7 � 15 91 i I , revised 9/2/98 Page 10 of I I r Page 1 I of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 9-19(odds)Captain Cook Lane,Bldg 2,Center Village Owner: c/o Huntingest Management Date of Inspection: 03/29/03 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 14+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: x Observed site(abutting property/observation hole within 150 feet'of SAS) x 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: Local conditions site at high elevations L --I - L.......... H hRo.�•J�� W Z • V CP �� 4 � BORTOLOTTI CONSTRUCTION,INC. gq� 1y9v 765 WAKEBY ROAD,MARSTONS MILLS,MA 0 6a8Np "�E 508-771-9399 508428-8926 FAX: 508428-9399. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM--,-, PART A CERTIFICATION Property Address: Date of Inspection:- Inspectors Name. Owner's Name and Ad(iress: 6 / CERTIFICATION STATEMENTo I certify that I have personally inspected the sewage disposal system at this address and that the informa- tion reported;below is true,accurate and complete as of the time of inspection. The in was per- formed based on my training and experience in the proper function and maintenance of on-site sewage disposal sy4tefns. The System: s Passes Conditionally Passes Needs Further Ev tioge Local Aproving Authority Fails:. .... Inspector's Signature: - Date:----1��, 9 The System.inspector shall submit a copy of this inspection report to the Approving authority within thir- ty(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 Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer,if applicable and the approving authority. INSPECTION SiiMMARV• A)SYSTE ASSES: I have not found 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. B)SYSTEM CONDITIONALLY PASSES; One or more system components need to be replaced or repaired. The system,'upon comple- tion of the replacement or repair,passes inspection. Indicate yes,nor,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,cracked,structurally unsound,shows substantial infiltration or enfiltraion,or tank failure is imminent. The system will pass inspection if the existing sep- tic tank.is replaced with a conforming septic tank as approved by The Board of Health. Sewage backkup 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 pass inspection if(with approval of The Board of Health): -1- '..s,)rSUBSURFACE'SEWAGE DISPOSAL SYSTEM INSPECTION FORM / PART A CERTIFICATION(continued) Broken pipe(s)replaced Obstruction is removed Distribution Box is levelled or replaced The System required pumping more than four times a year due to broken or obstructed pipe(s). The stem will ass inspection if(with approval of The Board of Health): system P Broken pipe(s)are replaced Obstruction is removed 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 the public health,safety and the environment. 1)SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT 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 APPROPRIATE)DETERMINES THAT THE SYSTEM IS FUNCTION- ING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system and is within 100 Feet to a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and is with a Zone I of a public water supply well. The system has a septic tank and soil absorption system and is within 50 Feet of a private water supply well. ° The system has a septic tank and soil absorption system and 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 the facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. � D)SYSTEM FAILS: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. 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. Backup.of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of efluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. ; ak Static liquid level in the distribution box above outlet invert due to an overloaded or clog- ged SAS or cesspool. Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow. . Required pumping more-than 4 times in the last year DM due to clogged or obstructed pipe(s). Number of times pumped 2- t SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) 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 a 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: The following criteria apply to a large system in addition to the criteria above: The design flow of a system is 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: The system is within 400 Feet of a surface drinking water supply The system is within 200 Feet of a tributary to a surface drinking water supply The system is located in a nitrogen sensitive area Interim Wellhead Protection Area (IWPA)or a mapped Zone II of a public water supply well. The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. 