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HomeMy WebLinkAbout42-44 FRESH HOLES ROAD - Health 42 - 44 FRESH HOLES ROAD, HYANNS A= l l i a ` Commonwealth of Massachusetts Title 5 Official Inspection Form tiIa Subsurface Sewage Disposal System Form -Not for Voluntary Assessments: 42 &44 Fresh Hole Road r _ Property Address € Eric Winer I Owner Owner's Name information is required for every Hyannis ✓ MA 02601 09-29-2020 — page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any ' way. Please see completeness checklist at the end of the form. Important:When A. Inspector Information 5/ /J4 9 3/ filling out forms on the computer, use only the tab Michael T Bisienere key to move your Name of Inspector cursor-do not Cape Septic Inspections use the return Company Name key. 52 Rivers End Road "ITV Company Address Teaticket Ma. 02536 City/Town State Zip Code 508-280-3356 S13938 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails �.E °-----.,.�.. 10-04-2020 Inspector's Signature "Date 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 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 form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: 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. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form yI Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ............ , 42 &44 Fresh Hole Road Property Address Eric Winer Owner Owner's Name information is H annis MA 02601 09-29-2020 required for every y page. CitylTown State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. =` 1) System Passes: ® 1 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: 2) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND) for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N FIND (Explain below): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form yI Subsurface Sewage Disposal System Form - Not for Voluntary Assessments u— 42 &44 Fresh Hole Road Property Address Eric Winer Owner Owner's Name information is required for every Hyannis MA 02601 09-29-2020 page. CityrTown State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 3) 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. a. 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: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 18 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 9 p Y rY 42 &44 Fresh Hole Road u— Property Address Eric Winer Owner Owner's Name information is required for every Hyannis MA 02601 09-29-2020 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ 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 b. 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 fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 1 Commonwealth of Massachusetts �v _ Title 5 Official Inspection Form I; Subsurface Sewage Disposal System Form - Not for Voluntary Assessments c � 42 &44 Fresh Hole Road Property Address Eric Winer Owner Owner's Name information is required for every Hyannis MA 02601 09-29-2020 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 'h day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. I . ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply 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. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd 10,000 gpd. ❑ ® 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. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the questions in Section CA. 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments !% 42 &44 Fresh Hole Road u Property Address Eric Winer Owner Owner's Name information is required for every Hyannis MA 02601 09-29-2020 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes" to any question in Section C.5 the system is considered a significant threat, or answered "yes" to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes" or"no" for each of the following for all inspections: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? El ® 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) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? I ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] I t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 Commonwealth of Massachusetts �n Title 5 Official Inspection Form �1� Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 42 &44 Fresh Hole Road Property Address Eric Winer Owner Owner's Name information is required for every Hyannis MA 02601 09-29-2020 page. Citylrown State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 plus GPD Description: Number of current residents: 6 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ❑ No Water meter readings, if available last 2 ears usage d town water -- Detail: ( Y 9 (gp ))� Detail: #42 used 130,152 gallons from 2/25/2019 -9/3/2020 and #44 used 141,372 gallons from 2/25/2019 -9/3/2020. Sump pump? ❑ Yes ® No Last date of occupancy: occupied Date t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form r I, Subsurface Sewage Disposal System Form Not for Voluntary Assessments v 42 &44 Fresh Hole Road Property Address Eric Winer Owner Owner's Name information is required for every Hyannis MA 02601 09-29-2020 . page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No, If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 r. ,fie Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ............. 