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HomeMy WebLinkAbout0140 PINE STREET - Health 1 40'Pine-Street ,Hyannis 'P A 248 024 i Ir O i r Town of Barnstable ti Inspectional Services Y i v BLE, i HARNf3?A � Public Health Division 200 Main Street, Hyannis MA 02601 Office: 508-862-4644 Thomas A.McKean,CHO FAX: 508-790-6304 CERTIFIED MAIL#7015 1730 0001 4988 1388 December 31, 2019 FEDERAL NATIONAL MORTGAGE ASSOCIATION PO BOX 650043 DALLAS,TX 75265-0043. ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located at 140 Pine Street, Centerville, MA was inspected on 12/09/2019 by James D. Sears, certified Title V Septic Inspector for the State of Massachusetts. The inspection of the septic system showed that the system "Conditionally Passes" under the guidelines of 1995 TITLE V (310 CMR 15.00) due to the following: • The distribution box is rotted. You are ordered to replace the distribution box within one (1) year from the date you receive this notification. Failure to repair/replace the septic system within the deadline period will result in future enforcement action. PER ORDER OF THE BOARD OF HEALTH T as McKean, R.S., HO Agent of the Board of Health f . . Q:\SEPTIC\Title V Inspection Report Letters Mailing\Conditionally Passes Letters\140 Pine Street Centerville.doc 7 THE Town of Barnstable 3 BA NSTABLE, 6 q � Inspectional Services Department AT fD MA'S Public Health Division 200 Main Street, Hyannis MA 02601 Office: 508-862-4644 FAX: 508-790-6304 Thomas A.McKean,CHO Feb 6, 2007 Rev. 4/26/19 DEADLINES TO REPAIR FAILED SYSTEMS (Town Code §360-44 and Title V: 310 CMR 15.000) An"x" marked in the ❑ is the failure criteria and associated repair deadline 60 DAY DEADLINE CRITERIA ❑ Discharge or ponding of effluent to the surface of the ground ❑ Pumping more than 4 times during the last year not due to clogged or obstructed pipe. ❑ Backup of sewage into the house due to an overloaded or clogged SAS or cesspool ❑ Structurally unsound septic tank or SAS ONE (1) YEAR DEADLINE CRITERIA ❑ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ Any portion of the SAS, cesspool, or privy below high groundwater elevation ❑ Any portion of the cesspool within a Zone 1 to a public well ❑ Any portion of a cesspool within 50 feet of a private water supply well with no acceptable water quality analysis. (This system passes if the water analysis indicates the well is free from pollution). TWO (2) YEAR DEADLINE CRITERIA ❑ Single Cesspool ❑ Any "conditionally passed systems" (broken cover, relocation of a pipe, relocation of a driveway due to H-10 components, etc) ❑ Leaching facility with standing liquid level at or above the invert pipe (per Town Code §360-20 h) 0 ER d— �Ox Repair deadline: G Q:\SEPTIC\DEADLINES TO REPAIR FAILED SYSTEMS.doc Dec 16 2019 15:55 HP Fax page 19 Commonwealth of Massachusetts Title 5 official Inspection Form n is Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ; j 140 Pine Street Property Address Federal National Mortgage Owner Owner's Name information is required for every Centerville MA 02632 12-9-19 1'. page. City/Town State Zip Code Date of Inspection r` 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. 011,IIIttI,f/„i,/,/ H OF 1,4,4S�'��_ Important:When A. Inspector Information (( filling out forms V/ /76/u ��p:• DAMES G on the computer, = use only the tab James D.Sears key to move your Name of Inspector cursor-do not Capewide Enterprises ��;•�'F... ��°: use the return Company Name , `cQ`.�� key. 153 Commercial Street �H��+/arrrrIN nsn �`� I�]I Company Address Mashpee MA 02649 City/Town State Zip Code 506-477-8877 S1623 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 12-16-19 spector'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.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 Dec 16 2019 15:55 HP Fax page 20 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 140 Pine Street Property Address Federal National Mortgage Owner Owner's Name information is required for every Centerville MA 02632 12-9-19 page. City/Town State Zip Code Date of lnspectlon C. inspection Summary Inspection Summary:Complete 1, 2, 3,or 5 and all of 4 and 6. 1) System Passes: ❑ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: Conn Pass- D Box. The system is a 1500 Gal. Tank D Box and two chamber's. 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 ❑ ND(Explain below): t5insp.doc•rev.7126/2018 Title 5 Official Inspect on Form:Subsurface Sewage Disposal System•Page 2 of 18 Dec 16 2019 15:56 HP Fax page 21 c Commonwealth of Massachusetts 9 Title 5 Official Inspection Form ; Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 140 Pine Street Properly Address Federal National Mortgage Owner Owner's Name information Is required for every Centerville MA 02632 12-9-19 page. Cityrrown State Zlp Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cunt,): ❑ 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): Need to replace D Box. ❑ 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.712 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 or 18 Dec 16 2019 15:56 HP Fax page 22 Commonwealth of Massachusetts : Title 5 official Inspection Form W Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ." 140 Pine Street Propery Address Federal National Mortgage Owner Owner's Name information is required for every Centerville MA 02632 12-9-19 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cons.) ❑ 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 tan k 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.7126/2018 Title 5 ORdal Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 r Dec 16 2019 15:57 HP Fax page 23 Commonwealth of Massachusetts Title 5 Official Inspection Form �I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 140 Pine Street Property Address Federal National Mortgage Owner Owner's Name information Is Centerville MA 02632 12-9-19 required for every Pale. cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 4 System Failure Criteria Applicable y to All Systems: (cunt.) Yes No ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in ewport is less than 6"below invert or available volume is less than Y day flow /Ei94111 4 ❑ ® 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. ❑ ® 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.] Li ® The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ ® The system falls. 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 16,000 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 10 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 15in5p.doc-rev.7126/2010 Tltie 5 Of ial Inspection Form:Subsurface Sewage Ofeposal System-Page 5 of 16 Dec 16 2019 15:57 HP Fax page 24 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 140 Pine Street Property Address Federal National Mortgage Owner Owner's Name information Is required for every Centerville MA 02632 12-9-19 page. City/Town State Zip Code Date of Inspection C, Inspection Summary (cant.) 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 C.4 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 al!