0 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B E CHECKLIST Check if the following have been done: t�Pumping information was requested of the owner,occupant,and Board of Health. None of the system components have been pumped for atleast 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. LAs-built plans have been obtained and examined. Note if they are not available with N/A. V" he facility or dwelling was inspected for signs of sewage back-up. t/The system does not receive non-sanitary or industrial waste flow. v"The site was inspected for signs of breakout. =All system components,excluding the.Soil Absorption System, have been located on site. _ZThe.septic tank manholes were uncovered,opened,and the interior of the septic tank was in- spect or condition of bales or tees,material of construction,dimensions,depth of liquid, th of sludge,depth of scum. e size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods. -3- r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST(continued) e facility owner(and occupants, if different from owner)were provided with,information on. the proper maintenance of Subsurface Disposal System SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION ' FLOW CONDITIONS Rr. ID . Design Flow: '14,0allons Number of Bedrooms: Number of Current Residents: Garbage Grinder: it/D Laundry Connected To System: Z e5 Seasonal Use: / 49 Water Meter Readings,if available: Last Date of Occupancy: COMME CIALIJNDiiST TAi � O Type of Establishment: Design F1ow: pallous/day Grease Trap Present: (yes or no) Industrial Waste Holding Tank Present: Non-Sanitary Waste Discharged To The Title V System: Water Meter Readings,If Available: Last Date of Occupancy: OTHER: Describe) Last Date of Occupancy: GEN RAL INFORMATION PUMPING RECORDS and source of informa ion. L0002 System Pumped as part of inspection:A If yes,v me pumped: gallons Reason for pumping: TYPE E 9F SYSTEM: 1/Septic Tank/Distribution Box/Soil Absorption System Single Cesspool Overflow Cesspool Privy Shared System(If yes,attach previous inspection records, if any) Other(explain): APPROXIMATE AGE of all components,date installed(if known)and source of information: LP/Z,,(2/II(2k� Sewage odors detected when arriving at the site:AJO - -4- SUBSURFACE SEWAGE DISPOSAL SYSTEM,INSPECTION FORM PART C GENERAL INFORMATION (continued) E SEPTIC TANK: 1' / Depth below grad Material of Construction: concrete metal FRP_Other (explain) ' Dimisions:/Z' Sludge Depth: 30 Scum Thickness: ' Distance from top of sludge to bottom of outlet tee or baffle: 3 6- Distance from bottom of scum to bottom of outlet tee or baffle: 9 Comments: (recommendation for pumping,condition of inlet and outlet tees or affles,depth of liquid level in ation outlet invert,struc al integ 'ty vidence of leakage,etc. �C�OO c GREASE TRAP: Depth Below Grade: Material of Construction:_concrete_metal_FRP_Other (explain) Dimensions: Scum Thickness: Distance from top of scum to top of outlet tee or baffle: 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.) TIGHT OR HOLDING TANK:Al) Depth Below Grade: Material of Construction:_concrete_metal_FRP_Other(explain) Dimensions: Capacity: gallons Design Flow: aallons/day Alarm Level: Comments: (condition of inlet tee,condition of alarm and float switches,etc.) DISTRIBUTION BOX: Depth of liquid level above outlet invert:l� Comments: (note if 1 1 and distribution is ual,evi nc of solids car ov r,evidenc of leakage into or out of box,etc.) to PUMP CHAMBER:1/ 1J Pump is in working order: Comments: (note condition of pump chamber,condition of pumps and appurtenances,etc.) -5 I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) / t SOIL.ABSORPTION SYSTEM(SAS): ✓ i (Locate on site plan,if possible;excavation not required,but may be approximated by non-intrusive a methods) If not determined to be present,explain: Type: Leaching pits,number: 3 Leaching chambers, number: Leaching galleries,number: Leaching trenches, number,length: Leaching fields,number,dimensions: Overflow cesspool,number: Comments:(note condition of soil,signs of hydra is failure level of ponding,condition of egetation, etc.)7� - e� ` Q.J CESSPOOLS: 