42 &44 Fresh Hole Road Property Address Eric Winer Owner Owner's Name information is required for every Hyannis MA 02601 09-29-2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ® 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) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: 1995 Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): 27" Depth below grade: feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: town water feet -. Comments (on condition of joints, venting, evidence of leakage, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form I, Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 42 &44 Fresh Hole Road Property Address Eric Winer Owner Owner's Name information is required for every Hyannis MA 02601 09-29-2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: 1.8 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: H-10 1500 gallon Sludge depth: 5" Distance from top of sludge to bottom of outlet tee or baffle 31" ram- Scum thickness 4" 5"Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle 13" How were dimensions determined? sludge judge Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): I recommend the new owner put the septic tank on a maint. plan with a local septic pumping co. based on the future use of the home. At the time of inspection the liquid level was at working level and the tee's were in place. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts n _ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 42 &44 Fresh Hole Road Property Address Eric Winer Owner Owner's Name information is required for every Hyannis MA 02601 09-29-2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. 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 per day t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form +_ lI; Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 42 &44 Fresh Hole Road Property Address Eric Winer Owner Owner's Name information is required for every Hyannis MA 02601 09-29-2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 01. 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.): At the time of the inspection the liquid level was at working level and there were no visible signs of leakage or solids carryover. a t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 9 p Y rY 42 &44 Fresh Hole Road Property Address Eric Winer Owner Owner's Name information is required for every Hyannis MA 02601 09-29-2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No" Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ® leaching chambers number: 5 Infiltrators ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 42 &44 Fresh Hole Road Property Address Eric Winer Owner Owner's Name information is required for every Hyannis MA 02601 09-29-2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): At the time of the inspection no visible failure criteria was found. 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 18 Commonwealth of Massachusetts :. Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ............ !% 42 &44 Fresh Hole Road u- Property Address Eric Winer Owner Owner's Name information is required for every Hyannis MA 02601 09-29-2020 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 13. Privy(locate on site plan): r Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): . y t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 18 X Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 42 &44 Fresh Hole Road Property Address Eric Winer Owner Owners Name information is required for every Hyannis MA 02601 09-29-2020 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately �^ Ijcas•p,�rri��c I t5insp.doc•rev.7/26/2018 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18 c Commonwealth of Massachusetts _ p Title 5 Official Inspection Form I e Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ............., 42 &44 Fresh Hole Road V Property Address i. Eric Winer Owner Owner's Name information is required for every Hyannis MA 02601 09-29-2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ® Check Slope ® Surface water ® Check cellar I ® Shallow wells Estimated depth to high ground water: 10 plus feet feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: I augered a hole at a lower elevation and shot it with a transit. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 __ 3 ' c Commonwealth of Massachusetts Title 5 Official Inspection Form �I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 42 &44 Fresh Hole Road Property Address Eric Winer Owner Owner's Name information is required for every Hyannis MA 02601 09-29-2020 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria) and 6 (Checklist) completed ® D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 Certified Mail#7015 1730 0001 4990 2779 �� rati Town of Barnstable O,r Regulatory Services 1639. a Public Health Division Thomas McKean,Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 May 8, 2017 Eric Winer 144 Barton Road Hodgdon, ME 04730 NOTICE TO ABATE VIOLATIONS OF 105 CMR 410.000, STATE SANITARY CODE II MINIMUM STANDARDS OF FITNESS FOR HUMAN HABITATION yZ The property owned by you located at Fresh Holes Road Hyannis, was inspected on May 8, 2017 by Timothy B. O'Connell, R.S., Health Inspector for the Town of Barnstable. This inspection was conducted on the basis of Chapter 170 of The Town of Barnstable. The following violations of the State Sanitary Code were observed: 105 CMR 410.500—Owner's Responsibility to Maintain Structural Elements: • Observed that kitchen flooring tile is broken, loose and in need of repair. • Broken cabinets within kitchen. • Loose outlets throughout dwelling unit. • Missing screens throughout dwelling unit. • Holes in bathroom wall in the area where lower wall meets floor. • Back door does no exclude wind and rain. Missing screen/storm door. You are directed to correct the violations listed above within thirty (30) days of your receipt of this notice. You may request a hearing before the Board of Health if written petition requesting same is received within ten (10) days after the date the order is served. Non-compliance will result in a fine of$100.00 per violation. Each day's failure to comply with an order shall constitute a separate violation. Should you have any questions regarding the above violations, please contact the Town Health Division and ask to speak with the inspector who performed the inspection. PER ORDER OF THE BOARD OF HEALTH Thomas A. McKean, R.S., CHO Director of Public Health Town of Barnstable I QAOrder letterMousing violations\Rental ordinance\5-8-17 42 Fresh holes .