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? ❑ ® 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? ❑ ® 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)] f tSinsp.doc•rev.7/26/2018 Title SOfficial Inspection Form:Subsurface Sewage Disposal System-Page 6 of 16 Dec 16 2019 15:57 HP Fax page 25 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ( 140 Pine Street V Property Address Federal National Mortgage Owner Owner's Name Informa required for is Centervilie MA 02632 12-9-19 required for every page. Cityl-rown State Zip Code Dare of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 2 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 Description: 1500 Gal.Tank D Box and two chamber's. Number of current residents: 0 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 Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d 2017-23,00OGais g ( y g (gp �)' 2018-26,000 Gal's Detail' Sump pump? ❑ Yes ® No Last date of occupancy: NA Date t5msp.doc-rev.7/2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18 Dec 16 2019 15:57 HP Fax page 26 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 140 Pine Street Property Address Federal National Mortgage Owner Owner's Name information is required for every Centerville MA 02632 12-9-19 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 Watertreatment 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: NA Was system pumped as part of the inspection? ❑ Yes ® No If yes,volume pumped: gallons How was quantity pumped determined? Reason for pumping: 15insp.doc•rev.7/26/20f8 Title 5 Dlficial Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 Qec 16 2019 15:58 HP Fax page 27 y Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 140 Pine Street Property Address Federal National Mortgage Owner Owner's Name information is required for every Centerville MA 02632 12-9-19 page. CitylTown State Zip Code Date of Inspection D. System Information (cant.) 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/Altemative 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 IIA 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: 2000 Permit #2000-751. Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): 18" Depth below grade: feet Material of construction: ❑cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage,etc.): Pipeing is 4" PVC SCH -40. t5insp.doc-rev.7126/2018 Title 5 Official inspecton Fenn:Subsurface Sewage Disposal System•Page 9 of 18 Dec 16 2019 15:58 HP Fax page 28 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 140 Pine Street Property Address Federal National Mortgage Owner Owner's Name information is Centerville MA 02632 12-9-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): 8rr Depth below grade: 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: 1500 Gal. Precast H-10 Sludge depth: 1" Distance from top of sludge to bottom of outlet tee or baffle 29� Scum thickness 0" 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 18" How were dimensions determined? Asbuilt- Plan-Tape 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.): Tank at working level. Tank and covers at 8"below grade. In and outlet tees. No sign of leakage or over loading. I 151nsp.Aoc•rev.7/2612018 Title 5 Official Inspection Form:Subswiace Sewage Disposal System•Page 10 0l 18 Dec 16 •2019 15:58 HP Fax page 29 Commonwealth of Massachusetts Title 5 Official Inspection Form - Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 140 Pine Street Property Address _Federal National Mortgage Owner Owners Name information is MA 02632 12-9-19 required for every Centerville page CitylTavn 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 Mnsp.doc•rev.7/2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 Dec 16 •2019 15:58 HP Fax page 30 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form •Not for Voluntary Assessments 140 Pine Street Property Address Federal National Mortgage Owner Owner's Name information is Centerville MA 02632 12-9-19 required for every page. CitylTown 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 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.): D Box is 16"x16"-16"below grade w/one line out Wall is gone , Need to replace D Box. t5insp.doc rev.7126/2018 Title 5 Official lnapedon Form:Subsurface Sewage Disposal System•Page 12 of 18 Dec 16 •2019 15:58 HP Fax page 31 Commonwealth of Massachusetts Title 5 Official Inspection Form ` Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 140 Pine Street Property Address Federal National Mortgage Cromer Owner s Name information is required for every Centerville MA 02632 12-9-19 page. CityfTown State Zip Code Date of Inspection D. System Information (cunt.) 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: ❑ Teaching pits number: ® leaching chambers number: 2 ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Mnsp.doc•rev.7126t2018 TAle 5 Official Inspedon Fort:Subsurface Sewage Disposal System•Page 13 of 18 IDec 16 •2019 15:58 HP Fax page 32 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments _ 140 Pine Street W Property Address Federal National Mortgage _ Owner Owner's Name information Is required for every Centerville MA 02632 12-9-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cant.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leaching is two 500 Gal. dry well chamber's w14'stone. Chamber's at 2' below grade. Chamber's are dry wlclean wall's, No sign of over loading. 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 Oticial Inspection Form:Subsurface Seurege Disposal System-Page 14 of 18 Dec 16 .2019 15:58 HP Fax page 33 i Commonwealth of Massachusetts Title 5 Official Inspection Form p Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 140 Pine Street Property Address Federal National Mortgage Owner Owners Name Information is required for every Centerville MA 02632 12-9-19 page. City/Tom Slate Zip Code Date of Inspection D. System Information (cont.) 13. 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.): t&nsp.doc•rev.712 61 2 0 18 Title 5 Official Inspection Form:Subsuface Sewage Disposal System•Page 15 of 18 Dec 16 •2019 15:58 HP Fax page 34 Commonwealth of Massachusetts . � Title 5 OfficialInspection Form 1 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments kwi 140 Pine Street Property Address Federal National Mortgage Owner Owner's Name information is required for every Centerville MA 02632 12-9-19 Page. CitylTown 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 Ila Pr 3 - % rl a A _?(9 Nnsp.doc•rev.7/26/2018 Tile 6 Of6oial InspWionform'Subsurface Sewage Disposal System•Page 16 of 18 Qec 16 .2019 15:59 HP Fax page 35 `r Commonwealth of Massachusetts k Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 140 Pine Street Property Address Federal National Mortna e Owner Owners Name information equiretio re Centerville MA 02632 12-9-19 required for every page. Cltylrown State Zip Code Date of Inspection D. System Information (cons} 15. Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 10, feet I 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: pate ® 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: Auger T.H. 10'no G.W.. Bottom of chamber's at 4'-6" below grade. Bottom of chamber's at 5'-6" above T.H. Depth. Before filing this Inspection Report, please see Report Completeness Checklist on next page. 15insp.doc-rev.7/26/2018 Title 5 Of ial Inspectm Form:Subsurface Sewage Disposal System-Page 17 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form •Not for Voluntary Assessments ls% 140 Pine Street Property Address Federal National Mortgage Owner Owner's Name information is required for every Centerville MA 02632 12-9-19 page. City/Town 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 checked ® C. Inspection Summary: 1;2, 3, or 5 completed as appropriate 4 (Failure Criteria)and 6 (Checklist)completed ® D. System Information: I 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 GRAB F 0 t5insp.doc•rev.7/26/2018 Title 5 Mial Inspection form:Subsurface Sewage Disposal System•Page iB of 1e 61, abed xed dH ZM 6 6 60Z 9 6 MU 6MT/2016 AQ 04-Asbestos Removal Notification Form ANF-001-Transaction M7461 Commonwealth of Massachusetts 100246632R2 Asbestos Notification Form ANF-001 Asbestos Project Nber Project Revision Notification ���Project RevisjP Nr 'ri } Project Ganceltadbn ate+ Q? rojclr:t Ftestq>r?� A. Asbestos Abatement Description v t, Facility Location: MtCwBLLE g1.LMAN 140 PINE=ST a.Name of Facility b,Street Address HYANNIS r MA 2Fip1 08-292-5261 c.Cltylrown d.State 9.Zip Cade f•Telephone SAME OWNER ....................................................................,....... ., .., h4truo6arts 1.All g.Facility Contact Person Name h.Facility Contact Person Title sectlons of this form Worksite Location: ASEMFNT „__....._.__..._____._.._..__._.._._._._....._...__.. must be completed in i,Building Name,Wing,Floor,Room,etc. order to comply with MassDEP notification 2, Blanket!permit Project Approval, if applicable: requiremenis of 310 Approval ID# CMR 7,15 and 3. Pion-Traditional Asbestos Abatement Work Practice Approval, if applicable: E., . 04panment of Labor ._....... ru n _._. ._.._.._......., .,.----.._....---------...._.._....---....__.._.._..,:..,.:,.:,.......�•. An vetto to Standards(DLS) _ notification requirements a.Project Start Date(MM/DD/YYYY) In.End Date(MMUDWYYYY) of 453 CUR 6,12 ;7AM-6PM q _._._..-.__................_...................._.._-.........................:......:......._._........._....._....._...i ............—........ __.::..::.._..._.,.-:.. c.Work Hours•Monday through Friday d.Work Hours-Saturday&Sunday MassDEP Use Only B. Other Pr . __ �_ oj®ct Revisions: DateReceived r.-.-.-.--...._._..._...............•-- -- -...........__..._.__...._.....,...,......_._:......:,...... _. 2.Submit drigG,al Form ! To;Commonwealth of Massachusetts P.O.box 4M Hotatan,MA on,1 C. Certification "I cart that I have personally ..............:'_....,,:__,..�.., .. ..__._.._.. . ifY pe ally examined OFW F4V the foregoing and am famWar with the 1.Name 2.Authortt:ed Signsture Note:Temporary information contained in this document -- - P 09/17l241�i Storage of Asbestos and all attachments and that,based on containing waste my inquiry of those individuals 3.Position/Titte a•Cate(MM/D01YYYY) material is only allowed immediately responsible for obtaining the at the place of business Information,I believe that the information 5.Telephone 6.Repreaen"of a DLS licensed Is true,accurate,and complete.I am — ^� -,..-.-_...•.._.__�__,,„. , ._�_ EE23 WYCHWOOD DR f7TLt TON............:..-.._....-......... . Asbestos contractor or aware that there are significant pehafties 7 Address 8.C;tylTown a transfer stsNon that Is for aubrritting raise Information,Including _ __ permits as by MsbEP Possible firma and imprisonment.The 1460 and operated in undersigned hereby states that I have 9.State 10.ZIp Code compbance with Solid read the Commonvveafth of Waste Reguiatlons 310 Massachusetts regulations governing CMR 19.000 asbestos abatement(453 CMR 6.00 promulgated by the Department of labor Standards and 310 CMR 7.15 promulgated by the Department of htfps://tW,dG.fnass.RavAWryorms/Aebestlo$SVVPANFOOl.aspx 90/Z0 3!)Vd QIAVC1 Zbb96EE8L6 LZ bI 9TOZ/LT/80 7l82019 AQW-Aabeatos Removal NoUricatlan Farm ANF-001-Transaction#841%187 Commonwealth of Massachusetts 10024F3fi32 Asbestos Notification Form ANF-001 Asbestos I� Project Revision J. Project Cancellation A A. Asbestos Abatement Description 1, Facility Location; MICHELLt=ALLMAN 1 i}INE T Name of Facility Street Addrass „-__--._•_� A 2601 0�282-5281 IiYANNi5 ._.._. � City/Town State Zip Code Telephone ... ME Facility Contact Person Name Facility Contact Person Title (nstruc lens 1.All WOrkafte Location: aectiona of this farm Building Name,Wing,Floor,Room,etc, must be completed In order to cornpy with 2, Is the facility occupied? ++;i Yes No , MaesDEP notlflcatbn ll requirements of 310 3, Is this a fee exempt notification(city,town,district, municipal housing authority, state facility,or CMR 7.15 and owner-occupied residential property of four units or less)?[`_ Yes JNo . Department of Labor Standards(DLS) 4,Blanket Permit Project Approval, If applicable: _ - holftatlon equirement9 Approval ID# of 453 CMR 8.12 _ 5. Von-Traditional Asbestos Abatement Work Practice Approval, if applicable: Approval ID N Mae80r;;P Use Only 6,Asbestos Contractor; ---....._. .............._..._..._.:-.I _C.. ..T,.,T. .,m.;,..,.,._,_,.,......_..._...:..._..v:..._.. ......._._._......._... INC -_ -._._---,._...........J Itii ENDIGpT STREET _. Date Received Name �1 Address C!`_^. . �201i2M 784-762y3390� __= w CltyCroarn State ZIP Code Telephone 2.3ubrnit Original Form =----.,,...._...,._.-,.____....,..,,.,....._.__..._-----,,,,.,...,�.----- 4G000464 ��� . �� Contract Type: a!°:Writte Var To:Gommonwrnith ,,._--_ .---„-� r. of Masaschuttrettst DLS L1canse# `"' P.O.BOit 4002 7, JAIMEEAMAYA f S080847 -• ""`^.^'•"--� Name of Contractors On-Site SuperviverlForoman DLS Certification# 8. IAMp(EL N G0HEN i �VvI0B0787 __...... Name of Project Monitor DIeS Certification#....•..,..` --- -- _..,_..__� 9. -i Name of Asbestos Analytical Lab MS Certification# —._.... Project Start Date(MWDDIYYYY) End Date(MM/DD/YYYY) work Hours-Monday'through Friday Work Hours-Saturday&Sunday 11; What type of project is this? Demolition Renovation ,I Repair �^ I ,..�Ott1er-PI®asa Speclry: 12, Abatement procedures(check an that apply); Glove Bag Encapsulation �.�Enclosure Cleanup Only Cleanup >• Sul Conteinmerit Other-PleaseSpeciy; -,..,.,. .4 -,.._. . , ._,,,.,.. ....... tie-I/adgp.deR.m9es,ptw/WormslAebestos/t3WPANF001 - .,-, n�,..,.....W„_�_..,,.,,. ..,_,..,.., ..._.,, ,. ,.�.,., ..,, .<,,, _.... .m<........ .. ............: ..,.I ,aSPX 90/60 39dd CIAVG ZVVS6EE8L6 LZ:V1 9TOZ/LT/80 7/(Y2018 A4 04-Asbestos Removal Notification Form AM F-001-Trarwactloo t#6461W 13,Job is being conducted: 4 Indoors rr_„ Outdoors 14.Total amount of each type of asbestos Containing materlais(ACM)to be removed, enclosed,or encapsulated: _ Lkrear Feet(Lin.Ft) Square Feet(Sq,Ft.) Boller,Breaching,Duct,Tank Transits Pips Surface Coatings Lin.Ft_ sq.Ft.r Lin.Ft. Sq.Ft. Pipe insulation _-- Transits Shingles Lin,Ft Sq.Ft Lin,Ft. Sq.Ft Spray-On Fireprootir:g �� µ Transits Panels Lin.Ft. Sq.Ft. Lin-Ft. Sq.Ft Cloths,Woven FeWty �_ I Other-Please Speclfy: Lin,Ft Sq.Ft Inauia Gernent Lin.Ft Sq.Ft Ln,Ft. 15. Describe the decontamination system(s) to be used: 15. Describe the containerization/disposal methods to comply with 310 CMR 7.15 and 453 CMR 6.14 2 6 MIL POLY SAGSy -- 17. For Emergency Asbestos Operations,the MassDEP and DLS officials who evaluated the emergency: Name of MassDEP Official title of MessDEP Official Date of Authorization(MWDDIYYYY) Waiver :_..-...._..-..__.n....-.,._.•_.._w.__._....... - ._..._ ..,.,..H......