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 soilk,signs of hydraulic failure, level of ponding,condition of vegetation, etc.) PRIVY: Materials of construction: Dimensions: Depth of Solids: Comments:(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation, etc.) -6- SUBSURFACE SEWAGE DISPOSAL SYSTEMINSPECTION FORM PART C SYSTEM INFORMATION (continued) SKETCH OF SEWAGE DISPOSAL SYSTEM: Include ties to atleast two permanent references, landmarks or benchmarks. Locate all wells within 100 Feet. i o 1 -3 .y, ao �1 #3 DEPTH TO GROUNDWATER: Depth to groundwater: Z® Feet Met-hod of Determination or Ap roxi lion: Aporl -7- William >Cielerman 141 STETSON LANE HYANNIS• MASSACHUSETTS 02601 - 617-.771-1341 December 28, 1976 Barnstable- Board of Health 397 Main Street Hyannis, Massachusetts 02601 REFERENCE: Barnstable -. Subsurface Sewage Disposal Proposed 30 Condominium Unit. Addition to Center Village Condominium Complex, Old Straw- berry Hill Road and Route 132. Job, No. 73-410--Approval Letter Dated October 18,1973 (Mass. Dept. of Public Health) and Sewage Permit #593 (Town of Barnstable) Gentlemen: This is to certify that the disposal facilities for building #2 have been inspected this day and found to be constructed in accordance with the approved plans in two sheets, the first of which is .titled: JULIUS DOLINER CONSTRUCTION CO. 850 Boylston Street Chestnut Hill, Mass. 0.2167 SCALE:. 1" 30' DRiiN BY: T. l DATE: 8-24-73. DWG: .NO. SP ��P ,v DWG. TITLE: SITE PLANyc'P CENTER VILLAGE CONDOMINIUMS ; WILLIAM HYANNIS, MASS. LIEBEI` IV1AN �. V Trul our ,nip fdo• �3yi�0�� Will (Lieberman, P. cc: . Department of Environmental Quality Engineering, Mr. Fred L. De Fe Feo, P.E. Regional Sanitary Engineer, Southeastern Health Region, Lakeville Hospital Lakeville, Mass. 02346 Strawberry Hill Realty Trust, Mr. R. Anderlot, 477 Main Street, Yarmouth- -port, Mass. 02675. �..�Jr . , iJ . ,ao-�rkGn •• ... No. S ,/ Fps...r........................ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEA TH ........._.OF........... 4_!, '!� ......:. ... ............. . Iirttt�nn fur 3i_q pwial Works Tonstrnrttnn Vanift Application is hereby'made for a Permit to Construct or Repair ( ) an Individual Sewage Disposal Sy t at: . P.�(_.tQ .e----------------------- ---�ac_e.....� .... A- � ---- ----------- -- - --- ---- -- L Aa' •A ress lea ... rSA.�.I ----------- ---- .1`1.VA-5f..... ��,'®�� --dr-f......--•.. t5� = Owner •.....Address Installer Address d Type of Building 02 Size Lot----------------------------Sq. feet V Dwelling—No. of Bedrooms ................................Expansion Attic (j 6) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) a' Other fixtures ---_--------------•----------__ W Design Flow ...............s��__.................gallons per person per day. Total,daily flow....... -_____--__-_---.---.-_-gallons. WSeptic Turk Liquid capacity2 S_-_OZ�allons Length---------------- Width................ Diameter_----...._._--_ Depth................ x Disposal Trench—No..................... Widt)i....._-------------- Total Length.................... Total leaching area........_.__._-------sq. ft. 3 Seepage Pit No.-----___-7-------- Diameter-_d:?�Z _3 jj)epth below inlet------- otal leachit red.;..,._5 __sq. ft. Other Distribution box ( ) Dosing to ( ) Q,e - 2 �q�Percolation Test Results Performed by._____._ _ . i ...___ Date. _. :___-__ ________. Test Pit No. 1................minutes per inch Depth of Test Pit-------------------- Depth to ground water------------------------ G14 Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water-..--.---__-__------.... ...................................----------- 0 Description of Soil---- (3.�_t-J6----•-- GZY�N•---5 G� —{ �� 1�'AY-ee` x -------- --- - ---- - Wa - ------ -�------- ----------------------------- VNature of Repairs or Alterations—Answer when applicable--------------------------------------------------.-__-_-_._-_-----..-..-..-._-.-.-..___---_-_.. ............................•---------------------------------• -- •---...._•---•-------•..---....----------...-----------------_.._._...-------------------------------------------------------------- Agreement The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article NI of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has b is e he and f ealth. Sie . ................................................. ..� � Date Application Approved By...... -• -..