+4 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS John Grad DEPARTMENT OF ENVIRONMENTAL PROTECTION DEP Title V Septic Inspector ONE WINTER STREET BOSTON MA 02108(617)292-3500 P.O.Box 2119 TeaTicket,Ma. (508)564-6813 TRUDY COXE Secretary ARGEO PAUL CELLUCCI DAVID B.STRUHS Governor Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A r CERTIFICATION Property Address: 42+44 FRESH HOLES RD. HYANNIS Name of Owner KOPPEN Address of Owner: 338 PLEASANT PINE AV.CENTERVILLE MA.02632 m J U L 2 2 1999 Date of Inspection: 7/13/99 Name of Inspector:(Please Print)JOHN GRACI � F�IAEA4W I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000) TM0EPE Company Name: n/a Mailing Address: n/a }� Telephone Number: n/a CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.The system: X Passes The inpection is based on criteria defined in Title V Conditionally Passes code 310 CMR 15.303.My findings are of how the system is _ Needs Further Evaluation By the Local Approving Authority performing at the time of the Inspection.My Inspection does Fails not imply any warranty or guarantee of the longgevity of the septic system and any of its components useful life. Inspector's Signature: Date:7/14199 The System Inspector shall iubmita 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 now 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. NOTES AND COMMENTS THE SYSTEM PASSES TITLE V INSPECTION.RECOMMEND PUMPING SYSTEM EVERY TWO YEARS FOR MAINTENANCE. revised 9/2198 Page 1 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 42+44 FRESH HOLES RD.HYANNIS Owner: KOPPEN Date of Inspection:7/13/99 INSPECTION SUMMARY: Check A, B, C, or D: A. SYSTEM PASSES: I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist.Any failure criteria not evaluated are indicated below. COMMENTS: System passes Title V inspection B. SYSTEM CONDITIONALLY PASSES: nLa One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Indicate yes,no,or not determined(Y,N,or ND).Describe basis of determination in all instances.If"not determined",explain why not. Wa The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection;or the septic tank,whether or not metal,is cracked,structurally unsound,shows substantial infiltration or exfiltration,or tank failure is imminent.The system will pass inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. Wa Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken,settled or uneven distribution box.The system will pass inspection if(with approval of the Board of Health). broken pipe(s)are replaced obstruction is removed _ distribution box is levelled or replaced nZa The system required pumping more than four times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed revised 9/2/98 Page 2 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 42+44 FRESH HOLES RD.HYANNIS Owner: KOPPEN Date of Inspection:7/13199 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 IN ACCORDANCE WITH 310 CMR 15.303(1)(b)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 surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER.IF ANY)DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well, The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well,unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,Method used to determine distance nLa..(approximation not valid). 3) OTHER Wa revised 9/2198 Page 3 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 42+44 FRESH HOLES RD.HYANNIS Owner: KOPPEN Date of Inspection:7/13/99 D. SYSTEM FAILS: You must indicate either"Yes"or"No"to each of the following: I have determined that one or more of the following failure conditions exist as described in 310 CMR 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. Yes No X Backup of sewage into facility or system component due to an 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 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 Wa. X Any portion of the Soil Absorption System,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 I of a public well. X Any portion of a cesspool or privy is within 50 feet of a private water supply well, . X Any portion of a cesspool or privy is less-than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis.If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic ompounds, ammonia nitrogen and nitrate nitrogen. X The liquid level in the SAS is over the invert pipe,is in Hydraulic Failure. E. LARGE SYSTEM FAILS: } 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: _ The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No X the system is within 400 feet of a surface drinking water supply X the system is within 200 feet of a tributary to a surface drinking water supply X 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 upgrade the system in accordance with 310 CMR 15.30412).Please consult the local regional office of the Department for further information. revised 912198 Page 4 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 42+44 FRESH HOLES RD.HYANNIS Owner: KOPPEN Date of Inspection:7/13/99 Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following: Yes No X Pumping information was provided by the owner,occupant,or Board of Health. X None of the system components have been pumped for at least two weeks and-the system has been receiving normal flow rates during that period.Large volumes of water have not been introduced into the system recently or as part of this inspection. X As built plans have been obtained and examined.Note if they are not available