_. - ._._...........__..__...-------------- . Name of DLS Official TMe'of DLS Official Date of Authorization(MWMYYYY) Waiver# 18. Do prevailing wage rates as per M.G.L. c. 149, §26, 27 or 27A-F apply to this Yes �iNo project? B. Facility Description 1. Current or prior use offacility; p -- ._..._._.,.,..,. _...._...........:._._.......- - 2. Is the facility owner-occupied residential with 4 units or less? y., Ysu ?No 8. MICHELLE Aa1MAN PINE ST Facility Owner Nome Addreee —^•-�-�---•.��--- -., iMA b2601 ISot3-292-528t Cit (Town y State Zip Coda Telephone 4. (SAM! ...... .....-_ Name of Facility Owher's On-Ska Manager Address AME �MA-` �72601 t5o 2 5261 -•--- --- -- - ... httM://efp,dep.mass.gov/VVebForms/Asbgsbml6WPANF001.wpx X 90/b0 39dd CIAVC ZPV96EE8Z6 LZ:bZ 9Z0Z/LL/80 7/6M16 AQ 04-Asbestos Removal Notificaffion Form ANF-0D1-Transaction#B45M7 GllylTown State rip Code Telephone 5. 41vA ........ .... NA Name of General Contractor Address LA .-j I [so � Cltyrrowh State Zip Code Telephone ....-- — _.._............._..................._...,......._............ :.....:...............-._._..._............................ Contractor's Worker's Compensation Insurer Mob;Temporary storage of Asbestos contalning Policy# Exoatlon Date(MM/DD/YYYY) waste material Is only allowed at the place of 6.What is the SIZe of this facility? 000 2 W ._ __ .....,.- business of a DLS square Feet !r!of Floors licensed Asbestos oontractor or a transf@r station that Ispermltted C. Asbestos Transportation & Disposal by MessDEp and operated in compliance 9.Transporter of asbestos-containing waste material from site of generation: with Solid Waste Directly to Landfill or , P.1'To Temporary Storage Locatlon/rransfer Station Regulations 310 CMR 19.000 _.._..__._:,-._:... , ........ _.._..................._.......... .. IR SAF@ INC r 2 WILL.QW ST.M 1 Name of Transporter IA�ddress GHELSEA A 2150 7t3.339-5361 �' City/Tom State Zip Code Telephone 2, If a temporary storage location/transfer station is used, list name of transporter of asbestos containing WOMO material from temporary storage locationliransfer station to final disposal site: SERVICE Tf2AN5 __ 8 PYi.E$LANE """" Name of Transporter Address ............................................ --- ------ 1 NEW CASTLE _ 77.989-95_59 Cltymwn State Zip Code Telephone 3. Name and address of temporary storage location/tranafar station for the asbestos Containing waste material: IR SAFE ...............�,�,..,— � _ —..--- •-------------,-.......,,_._...........Y,, •_....__-._._._......_._. WILLOW ST Temporary Storage Location Name Address -- .,...._..._.__._._.....__.._..._.............. MA 45fl _ 78 339.5361 Cify/Town State Zip Code Telephona tic".Contractor m ut 4. Name and location of final disposal site(asbestos landfill): sign this forth for DL3 �MINERVA INERVA ENTERPRISES,INC. notification purposes __-----•..,..:. .._.---------._.....,..,.. Final posal Site Name Final Disposal Site Owner Name Address f_,...,...688.....__._._._....i .._......,...--------................ 1"Y-°.�.., City/rown State Zip Code Telephone - D. Certification "I certify that I,have pereanatly examined the foregoing and am familiar with the Name Aulhorized S�neture•...,....� W,� information contained in this document and all attachmentsP 7/06 12016 and that based on _ - - - -- - :..._.__._... my inquiry of those individuals Position/Tlda data(MMrDD/YYYY) Immediately responsible for obtaining the Information,I believe that the Information Telephone Repraearging 1 Is true.accurate,and complete:I am 23 WYCHWOOD DR iITTLETpN h*j/wisp.depmass.gov/WOWOrms/AsbMbWBWPAN F001aspx VA 90/90 39Vd QIAVG ZVVS6668L6 LZ:b1 9TOZ/LT/80 70MI8 AG 04-AabeataB Removal Notification Form ANF-001-trarteadlon WSW aware that there are soriftant penalties Addreaa CityfTown for submitting}else Information,including -- possible fines and Imprisonment.The State Zip Code underslgnsd hereby states that I have read the CommonwaaRh of Massachusetts regulations governing asbestos abatement(453 GMR 6.00 promulgated by the Department of Labor 5tanaarde and 310 CMR 7.15 promulgated by the Department of Environmental Protection).and that I am aware that this permit application or notlPicatlon shall not be deemed valid unless payment of the applicable fee is made." httpa://edep.dep,mass.gov/WebForms/Asbestoa/BWPANFQD1.aspx Q4 90/90 3DVd QIAvc ZPPSGEE8L6 LZ:bI 9TOZ/L1/80 Ala` Safe, Inc. 61 Endicott Street,Bldg.32-1 Norwood,MA 02062 781-962-3390 Erpem In Asbestos and Mold Keneoval I i FAX TRANSMISSION �j DATE: TOTAL NUMBER OF PAGES INCLUDING COVER: Li 6, TO: BARNSTABLE BOARD OF HEALTH FAX RECEIVPVG: 508-790-6300/ PHONE 508-8624644 FAX SENDING: 781-762-2815 90/10 39dd GiAvQ ZVV9666BL6 LZ:bl 9Z0Z/LT/80 f COMMONWEALTH OF MASSACHUSETTS EXECUTIVE.OFFICE OF,ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION F PhRCEL �- �x LOT ; TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A 14® CERTIFICATION Property Address: Owner's Name:q APR 2 12004 Owner's Addres : f, n ZG-07 TOWN OF BARNSTABLE p �� ���'py -- HEALTH DEPT. Date of Inspection: Name of Inspector:fpl,ease print) 80do)c� Company Name: Mailing Address: ) -70P Telephone Number:QP-, -1-7/. 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: I/ Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority ils Inspector's Signature: Date: —% y 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 ofthe DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ; p Notes and'Comment CMG ****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. Title 5 Inspection Form 6/15/2000 page 1 Page 2 of l l ' OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGEDISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued] Property Address: Owner: Date of In pectiou: v Inspection.Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: I have not found any information which indicates that any of the failure criteria described in 310.CMR. 15:303 or in 310 CMR 15304 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 mplaced.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 exfnitration 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: 2 I Page 3 of 1'1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: n — Owner: t//Y�' jjl/AA/-?,e Date of I spection: C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR`15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier, if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone I of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than 100,feet but 50 feet or more from a private water supply well". Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A•copy of the analysis must be attached to this form. 3. Other: I 3 Page 4 of 1] OFFICIAL.INSPECTION_FORM-NOT FOR VOLUNTARY ASSESSMENTS 1 SUBSUR ,AM SEWAGE DISPOSAL SYSTEM-INSPECTION FORM s PART A CERTIFItCATION(continued) Property Address: P Owner: L Date of L► pection: ` D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes N _ Backup of sewage.irto facility or system component clue 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 Static liquid level in the distribution box above outlet invert due town overloaded or clogged SAS or / cesspool Liquid depth in cesspool.is less than 6"below invert or available volume is less than day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times.pumped _ Any portion of the 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. ✓ Any portion of a.cesspool or,privy is within a Zone 1 of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. t/ 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 colifor►n bacteria and volatile organic compounds indicates that Unwell is_free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen.is equal to or less than 5 pp►n, 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 detennine 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 drinkhIg 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 office of the Department. 