---- G�til- -_-------- -------- ---- - Date Application Disapproved for the following reasons----------------------------------------------------------------------------------------------------------------- -•..........•---•---------•••-•--•-••-------------------------------•-----•--••--•••--.............................................................--------------------------------------------------- Date PermitNo......................................................... Issued........................................................ Date No...---�(--•--Cl---a.-----• Fes$.-.� .. ..... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEA TH _ .....------...OF.......... �.a%�'!!✓�✓T. ..`......- - - Appliration -for Diquoiittl Workii Cnowilrurtion V rrmlit Application is hereby'made for a Permit to Construct (x) or Repair ( } an- Individual Sewage Disposal SyA em at: = P - - r Lo ation_A dress o of o. Yc: �_pr✓f_ ��. � 'Pu t � `{ ....------- 7 7 /`' Gih 5-�--------.��-_}" _(,q�11> 6 Y � .... Owner O Address Installer Address Type of Building r,2 Size Lot____________________________Sq. feet Dwelling—No. of Bedrooms____ _ _________________________________Expansion Attic 0/b) Garbage Grinder ( ) pa, Other—Type of Building ______________________...... No. of persons---------------------------- Showers ( ) — Cafeteria ( ) P4 Other fixtures -----_---------------------------------------------- Design Flow`!_______________5 .________.__.___gallons per person per day_ Total daily flow____._� .......................gallons. 9 Septic Tank Liquid Liquid capacitv;?_574JZ)gallons Length---------------- Width---------------- Diameter___-_- _-____ Depth--_-__-__-_-.-. xDisposal Trench—No_____________________ Width-------------------- Total Length_-______________--- Total leaching area------------._.-----sq. ft. 3 Seepage Pit No............?.-------- Diameter_ epth bel w inlet------4----------- otal leaching re --_?_S; ---- it. z Other Distribution boa: ( ) Dosing to�( ) Q,� - �- 7 � �9 ��'� � `-' Percolation Test Results Performed by.___-.../��2-l0_fl- _ 1-7G, a J A O Date��- Test Pit No. 1----------------minutes per inch Depth of 'lest Pit_--___________...___ Depth to ground water---____-_-_---__--__- t>~ Test Pit No. 2________________minutes per inch Depth of Test Pit--------------•----- Depth to ground water......___________..-- Ix -•-----••-•-------------- -----•-•------------------------------•----t- O Description of Soil x ' /" ------q!--c--------------- ------j r_wf e------------------------ -------------------------- w x ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- -------------- U Nature of Repairs or Alterations—Answer when applicable..-.------------------------------------------------------------------------------------------- . ----- 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 b is u the oarcj/of ealth. Si ed t, _ ---------•--•--- ---------- [?_. /_ Date Application Approved By----• --- ---- - •----- ------• • _ _l-t•-=vl- --------•-••-•--•--•----- r� /- Date Application Disapproved for the following reasons:----•--•--•-------• •---•-• ----------------------------------------------------------------------•••---•- --•---------------------------------------•-----------•---••-•---•------------- -------------- Date PermitNo......................................................... Issued........................................................ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD O,F HEALTH /.............OF .. .....�... 7 .....✓ ........ ttrdifirate of T'llomphaurr TH LET CER" IF T the Individual Sewage Disposal System constructed (v) or Repaired ( ) Instal e4�� ---•------ at... c 2 USAF �= '--e.......... r------------••-•- -- .. has been {nstalled in accordance with the provisions of . ( c e XI of The Sta e Sanitary Code as described in the application for Disposal Works Construction Permit No-_��__.S____ _P,j•_______________ dated--_./,Z---___ _-_ _ -________________ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE-----•----•-•-----•---•-----•-••••---------••-•--•------••--•--•••--------••-• Inspector.................................................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 7� ..__.. ... . FEE_/-_D.----•----.... Dinvarl .k Vnn,,ktr tion Vamit Permissio hereby granted---•-•----- ---__ - -----------•---- -•----------••------------------•-- to Constr o Fe air an Individual wa - Disposal stem � � p -- ) P- — at No:n �1- ---------2_-•- a&c .l!. �, 1..