with N/A, X The facility or dwelling was inspected for signs of sewage back-up. X The system does not receive non-sanitary or industrial waste flow. X The site was inspected for signs of breakout, X All system components,-excluding the Soil Absorption System,have been located on the site. X The septic tank manholes were uncovered,opened,and the interior of the septic tank was inspected for condition of baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge,depth of scum.The size and location of the Soil Absorption System on the site has been determined based on: X Existing information,For example,Plan at B4O,H, X Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable) (1 5.302(3)(b)) X The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of Subsurface Disposal Systems. revised 9/2/98 Page 5 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 42+44 FRESH HOLES RD.HYANNIS Owner: KOPPEN Date of Inspection:7/13/99 FLOW CONDITIONS RESIDENTIAL: Design flow:-44Q g.p.d./bedroom Number of bedrooms(design): 4 Number of bedrooms(actual):4 Total DESIGN flow: 44Q Number of current residents:4 Garbage grinder(yes or no):NQ Laundry(separate system)(yes or no): NO If yes,separate inspection required Laundry system inspected(yes or no):-W Seasonal use(yes or no):M Water meter readings,if available(last two year's usage(gpd): nLa Sump Pump(yes or no): NQ Last date of occupancy: nLa COMMERCIAL/INDUSTRIAL Type of establishment: nLa Design flow: n&gpd(Based on 15.203) Basis of design flow: Wa Grease trap present:(yes or no):M Industrial Waste Holding Tank present:(yes or no): MQ. Non-sanitary waste discharged to the Title 5 system:(yes or no):NQ Water meter readings.if available:nLa Last date of occupancy: n& OTHER: (Describe) n& Last date of occupancy: n& GENERAL INFORMATION PUMPING RECORDS and source of information: SYSTEM WAS PUMPED IN THE SLIMMER OF 98 System pumped as part of inspection:(yes or no):NQ If yes,volume pumped nLa_ gallons Reason for pumping: n& TYPE OF SYSTEM XSeptic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no)(if yes.attach previous inspection records,if any) I/A Technology etc.Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other: nla APPROXIMATE AGE of all components,date installed(if known)and source of information: 1994 Sewage odors detected when arriving at the site:(yes or no) NO revised 9/2/98' Page 6 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 42+44 FRESH HOLES RD.HYANNIS Owner: KOPPEN Date of Inspection:7/13/99 BUILDING SEWER: (Locate on site plan) Depth below grade: 2LE Material of construction:_ cast iron X 40 PVC _ other(explain) Distance from private water supply well or suction line: TOWN Diameter: nta Comments: (condition of joints,venting,evidence of leakage,etc.) nLa SEPTIC TANK: X (locate on site plan) Depth below grade: 2 Material of construction:X concrete_ metal_ Fiberglass Polyethylene _ other(explain) nta If tank is metal,list age Is age confirmed by Certificate of Compliance(Yes/No): NG WA Dimensions: L 10'6"H 5'7"W 5'8" Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: Distance from top of scum to top of outlet tee or baffle: 6" Distance from bottom of scum to bottom of outlet tee or baffle: 17"" How dimensions were determined: MEASURED 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.) SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND RECOMMEND PUMPING SYSTEM EVERY TWO YEARS GREASE TRAP: (locate on site plan) Depth below grade: Material of construction:_concrete_ metal_ Fiberglass _ Polyethylene_other(explain) II& Dimensions: WA Scum thickness: n& Distance from top of scum to top of outlet tee or baffle:iVa Distance from bottom of scum to bottom of outlet tee or baffle nLa Date of last pumping: Wa 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.) nLa ` revised 9/2198 Page 7 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 42+44 FRESH HOLES RD.HYANNIS Owner: KOPPEN Date of Inspection:7/13199 TIGHT OR HOLDING TANK: NO (Tank must be pumped prior to,or at time of,inspection) (locate on site plan) Depth below grade: n& Material of construction:_ concrete_ metal_ Fiberglass _Polyethylene_ other(explain) n1A Dimensions: n& Capacity: n& gallons Design flow: n/a gallons/day Alarm present: NO Alarm level:jiLa- Alarm in working order:Yes_No_: NQ Date of previous pumping: nla Comments: (condition of inlet tee,condition of alarm and float switches,etc.) D& DISTRIBUTION BOX: X (locate on site plan) Depth of liquid level above outlet invert:n& Comments: (note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.) n PUMP CHAMBER: NO (locate on site plan) Pumps in working order:(Yes or No): NQ Alarms in working order(Yes or No): NQ Comments: (note condition of pump chamber,condition of pumps and appurtenances.etc.) n/a revised 9/2/98 Page 8 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 42+44 FRESH HOLES RD.HYANNIS Owner: KOPPEN Date of Inspection:7L13L99 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,if possible;excavation not required,location may be approximated by non-intrusive methods) If not located,explain: nLa Type: leaching pits,number: nLa leaching chambers,number: 6-INFULTRATORS leaching galleries,number: _nLa leaching trenches,number,length: nLa leaching fields,number,dimensions: nta overflow cesspool,number: Wit Alternative system: nLa Name of Technology: jaLa Comments: (note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.) THE SAS APPEARS TO BE FUNCTIONING PROPERLY.SOIL IN LEACHING FIELD PROPED DRY_ CESSPOOLS: _ (locate on site plan) Number and configuration: nta Depth-top of liquid to inlet invert: Wa Depth of solids layer: nta Depth of scum layer. Wa Dimensions of cesspool: Wa Materials of construction: Wa Indication of groundwater: nLa inflow(cesspool must be pumped as part of