4 f i Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR'VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION'FORM `PART 13 CI•IECIMIST- Property Address: ` (�/,I l Q_( eg{ Owner: Date of Ins ection: Check if the following have been done.You must indicate"yes" or"no"as to each of the followine: _ Yes o >> Pumping.information was provided by the owner, occupant, or Board of Health F 1/ Were.any of the system components pumped out in the previous two weeks ? Has the system received normal flows in the previous two week period? _ V Have large.volumes of water been introduced to the system recently or as part of this inspection ? 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 backup 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 oo tl� baffles or tees,material of construction, dimensions,depth of liquid,depth of sludge and depth of scum? 7 Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems 4 f The size and location of the Soil Absorption System(SAS)op the site has been determined based on: Yes no -6— — Existing information. For example, a plan.at the Board of Health. _�/ _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)] s , Page 6 of 11 OFFICIALrINSPECTION,FORM.NOT FOR;VOLUNTARY ASSLSSMICNTS SUBSURI"ACE*SRWAGEc DISPOSAL SYSTEM INSPECTION FORM PART C '.----SYSTEM INFOIIMMATION' Property Address: Of Owner: L Date of I spection: !3,Cy — FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):. Number of bedrooms(actual): , DESIGN flow based on 310.CMR 15.203 (for example: 11.0 gpd x#of bedrooms): Number of current residents: Does residence.have a,garbage grinder(yes or no��°�.-. -,.... .; . .. Is laundry on a separate sewage system (yes or no);�f if yes separate inspection required] Laundry system inspected(yes or no)IYA, ""` Seasonal use: (yes or no); ✓ �W�- Water meter readings, ` .a le(last 2 years usage(g)d)):0 Z_ L,�gp1'h,a, �f av Sump pump(yes,or no • Last date of occupancy: COMMERCIAL/INDUSTRIAIJAI� Type of establishment: Design flow(based on 310 C.MR.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: /O Was system pumped as part of he inspection(fA or no): If yes, volume pumped: gallons`--Low was euanti pumped determined? Reason for.pumping: 'I'YPyiOF SYSTEM __Oeptic tank, distribution box,soil absorption system _Single cesspool _Overflow cesspool _Privy _Shared system.(yes or no)(if yes, attach previous inspection records; if any) _Imnovative/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):. Qroximate a �ofalfcon overt , date in talled(if kno %yand source of information: Were sewage odors-detected when arriving at the site(yes or no);/ 6 Page 7 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL•SYSTEM-INSPECTION FORt'VI 'PART C SYSTEM INFORMATION(continued) r Property Address: 2Q� Owner: Date of spection: BUILDING SEWER(locate on site plan)AW Depth below grade: Materials of construction: cast iron 40 PVC—other(explain):, Distance from private water supply well or suction 'line: - p Comments(on condition of joints, venting, evidence of leakage, etc.): SEPTIC TANK: (locate on site plan) Depth below grade: gr Material of construction:�oncrete_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: /0-S Sludge depth: Distance from top of.sludge to bottom of outlet tee or baffle: 3 2 Scum thickness: �r Distance from top of scum to top of outlet tee or baffle: Z Distance from bottom of scum to botto of outlet tee,or baffle; c� How were dimensions determined: a6Y�r��11 /awt Comments(on pumping recommen tions, { let and outlet tee or baffle condition,structural integrity, liquid levels s related to outlet invert vidence of leakage, etc-: r JOU GREASE TRIU 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.): 7• Page 8 of l l OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISP_ OSAL SYSTEM,INSPEC.TION FORM PART C SYSTEM INFORMATION(continued) Property Address: O s Owner: -- Date of Ii pection: 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.): 4 DISTRIBUTION BOX: ,.Z(if present must be opened)(locate.on site`plan) Depth of liquid level above outlet invert. Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover,any evidence of ---leakage into or out of box, tc.): / //// O tmij 2&4-",,o PUMP CHAMBI;R;�('�(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.): 8 Page 9 of 1 1 OFFICIAL• INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS -SUBSU"ACE'SEWAU DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: A Owner: Date of 1 spection: / SOIL ABSORPTION SYSTEM (SAS): "V (locate on site plan, excavation not required) If SAS not located explain why: Type (/ ] cc mg pits,number:_ 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 CESSPOOL✓(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 gr„undwaerinflow(yes or no): ._... p „ Comments(note condition of soil,.signs of hydraulic failure, level of ponding,condition of vegetation,etc.): PRI V (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): 9 Page 10 of 11 orFICIAL INSPECTION.FORM:-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE:DISPOSAL SYSTEM INSPECTION FORM ` PART C ,.SYSTEM jNFORMATION(continued) - Property Address:. /, . Owner: AP Date of L pection: 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. 1q , 10 Page 1 l of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM 'PART C rYYSTEM INFORMATION (continued) .Property Address: Owner: OZ4Q41'A AM Date of I spection: SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water f��feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked, date of design plan reviewed: Observed site (abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with local excavators, installers-(attach documentation) —y Accessed USGS database-explain: You must describe how you established the high ground water elevation: 5 ® Dr o �G� i ll Permit Number: Date: Completed by: HIGH GROUNL411ATER LEVEL COMPUTATION Site Location: ` �� j°/�� Lot No. Owner: Address: Contractor: Address' 7J�— � 7�✓� Notes: STEP 1 Measure depth to water table to nearest 1/10 ft. ........................... .............................................. Date 7fy' month/day/year STEP 2 Using Water-Level Range Zone and Index Well Map locate site and determine: ® Appropriate index well................................. ! ....... OWater-level range zone ..................................................... STEP 3 Using monthly report "Current Water Resources Conditions determine current depth to water level for index well ........................... month/year STEP 4 Using Table of Water-level Adjustments for index well (STEP 2A), current depth to water level for index well (STEP 3), and water-level zone (STEP 2B) 7 1 determine water-level adjustment ........................................................................................... STEP 5 Estimate depth to high water by subtracting the water- level adjustment (STEP 4) from measured depth to water level.at site (STEP 1) .............:............................................................................................... r Figure 13.--Reproducible computation form. 15 _ i� t,`w 4\�i.^ }'ate 3 . �. ^��I, �. ^�` 0 �.J' --�-.-__.._._ � 1� . 6• SM3 7� g a 2 8 . y. . g . 7"�-- s ��� j �� € ;� j. - � � r� :� E r i • t� .. s .. �� Z� S{ .. . � 9° ' � � � 9.q j. �: � � � , ���, ; � � . � _",,, f ry ��,. , +' 1�y . �.,� � � �, t . 1� S i t j� `•�� 8 { `�i i � `�`� , ' � 3 j f TOWN OF BARNSTABLE LOCATION / . D ��/�Q Sj SEWAGE #X oo v ' 7 S-/ 0- VILLAGE& A NNi S ASSESSOR'S MAP & LO � INSTALLER'S NAME&PHONE NO. �y1.4 SEPTIC TANK CAPACITY O LEACHING FACILITY: (type ,�L o u'�y�'Y$e,C' s (size) NO. OF BEDROOMS BUILDER OR O t PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: jMaximum Adjusted Groundwater.Table to the Bottom of Leaching Facility Feet 1 Well and Leaching Facili (If any wells exist Private Water;SuPP Y. g tY on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility (If any wetlands exist within 300 feet of leaching facility) Feet' Furnished by i . i y / TOWN OF BARNSTABLE LOCATIO JAI e .$'l SEWAGE # •oo a — S VILLAGE &YA&A1/S ASSESSOR'S MAP & LO -a INSTALLER'S NAME&PHONE NO.J: Z d.4 C 0 A4 l e f-#- S d 11 SEPTIC TANK CAPACITY /,.f 0 0 LEACHING FACILITY: (tyr5e 1-f'L o W C11Ay0eK' s (size) COO NO.OF BEDROOMS BUILDER OR OWNIJR Y -- 10190 PERMIT DATE: COMPLIANCE DATE: D, _ Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility (If any wetlands exist within 300 feet of leaching facility) Feet Furnished by r• A 1 d � - 'I l P No. J000 Fee 5 0.0 0 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 01pplication for Migooal 6pgtem Construction Permit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) X50 Complete System El Individual Components Location Address or Lot No. 1#0 Pine Street Owner's Name,Address and Tel.No. H yannip�Mass. 02601 Robert White 8 9 y 130 Pine Street Centerville,Mass. Installer's Name,Address,and Tel.No. 5 0 8—7 7 5—3 3 3 8 Designer's Name,Address and Tel.No. 2 J.P.Macomber & Son Inc. J.P.Macomber & Son Inc.. Box 66 Centerville,Mass. 02632 Box 66 Centerville,Mass. 02632 Type of Building: Dwelling XXNo.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 355 GPD gallons per day. Calculated daily flow 3 X 1 1 0=3 3 0 gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Loamy sand to medium fine sand. Nature of Repairs or Alterations(Answer when applicable)nmi t t ing C m s shoo 1 install , � 1 -1500 gallon tank, 1 -Distribution box and two_SOO gallon leaching chambers packed in 4 ' of 1 1" stone_ 25 ' x15. ' 1 (1"x2 ' Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issu d by this o of alth. Signed i Date 11 3 / 0 Application Approved by Date M Application Disapproved for the following reaZ_V�!��_�_ _1 Permit No. MI/ 101 Date Issued 17�ra '0.'ift� �Ye.wM d , No. _ ... Fee 5 0.0 THE.COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLES MASSACHUSETTS ZippYication for )Digpogar *pgtem Construction Permit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) X®Complete System ❑Individual Components Location Address or Lot No. 1430 Pine Street Owner's Name,Address and Tel.No. Hyannis Mass. Of601 Robert White Assessor'sMapfParcel ri C ,) y 130 Pine Street Centerville,Mass. Installer's Name,Address,and Tel.No. 5 0 8-7 7 5-3 3 3 8 Designer's Name,Address and Tel.No. J.P.Macomber & Son Inc. J.P.Macomber & Son Inc. Box 66 Centerville,Mass. 02632 Box 66 Centerville,Mass. 02632 Type of Building: Dwelling XXNo.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 355 GPD gallons per day. Calculated daily flow 3 X 1 1 0=3 3 0 gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank zhi Type of S.A.S. Description of Soil Loamy sand to medium fine sand. Nature of Repairs or Alterations(Answer`'�hen applicable)Omitting 1-1500 gallon tank, l -Distribution box and two 500 gallon leaching chambers packed in 4 ' of 1;" stone. 25'X12' 10' X2 ' Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issu d by this o of ealth. Signed _ f n Date 11 /3 /00 J Application Approved by I �, � �4I W �(f Date 1� 1�, Application Disapproved fo following reason v v- v r the � Permit No. i Date Issued o a l l-�o THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of (Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( )Repaired( )Upgraded(XX* Abandoned( )by J.P.Macomber & Son Inc. at 130 Pine Street Hyannis,Mass. has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. dated Installer J.P.Macomber & Son Inc. Designer J.P.Macomber & SovInc. IT— The issuance of this permit�sha not,�bbe construed as a guarantee that the system will fundtion asfiesigne'r�rd. /�/��/}� J Date y ref Inspector t �47Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS -ay liopogar *pgtem Conotruction hermit Permission is hereby granted to Construct( )Repair( )Upgrade(XX)Abandon'( ) System located at 130 Pine Street Hyannis,Mass. ; t and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction pust bi completed within three years of the date of this enn Date: Approved by r No.c21 V ` E Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS �$ appfiratiou for Disposal *pstem (Construction Permit r Application for a Permit to Construct( ) Repair(4 Upgrade( ) Abandon( ) ❑Complete System ndividual Components c Location Address or Lot No./,V,5 A;4R— er's Name,Address,and Tel.No. c . Assessor's Map/Parcelay$ () � Installer's Name,Address,and Tel.No.e4,iZ91 dV4(_ (4445jr Designer's Name,Address, Tel.No. , Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) 1 gpd Design flow provided 0 A gpd Plan Date Number of sheets Revision at Title Size of Septic Tank Type of S.A.S. OC, O e74//Gu1 Description of Soil Nature of Repairs or Alterations(Answer when applicable) 01;bi 2 &K Date last inspected: l� / Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisio94-1-TZ nmental Code and not to place the system in operation until a Certificate of Compliance has been issued r DateApplication Approved byDate Application Disapproved by Date for the following reasons Permit No. Date Issued Li�iJ'1f�'*<`',e i'`• ,.w.,..-'4^ ,.'f vt•.,.�; I '.� ._.;,'s�y'�r., t,.`.r,r.., N''1.�".�"`^,Sr"•"'.'.�°a^'•'d`'.i^'?'�_',�'4r<z::F �;,•'}1k. + -��'t+'.+-.�'�:�'a1t.:,k:•R', .,.,a++��»,,,�s;.4r^. •*+ No. "t -!d-� - Fee THE COMMONWEALTH OF MASSACHUSETTS Entered;ncomputer: t.4�/) es • PUBLIC•HEALTH DIVISION - TOWN F B O ARNSTABLE MASSACHUSETTS ftplitation for ZispoBal 6pstettt Construction i3ertttit Application for a Permit to Construct( ) Repair(� Upgrade( ) bandon( ) ElComplete System ©'Individual Components Location Address or Lot No. 00,'4g �-�- r 1j2p er's Name,Address,and Tel.No. } #YAP) M. Assessor's Map/Parcel,?c./gA Installer's Name,Address,and Tel.No.e4 j',rVi►.( Crjq,KI Designer's Name,Address,and Tel.No. • e"$A4 IV4 Ste- Type of Building: j Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design,Flow(min.required) Ji 1' gpd Design flow provided gpd 1 Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil k -Nature of Repairs or Alterations(Answer when applicable) T,ca 5144// 'Ve m v >n lX'3)"Qf Date last inspected: 07 o e /9 4 Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued b..thus BBoard ofUeralt,'/Signed �Q�/ /Yfi`l /)0 ram,--, Date � /S�y�)/{ Application Approved by / L,��� _. Milk, il�Iili� f .,1 �j Date �!a Application Disapproved by � f Date for the following reasons may,// Permit No. v ''( , 'l � Date Issued � / / p �/ v .. -- -- -- - - ---•- - --6 t THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(� Upgraded C_. (' ) Abandoned( )by 4•C�QIA, at /(>> has been constructed in accordanee� with the provisions of Title 5 and th for Disposal System Construction Permit No.Wke 2/'(;/,�G Installer �A S�</1 L [-a11Qs_rZGe111ry Designer #bedrooms�//} rr Approved design,flow 1l/}, gpd The issuance of this'pelmit shall not be construed as a guarantee that the system willLctio as designed. Date -2 1°/,2 0 Inspector _ t/ 0 1A 2 - -- -----------�/----. -------: - ------------------------- ------ ------------------------------------ - - No. /�%1h f Fee THE COMMONWEALTH OF MASSACHUSETTS . PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Misposal bpstem Construction 3permit Permission is hereby granted to Construct( ) Repair(f Upgrade( ) Abandon( ) System located at . and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with' .° Title 5 and the following local provisions or special conditions. ' Provided:Construction must be completed within three years of the date of this permit. / C Date 1/r 17-� Approved by COMMONWEALTH OF IVIASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION JED LRCE'\ 1 14 2004TITLE 5 o NTH IDEP-COFFICIAL INSPECTION FORM—NOT FOR VOLUNTAESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: Owner's Name:, Owner's Addres Date of Inspection: Name of Inspector: please print) Clllal� Company Name: �hG� Mailing Address: , ,(�1Z709 ' �� Telephone Number: 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: a/ Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority ils Inspector's Signature: Date: The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of I-Iealtl-t 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 DER The original should be sent to the system owner and copies sent to.the buyer, if applicable, and the approving authority. Notes and Comment�( _17 'L ✓w��l/rCC ****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 tinder the same or different conditions of use. Title 5 Inspection Form 6/15/2000 nar?e 1 Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE-DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: (l1 (jjZp J, Owner: Date of In pection: Inspection.Summary: Check A,B,C,D or E./ALWAYS complete all of Section D A. System Passes: I have not found any information which indicates that any of the failure criteria described in')10.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 explairi:. 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 distribudoiiboxdue 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 of 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 Paee 3 of 1'1 OFFICIAL INSPECTION FORM - NOT. FOR VOLUNTARY:ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTII+ICATION(continued) Property Address: tP �� Owner: I Date of I spection: UiL C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b) that the system is not functioning in a manner which will protect public health,safety and the environment: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier,if any) determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. _ The system has a septic tank and SAS and the SAS is within a Zone 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: 5 Pace 4 of l I OFFICIAL.INSPECTION FORM—NOT FOR.VOLUNTARY.ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: r'/k0Q� Owner: _ Date of In'pection: — D. System Failure Criteria applicable to all systeins: You must indicate"yes"or"no"to'each of the following for all inspections: Yes Np 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 i/ Static liquid level in.the distribution.box above outlet invert due to an overloaded or clogged SAS or / cesspool 11 Liquid depth in cesspool is less than 6"below invert or available volume is less than %s day flow �P 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. Ir Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface Jwater 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 10.0 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.weil 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.] / D (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CM 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.largesystem 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 office of the Department. 4 Page 5 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM :PART B ._ CHECKLIST Property Address: Owner: )/�eA Date of I ection: Check if the following have been done.You must indicate"yes" or"no"as to each of the following: Yes Pumping.information.was provided by the owner, occupant, or Board of Health ZWere.any of the system components pumped out in the previous two weeks Has the system received normal flows in the previous two week period ? _ v Have large.volumes of water been introduced,to the system recently or as part of this inspection? 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 0. a Were the septic tank manholes uncovered,opened, and the interior of the tank inspected for the condition oI the baffles or tees, material of constniction, dimensions, depth of liquid, depth of sludge and depth of scum Was the facility owner(and occupants if different from owner).provided with information on the proper maintenance of subsurface sewage disposal systems 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. _V/_ 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 1 I OFFICIAL INSPECTION•FORM—NOT FOR YOLUN`I`ARY°ASSESSMENTS SUBSURFACE SEWAC .{ DISPOSAL SYSTEM INSPECTION.,.FOR.M PART C - SYSTEM INFORMATION Property Address: yauoxa Owner: L Date of I spection:�&& C .. FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):.. Number of bedrooms(actual): , DESIGN flow based on 310.CvIR 15.203 (for example: 11.0 gpd x#of bedrooms): Number of current residents: 1�) _ Does residence,leave.a,garbage grinder(yes or no)- Is laundry on a separate sewage system (yes or no);/�g.-[if yes separate inspection required] Laundry system inspected(yes or no);) .,. / �T Seasonal use: (yes or no): ✓ Water meter readings; a le(last 2 years usage(- d)): Z-7�G�G�C tr'3- d�i� Sump pump (yes,or no • ' .Last date of occupancy: hD,4 �� ' /t 6wto(p A6aPCK"* COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR15.203): 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: /yU _ Was system pumped as part of(he inspection( or no): If yes, volume pumped: - gallons--How was quanti y pumped determined?= Reason for.pumping: TYP /OF SYSTEM __VSeptic tank, distribution box,soil absorption system _Single cesspool Overflow cesspool —Overflow Prrvy ' _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 fro.ni system owner) —Tight tank _Attach a copy'of the DEP,approval —Other'(des crib e): p roximate age of all con one-V , date installed(if kna n sand source of information: Were sewage odors detected when arriving at the site(yes or no);/ �j 6 Page 7 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: /z/0 aL j Owner:9' 4,1vt"hah&cf Date of ' spection: i BUILDING SEWER(locate on site plan)Ar Depth below grade: Materials of construction:_cast iron `. _40 PVC other,(explain) _ M Distance from private water supply well or suction line: Comments(on condition of joints, venting, evidence of leakage, etc.): SEPTIC TANK: (locate on site plan) Depth below tirade: O Material of construction: Zconcrete_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: Sludge depth:.(,, Distance from top of sludge to bottom of outlet tee or baffle: 3 2 Scum thickness: f �� Distance from top of scum to top of outlet tee or baffle: Z ®� Distance from bottom of scum to botto f outlet tee,or baffle' How were dimensions determined: ]aAa2,C�1 Comments(on pumping recommendations, fribet and outlet tee or baffle condition, structural integrity, liquid levels s related to outlet invert evidence of lea age, etc•: T ` GREASE TRAPUlocate 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 S.of 11 OFFICIAL INSPECTION.FORT!INI—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM.INFORMATION(continued) Property Address: 40 6 r27 l Owner:. Date of Ii pection: ' TIGHT or HOLDING.TANK/J1_�-(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: Alarin in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches, etc,): DISTRIBUTION BOX:. if present must be opened)(locate on site plan) Depth of liquid level above outlet inverta;e2A VA/* Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover, any evidence of akage into or out of box, tc.): PUMP CHAMBER (locate on site plan) Pumps in working order(yes or no): Alarms.in working order(yes or no): t« Comments (note.condition of pump chamber,condition of pumps and appurtenances,etc.):. 8 Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE ]DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INPORAATION (continued) Property Address: Owner: , Date of I specfion: SOIL ABSORPTION SYSTEM (SAS): 1►1 (locate on site plan, excavation not required) If SAS not located explain why: Type 1 c ing pits,:number:_ ]ll eaching chambers,number:.0 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 d td r CESSPOOL✓(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.): PRI` (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.): Pace 10 of 11 ' OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 7�A Property Address:. .o d?4&j 9. Owner: Date of I pection: 04341AMq,� � 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. rl 1 . 3 10 Pa2,e I of OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION continued .Property Address: _ A Owner:,9r" Date of I spection: SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water JZ� feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked, date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with local excavators, installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: .01 71 Permit Number: Date: Completed by: s� HIGH!: GROU\lP UU^,TER LEVEL COMPUTATION �7 Site Location: Lot No. Owner: jar Address: Contractor: /11��T Address •� 1�5 �✓ Notes: �✓��`,4 _5 STEP 1 Measure depth to water-table to nearest 1/10 ft. .............................................................................. .Date /d 7 mo 11 nth/day/year STEP 2 Using Water-Level Range Zone i and Index Well Map locate I site and determine: O Appropriate index we!I...:............................ . � ....... I I Water-level range zone .................................:................... E" STEP 3 Using monthly report "Current Water Resources Conditions" f determine current depth to p� C/ L , water level for index vveil ........................... monrh/year i STEP 4 Using Table of Water-level Adjustments for index well (STEP 2A), current depth to water level for index well (STEP 3), and water-level zone (STEP 2B) determine water-level adjustment ........................................................................................... STEP 5 Estimate depth to high ware: by subtracting the water- level adjustment (STEP 4) from measured depth to water. l level at site (STEP 1) ............... Figure 13.--Reproducible computation form. 15 ;'tip 4 i T f' _ i M s f j 4 ii r:Q E 7 i Jg i i n { d i;u 7 7 ' t/ti/99 NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANS). I, Joseph P.Macomber Jr, hereby certify that the application for disposal works construction permit signed by me dated 1 1 /3 0/0 0 concerning the property located at 130 Pine Street Hyannis,Mass. meets all of the following criteria: /7,e failed system is connected to a residential dwelling only. There are no commercial or business uses associated with the dwelling. /The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minuics per inch. There are no wetlands within 100 feet of the proposed septic system e/There are no private wells within 150 feet of the proposed septic system /There is no increase in flow and/or change in use proposed bl There are no variances requested or needed. 16/ The bottom of the proposed leaching facility will n2Lbc located less than five feet above the maximum adjusted groundwater table elevation. (Adjust the groundwater table using the Frimptor- ethod when applicable] I , If the S.A.S. will be located with 250 feet of any vegetated wetlands, the bottom of the proposedl leaching facility will =be located less than founcen (14) fect above the maximum adjusted I groundwater table elevation, __ s Please complete the following: A) Top of Ground Surface Elevation(cuing GIS information) -5 B) G.W. Elevation ' + the MAX. High G.W. Adjustment. t�7 DITYERENCE BETWEEN A and B 3 � SIGNED : DATE: 1 1 /30/00 [Sketch r sed plan of system on back]. Q:health folder,Bert A�t �R T-11LEI YX .btu a.d A �r c1. ° HYANNIS FIRE DEPARTMENT 93 HIGH SCHOOL ROAD EXTENSION HYANNIS, MASS. 02601 Harold S. arllnelle BUSINESS: 775-1300 CHIEF - S.oke Deft oea Save rC'ived EMERGENCY: 911 - FAX: 778-6448 To ; Town of Barnstable, Board of Health - T. McKean Town of Barnstable, Conservation Commission - From ; Fire Prevention Bureau, Hyannis Fire Department Subject ; The installation of above ground storage tanks. . Date ; 12/15/00 Persuant to, the applicable sections. of 527 CMR - Fire Prevention Regulations, this Department .has: i:nspected the following location for above ground storage. ADDRESS Pine 8t. Hyannis MA OZ OWNER/OCCUPANT. Robert White PHONE 778-244 _SIZE OF TANKS) (1) 975 gal _ SteP1 RaGement Tank COMMODITY STORED # 9 fnPl nil PURPSB FOR STORAGE THIS INSTALLATION IS s PRE-EXISTING A REPLACEMENT—- NEW This installation compl es does not comply with the required installation re ulation listed below. FIRE PREVENTION OFFICE For: HAROLD S.BRUNELLE,CHIEF ' HYANNIS FIRE DEPARTMENT V _ i BOND-TITE TANK SERVICE P.O. BOX 381 LEICESTER, MA. 01524-0381 TEL: (508) 892-4378 FAX: (508) 892-4295 DATE SHIPPED TO: Balcewicz Trucking & Salvage 12/27/00 103 Freemont Street Worcester, MA. 01603 QUANTITY DESCRIPTION 10 Residential aboveground#2 fuel oil tanks, cut in half with no liquid waste. i E TAG# 82658,82651,82659,82537,82654,82652,82570,82569 82681,82655, , �r4y i4X4 'RY �. QR9ER N DATE Received By: ?r�W l+1ATEEIAI RROGESS Eft4l ED SUPRIIn El D Ell ;,:JkN(17'Y MATERIAL PART NO. PRICE OP1.R.tiTION €±c LRLPT ON sT �4nY U'/� /"tQCAlION DEPT CODE CoUN7EU d WEIGH£F). CHECK£Q. 3Y L