� _ - '�c�r- ------------•-------••----•----•------•----•• Street i JJ as shown on the application for Disposal Works Construction rnnit __ _ _____ _______ Dated_/_ .-_�---?--5�............. jo �`:°� � DATE.................................... ............................................ Board of He It FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS THE COMMONWEALTH OF MASSACHUSETTS BOARD O HEALTH Trrtifirativ of Tomphaurr � � �- THX§ I TO ERTIFY `Tl a the Individual Sewage Disposal System constructed (4-1) or Repaired ( ) bY -------------------------------------------------- ------------------------------- --------------- - nstalle has been 7stalled in accordance with the provisions of A t?•� XI of The State Sanitary Code as described in the application for Disposal Works Construction Permit No.•. dated Z � 7,K-----• ------ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM diy FUNCTION SATISFACTORY. DATE----- ._!� ..................... '� j >� Inspector---- - ---- - ------ -- ................................................. .................................................0...0..............0.......... .......................0....0....0.............. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 1�� a�t sue................. ..oF_.._..... o—d( N .---- _ FEE.-I.a............. - - _ __ � I Porkg $)Ttn2 rat �to2t rr�ttt - - - - - - Permission i ereby granted---- -' ;_ to ConstrA or� pair � n Individual S a spos in •--- at No._-. - fir../ � P � gi Street / as shown on the application for Disposal Works Construction P mit _ _ ____ ______ Dated...`__x�_ '_� 7__5............ �2�4� t"� --a, ................................ Board of HeaV DATE----•----------_---------- -------------- ------------------ ---------------- FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS TOWN OF BARNSTABLE _ LOCATION 6441� J///e"EWAGE # VILLAGE ASSESSOR'S MAP & LOTe2�-6 INSTALLER'S NAME & PHONE NO.All SEPTIC TANK CAPACITY A)e&, - f LEACHING FACILITY:(type) i'� �o�� (size) NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER BUILDER O WNER / 7L.. DATE PERMIT ISSUED: z� �� `-?`-�L DATE COMPLIANCE ISSUED: 49 VARIANCE GRANTED: Yes No L •/ b m'q 1 a lei n� No. .n.67.0. ��fU6 D, / Fmi...... .� .-`--` . THE COMMONWEALTH OF MASSACHUSETTS 2? BOARD OF HEALTH /r TOWN OF BARNSTABLE Appliratiun for UiuVu!3tt1 Wurk.6 Tunstrurtiun Fr ntit Application is hereby made for a Permit to Construct ( ) or Repair 0 ) an Individual Sewage Disposal S stem at ` e ` r , �1l.lJ � ....................................................... .... Gf7 __ Y �........�•�`y r..J Location- 1 ess or Lot No .. /W I l l w/Q �!�- °� `' --------------�j ... ---`A/6-4---•--• �•--%- JV! -L W . ... . .... ►, I SIRS Owner Address Installer Address Q Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms------------------------------ - - -Expansion Attic ( ) Garbage Grinder ( ) P4 Other—Type of Building ____________________________ No. of persons._--__-__-______---.._-.___. Showers ( ) — Cafeteria ( ) A4 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. Seepage Pit No...................... Diameter-------------------- Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box (. ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ aTest Pit No. 1................minutes per inch Depth of Test Pit-------------------- Depth to ground water...................... (i Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water..--___---_-.-_--__----- 9 .....--••--•----•-------------------------------••••---........•-••-•-•--•------•--•----•------••--.......................................................... 0 Description of Soil........................................................................................................................................................................ U W U Nature f Repairs or Alterations=Answer when applicable.._ ------ ...................................... _ -rr�i �r1 . ---- -----•`-�"Uv�rt �.......•.............. ......... .i 3'..�. �5.. j C/ ................ - T 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 s be n is ued the ,bard of health. Signed ............ . -... . - ®�/Q . Dace Application Approved BY ` - -- ... .Q...-.1.�...�cg'.�--------- .. Date Application Disapproved for the following reasonr: ........................... ............. ............................................................................ ----------------------------------------------------------------------- --------------------------- ----------------------------------------------------------------------------------------------------- Date Permit No. ..... ..t,----r--- - ------------------------- Issued ...... .. ... . . . . . .. Date i v 1)c2 I }` Fxs.............................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE ,� lirtt#inn for i Vwial Wnrkri C�nni#rnr#inn rruti# Application is hereby made for a Permit to Construct ( ) or Repair (.,X) an Individual Sewage Disposal System at: h� - c' / ..... ' ( Location Address / t (A or Lot No. / L ' -111 l l/1� �c� S i � !-= _!-U... y1/1�11S i/�3 _I 1. 14 Owner Add ress '� 69. i Gu�I, C�r�1sT 7GS� l,J�ty a/1/1 F -----•--------------•--•---- 1` ---------------- Installer Address Q Type of Building Size Lot............................Sq. feet U Dwelling— No. of Bedrooms--------------------------------------------Expansion Attic ( ) Garbage Grinder ( ) PL44 Other—Type of Building No. of persons____________________________ Showers ( — Cafeteria a d Other fixtures --------------------------------------------------------------------------------------- ---------------------------------------•-----------•--------- W Design Flow................-__5�__ _----------------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.-.______.___-__--____-- fT Test Pit No. 2................minutes per inch Depth of Test Pit._____-.•-_-____._- Depth to ground water_-..--_____--__-.-_-___. P4 -------------................................................................................................................................................ 0 Description of Soil........................................................................................................................................................................ x U .....-•---------------------•---------------•---•••--•----•-------•-••-••--....-------•------------•------------------•-------------••---•-------------••-•---•-•---••-----...............---•••......--- w UNature f Repairs or Alterations—Answer when applicable._.. b_-___/?:----------(.bQtlf.C)_.�t�________t._ h C-....!_2!=1.— �''► '...-----•`S-%..Uvat.....------------------....--•--...-•--- .--------- _"J�----._------.--?-S_1 r !l l.........---•---- 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 s be n is uedb the)bard offhhealth. Signed ------------e .....,`. .. -i/ tr1- ✓c- �'............ ........ 4�/G�h y Dare Application Approved BY ... _ \ / ................. ...... /c� -.�. ...... �I , ' Dare Application~Disapproved for the following reasons: ---------_------------------------------------------------------------------------ --------------------------------------- I -------------------------------------------q--------------------------------------------------------------'---------------------------------------------......---------------------------- .......................... ,Permit No: ........[..`i :-�'-`''ter"`------ ------------- r Issued ............._............................. --. �.. -"` Dare —.—.--.—.—._ ---— �------ -----.----.—.—---------- --------------- -------. --- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN-OF BARNSTABLE Te'r#tftctt#e of (EdfuFfian e l THIS IS TO CERTlf),,That the Individual Sewage Disposal System constructed ( ) or Repaired (� ) Eby a .. r. ;' -L'J a"TC�.1 .(��.M :--- ------------------------------------------------------------- at ...... .. ..-- -----Yt�,.t GA-tom"" --GU.�. jZD - 1►�! I S 7 /has`been'installed in accordance with the provlslons of TITLE 5 of The State Environmental Code as described In the application for Disposal Works Construction Permit No. ..__�f .-.. ..�_5 ...... dated. .................. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE......... .......... .. .. Inspector 1 s :. ��c�%'%�� ...... e7 --- / ------ ------------------------------------------------------ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Btnpnsttl Workii Tnni#rur#inn "ami# Permission is hereby granted............. �1 -? 4.�'_ .._._-.._f '--!-�W---- to Construct ( ) or Repair an Individual Sewage Disposal System `fir ?- C _____tt,rlS Street as shown on the application for Disposal Works Construction Permit No--- _ Dated-------/ _-! t..`/........... ...... •-------------------- -Q�- ------------------------------ t Board of Health c V DATE.................6 D--- •• = ......................... FORM 36508 HOBBS&WARREN,INC..PUBLISHERS