inspection)Wit Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) n(a PRIVY: _ (locate on site plan) Materials of construction:nta Dimensions:n& Depth of solids: Wit Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) D<a i revised 9/2/98 Page 9 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 42+44 FRESH HOLES RD.HYANNIS Owner: KOPPEN Date of Inspection:7113/99 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100'(Locate where public water supply comes into house) n/a AA 3 a RR 3& /+c (Y,I s7 revised 9/2198 Page 10 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 42+44 FRESH HOLES RD.HYANNIS Owner: KOPPEN Date of Inspection:7/13/99 NRCS Report name: nla Soil Type: nta Typical depth to groundwater: Wa USGS Date website visited: n/a Observation Wells checked: MQ Groundwater depth:Shallow _ Moderate _ Deep _ SITE EXAM _ Slope _ Surface water _ Check Cellar Shallow wells Estimated Depth to Groundwater 12 Feet Please indicate all the methods used to determine High Groundwater Elevation: _ Obtained from Design Plans on record _ Observed Site(Abutting property,observation hole,basement sump etc.) _ Determined from local conditions _ Checked with local Board of health Checked FEMA Maps _ Checked pumping records _ Checked local excavators,installers X Used USGS Data Describe how you established the High Groundwater Elevation.(Must be completed) USGS MAPS AND CHARTS AND VISUAL-12+FEET revised 9/2198 Page 11 of 11 ) Commonwealth of Massachusetts 4 Executive Office of Environmental Affairs Cb Department of do* Environmental Protection 661 • 9 WIIIIamm FFF.Weld � Teurudy XB ,�� Se.y(:O,EOEA David B.Struhs Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: `I�" " Address of Owner: ��,,,,._ ,.-vi.0•.i_�c�ti.�.�ctc—T Date of Inspection: �La (`�� (If different) r 7— v Name of Inspector.r 7_u CA o 41,L uc_`_\ Company Name, Address and Telephone Num er: �r�G1•i�t.p/l.S• CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-si7Pa55age disposal systems. The system: es Conditionally Passes . i; I Needs Further Evaluation By the Local Approving Authority Fails i it .5 ' id' iif C lnspeclor'stStgr>aWr p` x, Date: The System Inspector shall submit a copy of this inspection report to the Approving Authority 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 Department of Environmental Protection. The original should be sen: tv the m-stem owner and copies sent to the buyer, if applicable and the approv ing authority. INSPECTION SUMMARY: Check A, B, C,or D: A] SYSTEM PASSES: �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 completion of the replacement or repair, passes inspection. Indicate yes, no, or.not determined (Y, N, or ND). Describe.basis of determination in all instances. If not determined", explain why not) The septic tank is metal, cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming.septic tank as approved by the Board of Health. (revised 8/15/95) One Winter Street • Boston,Massachusetts 02108 • FAX(617)556-1049 •. Telephone(617)292-5500 A • i?Printed on Recycled Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A ll CERTIFICATION (continued) Property Address: `�C7--y� � `-�� ►]�'� � �" �� Owner: � vlao� �0 <<`c<wi Date of Inspection: 17_�`�J Bj SYSTEM CONDITIONALLY PASSES (continued) /4 Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are 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 system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed C) FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: N 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 FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE EN"RONMENT: _ the wstem na-, a septic tanK anu soil absorptiun system anu is within i0u icci to 8 Su or trfbu�aij t0 a surface water supply. _ The system ha! a septic tank and soil absorption system and is within 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 that 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 pond.ing of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. (revised 6/15/95) 1 rr SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Propertyress: Owner: � Vy- V� %o,4,0 Gti1�r;°mot' Date of.Inspection: / ( -�-`� . DI SYSTEM FAILS(continued): Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of 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 large systems in addition to the criteria above: I I The design floor+r of 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 a4tributary 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 suppiy 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. Y (revised 6/15/95) 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property A11ress: 4c ;v- Owner: Date of Inspection: / Check if the following have been done: ✓Pumping information was requested of the owner, occupant, and Board of Health. None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. ZAs built plans have been obtained and examined. Note if they are not available with N/A. ZThe facility or dwelling was inspected for signs of sewage back-up. The system does not receive non-sanitary or industrial waste flow &/The site was inspected for signs of breakout. LZ/AII system components, excluding the Soil Absorption System, have been located on the site. L/The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. V/The size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods. the fdCi i o.:;,c ;J, J'' occupants, if d fr:r^^t f•om ovmeri were provided with information on the proper maintenance of Sub- Surface Disposal System. (revised 8/15/95) 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION _ Property ert Address.. Owner: (Z"AA ,"O Gam`\�w� Date of Inspection:. FLOW CONDITIONS RESIDENTIAL: Design.flow: jL4'2A* gallons Number of bedrooms: Number of current residents: 0 Garbage grinder(yes or no): u Laundry connected to system (yes or no).- Seasonal use (yes or no):� Water meter readings,.if available: Last date of occupancy:_j�)tJ� �'^J COMMERCIAUINDUSTRIAL: Type of establishment: Design flow:_gallons/day Grease trap present: (yes or no)_ Industrial Waste Holding Tank present: (yes or no)_ Non-sanitary waste discharged to the Title 5 system: (yes or no)_ Water meter readings, if available: -Last date of occupancy: - OTHER: (Describe) Last date of occupancy GENERAL INFORMATION PUMPING RECORDS and source of information: System pumped as part.of inspection: (yes or no)_ If yes, volume pomned gallons Reason for pumping: TYPE CIF SYSTEM . 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) Other(explain) APPROXIMATE AGE of all components, date installed (if known) and source of information: V S Sewage odors detected when arriving at the site: (yes or no) (revised 6/15/95) 5 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property A dress: �{ -��-� -'d Owner: kt v�-j 1 WvvvO cam, t- Date of Inspection: / SEPTIC TANK: (locate on site plan) Depth below grade: r1 Material of construction: 2 concrete._metal _FRP—other(explain) Dimensions: Sludge depth: O 1��� Distance from top gf sludge to bottom of outlet tee or baffle: Scum thickness: U Distance from top of scum to top of outlet tee or baffle: Q,;,V` ;5 Distance from bottom of scum to bottom 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.) GREASE TRAP: (locate on site plan) 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: Distance from bottom in ho!torn of tee o•battle' 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.) Ire vised 6/:5/95) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: L 'c)�-_ }=J e­s vl Owner: Date of Inspection: TIGHT OR HOLDING TANK: (locate on site plan) Depth below grader Material of construction: _concrete _metal _FRP—other(explain) Dimensions: Capacity: gallons Design flow: gallons/day Alarm level: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX: (locate on site plan) Depth of liquid level above outlet invert: Comments: mote ii ievei and distribut,w eyu4 e�,'.dence of soliJ_ co;r)o�,er, evidence of leakagel into or out of box, etc. PUMP CHAMBER: (locate on site plan) Pumps in working orderAyes or no) Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) (revised 8/15/95) 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Ad ress:Owner: �,W-(W�v��-1� Gr-�� -,.,•_� Date of Inspection: SOIL ABSORPTION SYSTEM (SAS)._ (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: Type: leaching pits, number:_ leaching chambers, number:_ leaching galleries, number: leaching trenches, number,length: �r�v4��Y�y 3 l leaching fields, number, dimensions: overflow cesspool, number: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,etc.) ,• � 'I r CESSPOOLS: (locate on site plan) Number and configuration: Depth-top of liquid to inlet.invert: Depth of solids layer. Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater. inflow(cesspool must be pumped as part of inspection) Comments: (note condition of soil, signs of.hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY: ,/,--I (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) (revised 8/15/95) 8 r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: i_4 Owner: r- Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' _c tc l _ .. .� _I. DEPTH TO GROUNDWATER �T Depth to groundwater._2.�:feet method of determination or approximation: !revised 6/15/9S) 9 TOWN OF BARNSTABLE LOCA-! ON — `l`� 1"'dt� I�t he - SEWAGE # VILLAGE � ASSESSOR'S MAP & LOT INSTALLER'S NAME & PHONE NO. L*lvc" sesw L SEPTIC TANK CAPACITY LEACHING FACILITY:(type) a, i:Tr�lTzf d2-S (size) NO. OF BEDROOMS PRIVATE WELL OR'`PTJB W TA BUILDER OR OWNER DATE PERMIT ISSUED: ` DATE COMPLIANCE ISSUED: � � G VARIANCE GRANTED: Yes No , . 1 �T C r V ASSESSORS MAP N0: ` PARCEL NO: � � � .�. F�s...���.......... THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH TOWN OF BARNSTABLE Appliration for DiipnsFal lVork.6 C omitrurtion ramit Application is hereby made for a Permit to Construct ( ) or Repair (tea' an Individual Sewage Disposal System at: VY......F lf Location ddress ` or Lot No. Owner Address A n . /rC/f Installer Address d Type of Building Size Lot................ Sq. feet f_, Dwelling— No. of Bedrooms.__.._.._-------------------------__---Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons---------------------------•Showers ( ) — Cafeteria ( ) dOther fixtures -------------------------------------------------------------------------------------------------------. .u...... ................................... w Design Flow...... ...........................gallons per person day. Total da• flow._....... ...0 ......................gallons. WSeptic Tank T Liquid capacid__�__1�allons f ength-_ -.---- Width-_ ----. Diameter_.............Depth................ x Disposal Trench—' No.� Int Width.....9__.......... 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........................................ 14 Test Pit No. I-.-._---.-__---minutes per inch Depth of Test Pit-------------------- Depth to ground water........................ (T Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ P4 ---------------------------------------------------------------------------------------------------------- •---------------------------------- -... ------------ 0 Description of Soil---------------------------------------------------------------------------------------------- -----.....--- .......................................................... x c., w r �.�-y� - ------•---------------------- U Nature of Repair or Alter ions—Answer when a licable =-*L-!J"C _(._+..__.� �.....��- � . --------------- .,� 7_ _ 3 •-� .................. 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 f ther agrees not to place the system in operation until a Certificate of Complian i board ,heal Signed ----...----- --- ------- ------- - ..�� Date Application.Approved BY - ---�----- �� ��"---------------------------------.. .. ............... Date Application Disapproved for the following reason - --------------------------------_...-----------------------------------------------------._--------------------------- ........................................................�-----�--^----------- ---------------------- ------------------------------...--...........-..-- --------------.-...-..--....----..........- ....................................................... / 1 Permit No. ......... � _- Issued ..... .. ........................ .Date..... Date .................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Applitation for Di-n-Vitial lVarlai Tomilrnrtinn ramit Application is hereby made for a Permit to Construct ( ) or Repair ( ' an Individual Sewage Disposal System at: �•^� Location-i•\ddmss or Lot No. ..... Owner Address �- ff++= ......................................... tl Installer Address Type of Building Size Lot__________________________ Sq. feet �. Dwelling— No. of Bedrooms.._____,V____________________--_____.--_._-Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ---------------------------- No. of persons__..._--_-__-___.-._:--_-_-- Showers ( ) — Cafeteria04 ( ) Other fixtures ------------------------- ---------------------------------------- W Design Flow------- __ _________________________)gallons per person per day. Total daily flow..--....��.( _....................gallons. Gd Septic Tank-- Liquid capacity'__,,gallons Length__ (...__._ Width-----�---------- Diameter.-.-._....._... Depth................ W Disposal Trench—No."::;._TA _+J- Width._...9_.......... Total Length._73..?.L_____ Total leaching area....................sq. ft. Seepage Pit No--------._--_-._._.- &meter-------------------- 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...................... Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water........................ •-••---------••---------------------------•---•--..__._._._..._.._._.....-•-•-•----.._....-•--------.......................=.................................. 0 Description of Soil........................................................................................................................................................................ �C W ------------------- ---------- -------------------------------------------------------------------------------------------- - --- --------- -- - - _ U Nature of Repairs or Alterations—Answer when applicable.--�".c!L.��`t' _(.- -----_��-SG��! :��_ � ....... c ...........................t.L .....f• ,-- =--- G `r................ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned,'further agrees not to place the system in operation until a Certificate of Compliance has-been iss ed.by the board of(health. --- - _ ---------------------------------------- Signed `.--- -- f Dare •- Application.Approved BY ----- � ,-- ------ ---------------------------------------------------------':.._...... ...... fir'= R � Application Disapproved for the following reasonr: ...........................................-------------------..................... . ....... ............ .. .- ..................................... ............_............... --------------- ---------------------......--------------------------------------- ---------------------------------------- Date Permit No. .......... .y��-.........D-= -------------- Issued. ........................................... Dare THE COMMONWEALTH OF MASSACHUSE17S BOARD OF HEALTH TOWN OF BARNSTABLE Tertif rate of Complinnu THIS IS TO CERTIFY, That the Individual Se age Disposal System constructed ( ) or Repaired Y ---------------------------------------.------------ ------- r-L- ----------------------------------------------- --------------------------------------- at --------------------------------------- -------7 --- ----�`f--------V_� h,�.d.l-�. -� .'------........----------......------------------------------------- -- /t has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in the application for Disposal Works Construction Permit No. ---_--�.?1� _. �� --------- dated ------------------------_......._------..... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE ..- '. � 1f ..-- V THE COMMONWEALTH OF MASSACHUSETTS _ - BOARD OF HEALTH g TOWN OF BARNSTABLE Mipmal Workii Tamitrurtion hermit Permission is hereby granted_.. 1 - L-l�'�.�' -�-- =----------------•------------------------------------------•--------....._.. to Construct ( ) or Repair O an ndivid.ual Sewage Disposal, System /I� atNo...................................................... � �/Z�-I�. �r ' 1-�-C as shown on the application for Disposal Works Construction Permit Street /-_-� : __ Dated----__-_.a ...'_ _.�. ._' 1 ............................................................ _ p ..-�-..---•--•-•--•---•----.... (� � Board of Health DATE.................... �"'__-.`..A_.`?. �. FORM 36508 HOBBS 6 WARREN.INC..PUBLISHERS PERMIT N LOCATION SEWAGE E MIT 0 Fto ler-l20 , S I 5005 cif-i VILLAGE N YAJ,)Q%S INSTA LLER'S NAME i -ADDRESS F..Jo$;pa R . ©ors. CD (uc. IC*-tWA C)264 s e UILDER OR OW ER Qualc�� h1.t U.4G� � a•Lr�i,t 01.1 S O`Zfo4�i DATE PERMIT ISSUED 8� DATE COMPLIANCE ISSUED � A cop' Ql a 'v v � 14 r t� V , 5-5 BOARD OF HEALTH Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal ,System at: Location-Addrdss or Lot No. Installer Address Z Other Distribution box ( ) Dosing tank ( ) The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions IZ- 5 of the State Sanitary Codc—Theondersigoed further agrees not to place the system in ' operation until u Certificate of Compliance has been issued bv the board ofhealth. Signed...................... _______ ---------- Date Bv-'--- Application ' '' -----------__........... »"* Application Disapproved for the following reasons:.............................................................................................................. - . � Date � | �cro�t . � Date ZVE, NQ.X Fic ....... . IC................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ... ... .. . ..OF.. ............... .................... . .......... ............................................... Appliration for Disposal Works Tonstrurtion "truth V Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal System at: ...............`�__CQ.........deo!� -4 ------------------------------------------------------------- Location Address or Lot No. ----------------­--------- -------------------- ----------------------------------- ------------------------—- Address .................... ...... .... ......... ............... .................................................................................................. Installer Address U Type of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic Garbage Grinder ( ) Other—Type of Building ............................ No. of persons........................... Showers Cafeteria ( ) Otherfixtures ...................................................................... -----------------------------------------------------------------­­---------Design Flow............................................gallons per person per day. Total daily flow............................................gallons. 1:4 Septic Tank—Liquid capacity............gallons Length................ Width_............... Diameter._..._........_. Depth.._..._..__..... Disposal Trench—No..................... Width.._.._._.._.__...... Total Length..._................ Total leaching area....................sq. ft. Seepage Pit No--------------------- Diameter............___..... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.....................................................................z.... Date........................................ Test Pit No. I................minutes per inch Depth of Test Pit..............____.. Depth to ground water........................ 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water._._._.................. 9 ----- .................................................................................... 11.... ........................................ ------------ ----- 0 oil.....................Description of S "l-V.............. .......... ... .......<,.,p......................... U ......................................................................................................................................................................................................... ......................................................................................................................................................................................................... U Nature of Repairs or Alterations—Answer when applicable................................................................................................ .......................................................I................................................................................................................................................ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TIT 12 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Signed...................................Ix•................................................ ................................. Date Application Approved By............... ...... ....... ...........-- ----- -------- Date Application Disapproved for the following reasons:.............................................................................................................. .................................4...................................................................................................................... ...................................I........... Date PermitNo........................................................I Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .........7a:'le�M.........OF....... ..................................... (9rdifiratr of Tompliaurr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed or Repaired by.............. ......<::� a..",............................................................................................................................ In stall at...... . Z 2 .1 .4 ............................................................................ has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No.__ ......3ZP............. dated------------------------------------------------ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE......................IIIVIZI ................................... Inspector....&A�................................................................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH , 7.1e_.w11.............OF..... ......................................... FEE.... ................ Disposal Works T-Konstrudivit frrmit Permission is hereby granted.......——..4—"-??----- ...........(2_e..4---------------*......*----------------------- .........*---------------- .to-Construct or Repair an Individual Sewage Disposal Sys atNo................... .......... ........ ---------Street ------------------------------------------------------------------ as shown on the application for Disposal Works Construction Permit No----------�t.......... Dated.......................................... ....... .......... .. ............................................................ DATE................ /Z 46 .............. Board of Health /'/' ....."..........*­... FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS