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Home My WebLink About0081 SAINT JOSEPH STREET - Health 8 { 5t7}i N0 .....��.� V V - FIJ.0...................... THE COMMONWEALTH.OF MASSACHUSETTS BOAR® OF HEALTH ..---....OF........ �/tJ.�S:�._/�. � /...... Appliration for flispos al Works Tnnstrnrtinn Prrmit Application is hereby made for a Permit to Construct 4--ror Repair ( ) an Individual Sewage Disposal System at :... ..7_. ...O.. .. ... ............................... .. ....... --..... .................. . ................................... ...... - L a'on:Address N/�`�Lo o ...... . �r. .... . .............. 2 -- . .................. ... _ - ner ess a .................. .... ... ..... .......-•- . ....---•-•--------------- .....G............--••......_... ..... !Yt .. ........ Installer V Address d Type of ilding Size Lot............................Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) dOther fixtures -••--••••---•-••••-•-•--•-•----•••--........-••---•••..•••--.....-•••••-•-•-•---•--••- W Design Flow__________ _____ ________________•.....gallons per person pert flay. Total daily.,gow.... ................•..•.�...,..g lons. WSeptic Tank—Liquid capacity :�..gaIIons Length f.. ...._.. Width. . ........ Diameter................ Depth�_._....... x Disposal Trench—No..................•.. Width---7............... Total Length...... . Total leaching area....................sq. ft. Seepage Pit No..................... Diameter.....-_._........... Depth below inlet..... Total leaching area..A�....sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ (Z, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water-----------:............ 04 .................................................._........................................................................................................... 0 Description of Soil..................................................••-•-----................-•••••-•-•--•----•••-----•-••-••-•----•-•-••-•-•-•.••••••-•-•--------•-----•................ x w UNature of Repairs or Alterations—Answer when applicable............................................................................................... ....----•-------------------------------------•----......--•---•--•------------------•--•----------......•....----------------------•------------------•--------....................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TIT1Z 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been ' sued by the board of health. Signed. ._.... 1 - -•---- •------�------ --•-•----------•- -•--------------------•----••- ApplicationApproved B .::= ... ••-••••• --••-----------------•-----•----•----------------......-••-.•••-- al e------•-••---- Date Application Disappro d r th f ollowing reasons----------------------------•------------------------•---------••--------------------........................... -•---------------------------•------......---------------•-•------------....-----•---------------•--------•-••---•----•---••----••-•----•-•----•••--•----•-------•-•---•-••-•-•••-•--•••-•---•------•-- Date PermitNo. -A....... . . ........................... Issued_....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD F' HE T _ ........................OF .. . . . .. ....,:.. .. ........................................... (9rrtifirair of Tour rlianrr T C IFY, That the Individual Sewage Disposal System constructed (411/or Repaired ( ) by: ......---•-------------- •..... •••••-••-----•---•-••-•-•.....................•-•••---••--......--......_..----•••-----_... '''''')) /A,w /. i staller �•' _..l... _... 1e�l�Llli2i(� ----------------------- q has been installed in accordance with the provisions of TLE 5 f The State Sanitaryod s d i d in the application for Disposal Works Construction Permit No _._I _.--., /..Z_......... dated-.: ............... TIME ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE................................................................................ Inspector.................................................................................... No.........�7............ FEx.310.... ........... fi THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...................................OF.........................----........................... Appliration for Uhiposal Workii Tomotrurtion Vamit Application is hereby made for a Permit to Constru t or Repair an Individual Sewage Disposal SySt C_ .............. . ......... ........ ...2 ............ .................................................... ............................................ or ........ .... Lo........ ....... r s. . ................... ............................................. Lot-No....................................................er Address ........ . ....... ..... .. . ................................................... .................................................................................................. nstaller Address y y pe of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic Garbage Grinder P4 Other—Type of Building ............................ No. of persons............................ Showers Cafeteria Otherfixtures ...................................................................................................................................................... Design Flow............................................gallons per person per day. Total daily flow............................................gallons. 9 Septic Tank—Liquid*capacity............gallons Length................ Width.........._...._ Diameter.___.._......... Depth................ Disposal Trench—No..................... Width.....__......_...... Total Length.................... Total leaching area....................sq. f t. Seepage Pit No_.................. Diameter.................... Depth below inlet.................... Total leaching area..................sq. f t. Z Other Distribution box ( ) Dosing tank ( ) 1.4 0-4 Percolation Test Results Performed by.......................................................................... Date........................................ 04 Test Pit No. 1................minutes per inch Depth of Test Pit._____............_. Depth to ground water........__.........._._. fTq Test Pit No. 2................minutes per inch Depth of Test Pit............__.__... Depth to ground water_.__._.............._... 9 ..................................................................................................................................................."--------- 0 Description of Soil........................................................................................................................................................................ W U ........................................................................................................................................................................................................ W ----------------------------------------............................................................................................................................................................... U Nature of Repairs or Alterations—Answer when applicable............................................................................................... .........................I...........................................................................I.................................................................................................. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of T I TAI.E . 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Signed..Z. ..... ... -------------------- ----------------------- ApplicationApproved By . ................................................................ ................ .. ................................ Date Application Disapprove ihelollowing reasons:................................................................................................................ f ......................................................................................................................................................................................................... Permit No._ ...31 ......................... Issued_........... Date....... .. ...... ....... ..... Date THE COMMONWEALTH OF MASSACHUS&TS BOARD,OF .................................Or................... ................................................................ fit Qpwrfifiratr of Tom'- p'liaurr TI-PIS FY, That the Individual Sewage Disposal System constructed or Repaired by...... .%I;............ ............................. ----- ---- -------------------- ......."-------------------------------------------------- at .....3..). ... . ... ......... . ............... . ...... i.. ..the ...... e provisions o ----------------------------------------------------Cede..--_..... de 4- ',,Ib n as been installed in accordance with the f TITLE 5 ol The State Sanitary ......_ dated------16 .......................... application for Disposal Works Construction Permit No.--k- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE................................................................................ Inspector............................................................. ...................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTI .........................OF ............................... No.... . FEE........................ iitrudivit "prrutit Permissionis 'r y anted_- .:.......... .. .... . ......................................................................................... y. to Construct C ,. . or e, it an In ividu e posal System atNo....... ...... . .. .......-2.7. z..�. . - ............... --------------------- ------------------------------------------------------------ Street as shown on the application for Disposal Works Construction-pprmit No/—_________________ Dated ....................... Dated___.__. ... ...................... ------------- 0 Board of Health DATEI._ ...... 7 /��l.................-------------------------- FORM 1255 HOBBS & WARREN. INC.. PUBLISH 'Ep 17 r-- ST 1 .�.. Q,Oi' 04 +r*f �vaw s 11t� ,c 3 z 3 0 - Sep"C_ TAUK * 3'3Cf It lh© yo10 ik,GP GA 1.- �, , _ � . .41 U S E 1Q G o Co X.L.. LA,B1�..' PIT 'atSPtY5A.L PCT V;E (a00 &t. : t o OOTTOAA ARICA% t t 1 3- o 1 ,�C�, ToTA vEst6N g, r [[��] , PE�ZCOt.dT l0►.l QQ1'[= l t W Z MttJ OQ LF*S .. ` `�:...t�' �,.. (e►�; .,tom •,,.� r.:�.. �.:. +��, _. _ - �'„ BAXTO1 t Hy ; � j 1 �.. t:S.4 cis 94 .r- w_ ...i. +;._`++s.+l w +lF ' dd•. d .' aw�.-Y,..«+�...-e� �-•--•----_._—fa, ._�...-_ i».� .......+. - 14 - � y.1 sf iY .. � �3� �-• � µ.�.J. —.e f • . ty � oP Fa,v * too', aim �noo twv. ^ 9L.5 t.s S�f G Ca"40 . ttiN. TAuK. i`• + Low►-i _ AM - Skit; sai 10 WAW SANDY GRAY ki L ii CEQ T IF t FIB Pt-cfr Pt-A F.► 4.io ,6cb Lc= j.#..4v 4o FT D o.-r c Zi /81 I t C4tCTtFY T"AT Te4u'jOUND*,T.jq(-4 Shyuj s-1E2Es�►.t GOM Pc-%S' W t T'�a T4bcl sum-1 i.t� L C� E' w ? A► I>. CEV'F3ACK OF TLiE ��_-Pk t k $. . . `1 G.`t p G• �S OW DL►T6. 2 _` 15A.X-rest g.. _ SZ.6`t-STE ZLE� LL�f.ID �QVE`PR:; TU14 PlAW► 14 UbT BASED Ot.l AU 1"4TCOMEM't OSTE v�La>ii► - A�t�.SS. 5utU✓Mt 4 TWr6 oFFseT; '91j04>Ll,-► 'UOT EE 'U 'lpe0 v.�"• APPLtC To -VET r_RM l N L t..OT t..t W ES; 91 St. Joseph Street - Hyannis �i A=291 —211 • - 1 i i 4 o t I �( TOWN OF BA>f2NSTABLE . LOCATION U J O s-e—P 4 67L SEWAGE # VILLAGE .. i G✓1 e► S ASSESSOR'S MAP&LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANR-CAPACFI'Y LEACHING FACiLIW: (type) `Ce I (size) ao "?c 9311 NO.OF BEDROOMS � BUILDER OR OWNER PERMITDATE: COMPLIANCE DATE; Separation Distance Between the: Maximum Adjusted,Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 30CI feet of}}eaching facility) Feet Furnished by S�tQtlrt �G�:CI _ I I Lj .� 1 -TA TOWN OF BARNSTABLE LC?CATION -3"c�S T� ,t�t-�` ' SEWAGE# VILLAGE Y eaaw t� ASSESSOR'S MAP&PARCEL nit r., INSTALLERS NAME&PHONE NO. �� ,.� SEPTICTANK CAPACITY LEACHING FACILITY:(type) �, Q (size) `X3 (® NO.OF BEDROOMS OWNER L�.�►wv� ��'.J—' PERMIT DATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility ' Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED v Vl' 00 - c� � r cil f <. cj 00 - oC 103 ` l a9/-- L Commonwealth of Massachusetts Title 5 Official Inspection Form _J Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 81 St.Joseph Street ; Property Address Stephan Rogers Owner Owner's y Nam information is Hyannis J Ma 02601 2-8-2021 required for every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. Inspector Information on the computer, Brett Hickey use only the tab key to move your Name of Inspector cursor-do not B&B Excavation use the return Company Name key. 374 Route 130 Company Address Sandwich Ma 02563 City/Town State Zip Code tx�1 (508)477-0653 S113747 — 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 Brett Hickey Digitally signed by Brea Hickey p -'Dale:2021.02.1212:13:16.05'00' 2- -2021 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note:This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 c � Commonwealth of Massachusetts w. - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 81 St.Joseph Street Property Address Stephan Rogers Owner Owner's Name information is Hyannis Ma 02601 2-8-g021 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: 4 ❑■ 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: The system was in working order at the time of inspection. 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.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 18 Commonwealth of Massachusetts ytl Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments t � 81 St.Joseph Street Property Address Stephan Rogers Owner Owner's Name information is Hyannis Ma 02601 2-8-2021 required for every y page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): EJ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: I t5insp.doc•rev.7/26/2018 Tile 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts �n = = Title 5 Official Inspection Form - b Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 81 St.Joseph Street Property Address Stephan Rogers Owner Owner's Name information is Hyannis Ma 02601 2-8-2021 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No El El clogged of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ J ❑ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 18 Commonwealth of Massachusetts m op Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 81 St.Joseph Street Property Address Stephan Rogers Owner Owner's Name information is Hyannis Ma 02601 2-8-2021 required for every y page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ❑ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ O Liquid depth in cesspool is less than 6"below invert or available volume is less than %day flow ❑ El Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ El 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. ❑ El Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ 0 Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ El 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.] ❑ 0 The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ O The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section CA. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 c Commonwealth of Massachusetts -� Title 5 Official Inspection Form -- - @ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 81 St.Joseph Street Property Address Stephan Rogers Owner Owner's Name information is Hyannis Ma 02601 2-8-2021 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered"yes"to any question in Section C.5 the system is considered a significant threat, or answered"yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes" or"no"for each of the following for all inspections: Yes No ❑ El Pumping information was provided by the owner, occupant, or Board of Health ❑ El Were any of the system components pumped out in the previous two weeks? R ❑ 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? 0 ❑ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ❑ El Was the facility or dwelling inspected for signs of sewage back up? E ❑ Was the site inspected for signs of break out? 0 ❑ Were all system components, excluding the SAS, located on site? 0 ❑ 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: 0 ❑ Existing information. For example, a plan at the Board of Health. ❑ El 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)] t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 Commonwealth of Massachusetts a - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 81 St.Joseph Street Property Address Stephan Rogers Owner Owner's Name information is Hyannis Ma 02601 2-8-2021 required for every y page. City/Town State Zip Code_ Date of Inspection D. System Information 1. Residential Flow Conditions: 3 3 Number of bedrooms(design): Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330/GPD Description: 1 Number of current residents: Does residence have a garbage grinder? ❑ Yes No Does residence have a water treatment unit? ❑ Yes rol No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes RI No information in this report.) Laundry system inspected? ❑ Yes 0 No Seasonal use? ❑ Yes CE No See below Water meter readings, if available(last 2 years usage(gpd)): Detail 2020- 4,488gallons 2019- 18,700gallons Sump pump? ❑ Yes ❑■ No Last date of occupancy: currentDate 15insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 Commonwealth of Massachusetts �. P Title 5 Official Inspection Form la Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 81 St.Joseph Street Property Address Stephan Rogers Owner Owner's Name information is Hyannis Ma 02601 2-8-2021 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: NA Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ® Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Owner- date of last pump is unknown Source of information: Was system pumped as part of the inspection? ❑ Yes ❑■ No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc-rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 I , Commonwealth of Massachusetts Title 5 Official Inspection Form _ , Subsurface Sewage Disposal System Form -Not for Voluntary Assessments -- �l 81 St.Joseph Street Property Address Stephan Rogers Owner Owner's Name information is Hyannis Ma 02601 2-8-2021 required for every y page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ❑ Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no)(if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known)and source of information: 1998 per permits Were sewage odors detected when arriving at the site? ❑ Yes ❑■ No 5. Building Sewer(locate on site plan): 2' Depth below grade: feet Material of construction: ❑cast iron ■❑40 PVC ❑ other(explain): Town water Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): t5insp.doc•rev.7/262018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 cry Commonwealth of Massachusetts Title 5 Official Inspection Form - to Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 81 St.Joseph Street Property Address Stephan Rogers Owner Owner's Name information is Hyannis Ma 02601 2-8-2021 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): 1' 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 1 Dimensions: 000gallons 11 Sludge depth: �} 3211 Distance from top of sludge to bottom of outlet tee or baffle 1" Scum thickness 611 Distance from top of scum to top of outlet tee or baffle 1511 Distance from bottom of scum to bottom of outlet tee or baffle measured How were dimensions determined? Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): The tank was in working order at the time of inspection. The tank is not in need of pumping at this time but should be pumped every two years for maintenance. t5insp.doc•rev.7/2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts - -iO Title 5 Official Inspection Form :�j Subsurface Sewage Disposal System Form -Not for Voluntary Assessments r 81 St.Joseph Street Property Address Stephan Rogers Owner Owner's Name information is Hyannis Ma 02601 2-8-2021 required for every y page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap(locate on site plan): NA 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: I 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: NA Material of construction: ❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 Commonwealth of Massachusetts �= ===_� Title 5 Official Inspection Form 1" ,la .Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 81 St.Joseph Street Property Address Stephan Rogers Owner Owner's Name information is Hyannis Ma 02601 2-8-2021 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box(if present must be opened) (locate on site plan): OilDepth of liquid level above outlet invert Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): The d-box was in working order at the time of inspection. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 c� Commonwealth of Massachusetts isp Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 81 St.Joseph Street Property Address Stephan Rogers Owner Owner's Name information is Hyannis Ma 02601 2-8-2021 required for every y page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): NA * If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: 20'x23'x6" 0 leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form �- la Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 81 St.Joseph Street Property Address Stephan Rogers Owner Owner's Name information is Hyannis Ma 02601 2-8-2021 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS)(cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): The SAS was in working order at the time of inspection. No evidence of past backup was observed when viewed. 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration NA Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments /1 81 St.Joseph Street Property Address Stephan Rogers Owner Owner's Name information is Hyannis Ma 02601 2-8-2021 required for every y page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. Privy(locate on site plan): NA Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs.of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 Commonwealth of Massachusetts m Title 5 Official Inspection Form , Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 81 St.Joseph Street u� Property Address Stephan Rogers Owner Owner's Name information is Hyannis required for every y Ma 02601 2-8-2021 page. City/Town 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 _ TOWN OF BARNSTA.BL:E LOCATION, i_ . t>>' r� S "" _9 YII.LACiE ASSESSC)'!t S MAP 1NSTA A_P_WS NANM �c ♦. .SEPTIC TANK CAPACTT-Y LEACHING.FACILITY: (typz,) - 1?,,,rr`� 3 L—. J` ;`.,(size) ✓9 .J �+s :NO.OF SEI7ROOMS BUMDER CAR OWNER.... PERM17MATEc �!S—r 7:!! CC.3MPT_lANCJe nA:TE: Separation Mstance Between the: Meximurin.Acljustett 0iroundwatec Table to the Bottom cif.I..e tng"Facility Feet Private' Water Supply Well and Leaching Facility. (If y wells exist on site or within.200 feet of teaching taciliryA� Feet Edge,ofWetland:and Leaching Fscil3tj+y(If any Hands exist within 500 fact of leaching facility) Feet F'unished by ......... .........,._...,.�...�.�. c - t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18 i Commonwealth of Massachusetts i x Title 5 Official Inspection Form I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 81 St.Joseph Street Property Address Stephan Rogers Owner Owner's Name information is Hyannis Ma 02601 2-8-2021 required for every y page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ❑■ Check Slope ■❑ Surface water On Check cellar ❑■ Shallow wells No GW 4' below SAS Estimated depth to high ground water: feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers -(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: A hand hole was augured to determine high groundwater. The hole was augured 4' below SAS and no water was encountered. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 c Commonwealth of Massachusetts -- Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 81 St.Joseph Street Property Address Stephan Rogers Owner Owner's Name information is Hyannis Ma 02601 2-8-2021 required for every y 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 4 checked 0■ C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4(Failure Criteria)and 6(Checklist)completed �■ D. System Information. For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc-rev.72612018 Title 5 Official Inspection Foam:Subsurface Sewage Disposal System•Page 18 of 18 Commonwealth of Massachusetts Tie 5 v rficia inspection -rorni Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 81 St Joseph St Property Address Lynne Kreger Owner Owner's Name information is required for every Hyannis MA 02601 7-19-11 page. Cityrrown State Zip Code Date of Inspection Inspection results must be submitted on this form.Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. A. General Information 1. Inspector: J ll! 1 Shawn Mcelroy Name of Inspector Upper Cape Septic Service Company Name 29 Atwater Dr Company Address E. Falmouth MA 02536 City/Town State Zip Code 1-508-495-0905 S13971 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 7-20-11 Inspector's Signature Date The system.inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent,to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. 1 t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments b�M 81 St Joseph St Property Address Lynne Kreger Owner Owner's Name information is required for every Hyannis ` MA 02601 7-19-11 page. Cityfrown' State Zip Code Date of Inspection B. Certification (cont.) 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 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: System is in good working order with no sign of failure. 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. 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. El Y ❑ N ❑ ND (Explain below):- t5ins-11/10 - Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 I . . f Commonwealth of Massachusetts Title 5 Official Inspection Form . Subsurface Sewage Disposal System Form -Not for.Voluntary Assessments 81 St Joseph St Property Address Lynne Kreger Owner Owner's Name information is required for every Hyannis MA 02601 7-19-11 page. City(rown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: El 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 1 t5ins-11I10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 e Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 81 St Joseph St Property Address Lynne Kreger Owner Owner's Name information is required for every Hyannis MA 02601 7-19-11 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 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 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. 3. Other: D) 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 ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/day flow t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 L Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM 81 St Joseph St Property Address Lynne Kreger Owner Owner's Name information is required for every Hyannis MA 02601 7-19-11 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® 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. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] The system is a cesspool serving a facility with a design flow of 2000gpd- ❑ ®.t, 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. 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. t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 81 St Joseph St Property Address Lynne Kreger Owner Owner's Name information is required for every Hyannis MA 02601 7-19-11 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done.You must indicate "yes"or"no" as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? El ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® E 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 ® El approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 , Number of bedrooms (actual). 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 81 St Joseph St Property Address Lynne Kreger Owner Owner's Name information is required for every Hyannis MA 02601 7-19-11 page. Cityfrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [f yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy:. 7-2011Date 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 Industrial waste holding tank present? ❑ 'Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 81 St Joseph St Property Address Lynne Kreger Owner Owner's Name information is required for every Hyannis MA 02601 7-19-11 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information:. N/A Was system pumped as part of the inspection? ❑ Yes ® No If yes,volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank,distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (f yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): t5ins•11/10 Title 6 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 81 St Joseph St Property Address Lynne Kreger Owner Owner's Name information is required for every Hyannis MA 02601 7-19-11 page. City[Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (f known) and source of information: 1999 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 16"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.): Good condition. Septic Tank(locate on site plan): 8 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: 1000 gal Sludge depth: 101, t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form _ o Subsurface Sewage.Disposal System Form -Not for Voluntary Assessments ^M 81 St Joseph St Property Address Lynne Kreger Owner Owner's Name information is required for every Hyannis MA 02601 7-19-11 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 22 Scum thickness 0 Distance from top of scum to top of outlet tee or baffle 6 Distance from bottom of scum to bottom of outlet tee or baffle 16" How were dimensions determined? Tape 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 is in good condition with baffles installed and no sign of leakage. 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 t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments a 81 St Joseph St Property Address Lynne Kreger Owner Owner's Name information is required for every Hyannis MA 02601 7-19-11 page. City(rown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: El concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day 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 t5ins•11110 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 81 St Joseph St Property Address Lynne Kreger Owner Owner's Name information is required for every Hyannis MA 02601 7-19-11 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 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.): Good condition with water at working level and no sign of leakage. 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.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M , 81 St Joseph St Property Address Lynne Kreger Owner Owner's Name information is H annis MA 02601 7-19-11 required for every y page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ® leaching fields number, dimensions: 1-20'x23' ❑ 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.): Leach field in good condition with no sign of back-up into d-box or surrounding stone. 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 t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 81 St Joseph St Property Address Lynne Kreger Owner Owner's Name information is required for every Hyannis MA 02601 7-19-11 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 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.): t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °�M y 81 St Joseph St Property Address Lynne Kreger Owner Owner's Name information is required for every Hyannis MA 02601 7-19-11 page. City(rown State Zip Code Date of Inspection D. System Information (cont.) 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 r ---- 13 R t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface.Sewage Disposal System Form -Not for Voluntary Assessments 81 St Joseph St Property Address Lynne Kreger Owner Owner's Name information is required for every Hyannis MA 02601 7-19-11 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 5 feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: ® Checked with local excavators, installers-(attach documentation) ® Accessed USGS database-explain: You must describe how you established the high ground water elevation: Original design plans show grounwater at 5' below leach field. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 81 St Joseph St Property Address Lynne Kreger Owner Owner's Name information is required for every Hyannis MA 02601 7-19-11 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 TOWN OF BARNSTABLE ATION s bS S ✓ SEWAGE # VII.LAGE ��)� i'-1L'1 ASSESSOR'S MAP & LOT , f INSTALLER'S NAME&PHONE NO. F-01 !0-:3�'�^' . �71 SEPTIC TANK CAPACITY LEACHING FACII,= (type) r, (size) NO.OF BEDROOMS '�1�� BUILDER OR OWNER S 4 A.-e-A N" .-'PERMITDATE: g COMPLIANCE DATE:5" Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Le ing Facility Feet Private Water Supply Well and Leaching Facility (If y wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any tlands exist within 300 feet of leaching facility) := 4 " Feet Furnished by . r . q ri w a �. No. • r' Fee $50 r� THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 01ppYication for Miopooal 6pgtem Construction permit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System El Individual Components o ati ddre or Lot N Own 's Name A ass and Tel.No. V. 3osep�s St . , Barnstable , MA ffhri� �u.;�anaring Assessor'sMap/Parcel 4?_C /— P,j/ 390 E . 8th St . #3 , S . Boston 02127 Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Wm. E . Robinson Septic Service David. B . Mason, East Sandwich, MA PO Box 1089, Centerville , MA Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil S and. Nature of Repairs or Alterations(Answer when applicable) new Title-5 Septic to the plans of Dave Mason 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 ' ued by this�oarealth. Sign Date 6- Application Approved by Date Application Disapproved for the following reason Permit No. --YII, Date Issued Ye l�to.• �r � Fee � 0 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLES MASSACHUSETTS Yes Zipprfcatfon for �Dfgpoml *pgtem Congtructfon Vermit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components fatig tddre or Lot Own s Name A ess and T 1.No. t51 osepis St . , Barnstable , MAhriran�ring Assessor'sMap/Parcel '7—C? /— Z �� 390 E. 8th St:,#3, S . -Boston 02127 Installer's Name Address,and Tel.No. Designer's Name,Address and Tel.No. Wm. E. Robinson Septic Service David B. Mason, East Sand.wich, `MA PO Box 1089, Centerville , MA \ Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) ` Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Sand. a, Nature of Repairs or Alterations(Answer when applicable) new Title-5 Septic to the plans of Dave Mason 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 bee ' sued by this oar f ealth. Sign !/ Date ��. Application Approved by 6 ® J Date Application Disapproved for the following reason61 /I All Permit N t. Date Issued THE 4MMONWEALTH OF MASSACHUSETTS Standrifig BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired(X )Upgraded( ) Abandoned( )by Wm. E. Robinson; Septic Service at 81 S t. Josephs S t . , b n constructed in accordance with the provisions of Title 5 and the for Disposal Syst m Construction Permit No. t dated Installer Wm. E. Robinson S r. Designer I ,ll r, The issuance of this pe t shal no �e c• rued as a guarantee that the ste will function as ddsgned''' '`v Date Inspector %'ir`l - 17 _ ___ No.-- ./ ^--------------------------Fee $50 -- 1 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS Sta.nciring of 6pogar 6p tens Con!5tructfon 3ermit Permission is hereby granted to ConstruEL(,-- )FZF air K ): pgrade( )Abandon System located at 81 St . J,dSe;phsc' -Bar ' stab n `✓' t and as described in the above Application for Disposal System Construction Permit. The applicant recognizes hi0her duty to comply with Title 5 and the following local provisions or special conditions. n Provided:Constructio m st be c0tr within three years of the date oft nerrhit. Y Date: Approved b "eII'�'' I �+� vaj' TOWN OF BARNSTABLE LOCATION J 3(25 ` S SEWAGE # VILLAGE ��' 9 r/mil ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE N.O. 01'iIF SEPTIC TANK CAPACITY LEACHING FACIL=: (type) 2-0 —,7-3 L—> / (size) —,' J NO.OF BEDROOMS. l 1' BUILDER OR OWNER PERMITDATE: COMPLIANCE DATE: IIF 1 e. Separation Distance Between the: i Maximum Adjusted Groundwater Table to the Bottom of Le ing Facility Feet Private Water Supply Well and Leaching Facility (If y wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any tlands exist within 300 feet of leaching facility) Feet Furnished by I f a Z � � Commonwealth of Massachusetts r-4 Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 81 St Joseph Street Property Address Lynn Kreger Owner Owner's Name information is required for y H annis MA 02601 February24 2009 every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Important: A. General Information When filling out forms the I Uz computer, ajr,use 1. Inspector: L�iJS only the tab key to move your Patrick T. Sullivan cursor-do not Name of Inspector use the return key. Ready Rooter, Inc. Company Name r� PO Box 371 -17 Jan Sebastian Dr. Company Address Sandwich MA 02563 A Cityrrown State Zip Code 508-888-2805 S112843 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority � �---- March 3, 2009 Inspector's Signature7 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 is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****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. l�0 3/01 81 stjosephsst•03/08 Title 5 Official Inspection Form:SubsIMSewage Disposal System•Page 1 of 1 Commonwealth of Massachusetts W Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 81 St Joseph Street Property Address Lynn Kreger Owner Owner's Name information is required for Hyannis MA 02601 February 24, 2009 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: Surface water for wetlands area over 150'from SAS 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 then❑ 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>nfiltration 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 th'e tank is less than 20 years old is available. ND Explain: r /f 3f J� ❑ Observation of� ewage 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): ❑ b oken pipe(s) are replaced ❑ obstruction is removed 81 stjosephsst-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 2 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 81 St Joseph Street Property Address Lynn Kreger Owner Owner's Name information is Hyannis MA 02601 February 24, 2009 required for y State Zip Code Date of Inspection every page. Cityrrown B. Certification (cont.) B) System Conditionally Passes(cont.): ❑ 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 4ith approval of the Board of Health): ❑ broken pipe(s) argerr`eplaced ❑ obstruction is emoved ND Explain: C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of�ealth in order to determine if the system is failing to protect public health, safety or the envirortment. 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 surfacerwater F ❑ '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 'i a manner that protects the public health, safety and environment: ❑ The system has a septic tank an 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 tan k4nd 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. 81 stjosephsst•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 3 r Commonwealth of Massachusetts Title 5 Official Inspection For1m o Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 81 St Joseph Street Property Address Lynn Kreger Owner Owner's Name information is Hyannis MA 02601 February 24, 2009 required for y every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ The system has a septic tank and SAS and the SAS is leis 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 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. 3. Other: f ' P D) 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 ElStatic liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/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. 81stjosephsst-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 4 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 81 St Joseph Street Property Address Lynn Kreger Owner Owner's Name information is Hyannis MA 02601 February 24, 2009 required for y every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No ❑ ® 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. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the questions in Section D. Yes No F El Elthe system is within 400 feet 0,ra surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply El El Area 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 thre t under Section E or failed under Section D shall upgrade the system in accordance with 310 CIVIR 15.304. The system owner should contact the appropriate regional office of the Department/ 81 sljosephsst•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 5 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 81 St Joseph Street Property Address Lynn Kreger Owner Owner's Name information is Hyannis MA 02601 February 24, 2009 required for State Zip Code Date of Inspection every page. Cityrrown C. Checklist Check if the following have been done. You must indicate"yes"or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? Have large volumes of water been introduced to the system recently or as part of El ® 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? ® El information 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)] 81 stjosephsst-03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 6 Commonwealth of Massachusetts v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 81 St Joseph Street Property Address Lynn Kreger Owner Owner's Name information is Hyannis MA 02601 February 24, 2009 required for y every page. Cityrrown State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): .3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 340.4 GPD 1 Number of current residents: Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): 2007+2008=33GPD Sump pump? ® Yes ❑ No Current Last date of occupancy: Date Commercial/Industrial Flow Conditions: Type of Establishment: I Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): I' Grease trap present? ❑ Yes ❑ No I Industrial waste holding tank present? ,<` ❑ Yes ❑ No Non-sanitary waste discharged to the`Title 5 system? ❑ Yes ❑ No Water meter readings, if availab e: Last date of occupancy/use: Date Other(describe): 81stjosephsst-03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 7 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 81 St Joseph Street Property Address Lynn Kreger Owner Owner's Name information is Hyannis MA 02601 February 24, 2009 required for y every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: No previous records found Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: gallon 1000s How was quantity pumped determined? Site tube on truck Maintenance Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: Septic tank installed 1981. D-Box and SAS installed Aug. 17, 1999. As-built and engineered plans on file at Board of Health. Were sewage odors detected when arriving at the site? ❑ Yes ® No 81stjosephsst°03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System°Page 8 of 8 Commonwealth of Massachusetts 4 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 81 St Joseph Street Property Address Lynn Kreger Owner Owner's Name information is Hyannis MA 02601 February 24, 2009 required for y every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 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.): Septic Tank(locate on site plan): 911 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: 8 X 4.5 X 4.5 1000 gallons 311 Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle 31" 211 .Scum thickness 6" Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle 13" How were dimensions determined? Tape measure and dip tube. 81 stjosephsst•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 9 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments w 81 St Joseph Street Property Address Lynn Kreger Owner Owner's Name information is Hyannis MA 02601 February 24, 2009 required for y every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Inlet and outlet PVC tees in place. Liquid level at outlet invert. Recommend pumping every 2 years for maintenance. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: r ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thicknessv Distance from top of scum to by 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.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on.site plan): Depth below grade: Material of construction: ❑ concrete El metal ,,❑fiberglass El polyethylene ❑ other(explain): J. 81stjosephsst-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 10 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 81 St Joseph Street Property Address Lynn Kreger Owner Owner's Name information is Hyannis MA 02601 February 24, 2009 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank(cont.) 1 Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: / ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (conditi ,/of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 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.): One intet, 4 outlets with equal flow. No solids carryover. No high water staining over outlet inverts. No sign of leakage into or out of box. Riser brings cover within 6" of grade. Pump Chamber(locate on site plan): Pumps in working order: % ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No i` 81 stjosephsst•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 11 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form Not for Voluntary Assessments 81 St Joseph Street Property Address Lynn Kreger Owner Owner's Name information is Hyannis MA 02601 February 24, 2009 required for y every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ® leaching fields number, dimensions: 1-20'X23'X6" ❑ 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.): Leach field located and inspected with camera. No sign of past hydraulic failure. Hand probing over SAS found no ponding. 81 stjosephsst•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 12 Commonwealth of Massachusetts W Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 81 St Joseph Street Property Address Lynn Kreger Owner Owner's Name information is Hyannis MA 02601 February 24, 2009 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 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 sail/signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: / Dimensions f" i Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 81stjosephsst•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 13 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments N 81 St Joseph Street Property Address Lynn Kreger Owner Owner's Name information is Hyannis MA 02601 February 24, 2009 required for y every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 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. Li A 3 : y Ill _ 3 d _ 81 stiosephsst•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 14 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 81 St Joseph Street - Property Address Lynn Kreger Owner Owner's Name information is Hyannis MA 02601 February 24, 2009 required for y every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ® Surface water ® Check cellar ❑ Shallow wells 5' Estimated depth to high ground water: feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: July 9 1999 Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: ❑ Checked with local excavators, installers-(attach documentation) ® Accessed USGS database-explain: ma water usgs gov terraserver-usa.com You must describe how you established the high ground water elevation: System design plans state ground water artificially elevated due to sewage treatment plant. Adj ground water EIv= 93.50. Base of SAS is at EIv= 98.50. Accessed local ground water contour and topo mapping 81 stjosephsst-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 15 - TOWN OF BARNSTABLE BAR-W 1139 Ordinance or Regulation WARNING NOTICE Name of Offender/Mans er 1V�/V/ I h(`] S S #V 0 6f�� g � � I � Address of Offender �o�� MV/MB Reg.# Village/State/Zip fiYAdff LOA c (_6 J / Business Name � am m on , Wq 1911/ Business Address Signature of or"cing Officer Village/State/Zip Location of Offense a.. forcing Dept/Division Offense ��/)'�.//� � (y`Ch d`yl ! ilVl/ 11�. ALP � Facts / �/� � Y_ - iC � s // L This will serve only as a warning. At this time no .legal action has been taken. It is the goal of Town agencies to achieve voluntary compliance of Town Ordinances, Rules and Regulations. Education efforts and warning notices are attempts to gain voluntary compliance. Subsequent violations will result in appropriate legal action by the Town. ....,...,.:.,ao,....r. , „ .-.., ...�^":_a_. z:-...:F"v Tts�;....:_�....�'yK 3^N",;.rr.,,.._�,„ s-+tom.- r. �.._ -.:,r..•,.•;.-^. .•, <`s. TOWN OF BARNSTABLE BAR-W 1139 Ordinance or Regulation 4\ WARNING NOTICE/ } �^ ✓ /�; / 71 Name of Offender/Manager `I ! /' .; €� � 4„ j Address of Offender ,'ii .� R MV/MB Reg.# Village/State/Zip YM i,'� s A A � Business Name am pm;%on 19 2 7, Business Address Signature of Enforcing Officer t Village/State/Zip Location of Offense14, ; f �' •t, � � a i h E°nf�orcing Dept/Division Offense rA k :. L /.f S k! J +,ZA t Facts / (✓ rs - f his will serve only a"s a warning. :At this time no legal action has been taken. It is the goal of Town agencies to ,achieve voluntary , compliance of Town Ordinances, : Rules and Regulations`. Education efforts and warning notices are attempts to ,gai:n. 4oluntary compliance. Subsequent .violations will result in appropriate legal ,action by the Town. TOWN OF BARNSTABLE BAR-W j 139 0-r-dinance or Regulation I�OTICEQ, 3 ./ � r f .,� f`..., � -ice""��.A` `�.✓' w i ••, � . Name of Offender/Manager r�J �✓ �., #f �` Address of Offender ) `\i :, . � ,� MV/MB Reg.# Village/State/'Z( p�\ \ r`: c-` '\ � l c' _ t Business Name am/pm on 19,- Business Address �, 1 y} ! 'Signature of{.En-forcing Officer Village/State/Zip , , r Location (of Offense, Enforcing Dept/Division ' a ,' •F / �„cr Offense . `,.� s x Facts � `A? d 1`:= a 'r, c x..� �- r; ��✓_ ! 1µ s s n This will serve only, as a warning. +At this time no legal action has been taken. It is the go�ah'Hof Town ,age a ncies \to ;'achieve ,voluntary compliance of Town Ordinances;, Rules 'and Regulations. Ed ."achieve and warning notices are attempts , to gain voluntary compliance. Subsequent violations will result in appropriate. legal` 'action by the Town. .. .: .. .. a .. .. . .. .,.:...E . ....- - ... „-. .' cm GO �lj COMMO.'\IVEALTH OF MASSACHUSETTS j, EXECUTIVE OFFICE OF E.N NME\TAI AFF SIRS �•• = _ F DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET. BOS T ON D1A 0210E (614) 292-550o TRUDY CONE Secretan ARGEO PAUL CELLUCCI DAVID B. STR',.'HS Governor Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: 81 St . Josephs St . , '� '� �Owner S t ands ing Barnstable, Address of Owner: 3Qnth` t , S . Boston Date of Inspection: 02127 Name of Inspector:(Please Print)WM.. E . Robinson Sr . 1 am a DEP approved systerq inspector rsuant to Section 15.340 of Title 5(310 CMR 15.000) Company Name: Wm. E . Robinson 1eptic Service Mailing Address: PO Box 1.0b9, Centerville , MA 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 inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: _L Passes Conditionally Passes Needs Further Evaluation By the Local Approving Authority _ Fails Q n Inspector's Signature: Date: The System Inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within thirty (30)days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. NOTES AND COMMENTS Ake, �d RED EO AUG 2 0 1999 TOWN OF BARKTABLE i . HEALTH DEFT. revised 9/2/98 Page Iof11 `i ✓r:^red on Recgclyd Paper �r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM N PART A CERTIFICATION (continued) 'property Address:81 St . Josephs St . , Barnstable a"'ner: Chris Stand-ring Date of Inspection: INSPECTION SUMMARY: Check A, B, C, o/ D: A. ,SYSTEM PASSES: v 1 have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist. Any failure criteria not evaluated are indicated below. COMMENTS: B. YSTEM CONDITIONALLY PASSES: r �.c..--o 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. Indicat yes, no, or not determined(Y, N, or ND). Describe basis of determination in all instances. If "not determined', explain why not. The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance (attached)indicating that the tank was installed within twenty (20)years prior to the date of the inspection; or the septic tank, whether or not metal, is cracked,structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health). broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass ` inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed 41 t 1 <-y J revised 9/2/98 Page 2of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 81 St . Josephs St. , Barnstable owner: Chris S t ands ng ` Date of Inspection: p /7-1 C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: i Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 15.303(1)(b)THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER,IF ANY)DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well. _ The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. _ The system has.a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine distance (approximation not valid). 3) OTHER t revised 9/2/98 Page 3of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM `z PART A CERTIFICATION (continued) Property Address: 81 St . Josephs St,. , Barnstable ° Owner: Chris Stand-ring Date of Inspection: ,. D. SYSTEM FAILS: You must indicate either "Yes" or "No" to each of the following: I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Ye No Backup of sewage into facility-or system component due to an 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 to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped_. Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less-than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E. RGE SYSTEM FAILS: You m st indicate either "Yes" or "No" to each of the following: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater(Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone 11 of a public water supply well) T owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional o ice of the Department for further information. revised 9/2/98 Palar4ofII o- r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B ` CHECKLIST e e Property Address: 81 St . Josephs St . , Barnstable Owner: Chris S tand.r ing Date of Inspection: Check if the following have been done:You must indicate either "Yes" or "No" as to each of the following: Yes/ No Pumping information was provided by the owner, occupant, or Board of Health. None of the system components have been pumped for at least two weeks and-the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. As built plans have been obtained and examined. Note if they are not available with N/A. V _ The facility or dwelling was inspected for signs of sewage back-up. _ The system does not receive non-sanitary or industrial waste flow. _ The site was inspected for signs of breakout. �/ _ All system components, excluding the Soil Absorption System, have been located on the site. t/ _ The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. The size and location.of the Soil Absorption System on the site has been determined based on: V _ Existing information. For example, Plan at B.O.H. _ Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of,distance is unacceptable) / 115.302(3)(b)] _ The facility owner (and occupants,if different from owner) were provided with information on the proper maintanaacw.of SubSurface Disposal Systems. revised 9/2/98 Page 5of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Drop"Address: 81 St , Josephs St . , Barnstable Owner: Chris S t ands ing Date of Inspection: g17-g � FLOW CONDITIONS RESIDENTIAL: Design flow: 1 0 g.p.d./bedroom. Number of bedrooms(design):_a Number of bedrooms lactual)3 Total DESIGN flow q 90 Number of current residents: Garbage grinder(yes or no):-40 �j� Laundry(separate system) (yes or no)-AC) If yes, separate inspection required Laundry system inspected (yes or no) Seasonal use(yes or not:Ai 0 1998 81 , 000 gal. Water meter readings, if ava•able (last two year's usage (gpd): Sump Pump lyes or no): /''� 1997 64, 500 gal. Last date of occupancy: 7- j �! COMMERCIAL/INDUSTRIAL: T e of establishment: bes n flow: gpd ( Based on 15.203) Basi of design flow Grea a trap present: (yes or no!_ Indus rial Waste Holding Tank present: (yes or no)_ Non-s nitary waste discharged to the Title 5 system: (yes or no)_ Wate meter readings,if available: Last ate of occupancy: 0 R:(Describe) Las to of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: System purrfped as part of inspection: (yes or no)_ If yes, volume pumped: gallons Reason for pumping: TYPE 0 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) I/A Technology etc. Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other G APPROXIMATE AGE of all components, date installed(if known)and source of information: /t yn<"—• o Sewage odors detected when arriving at the site: (yes or no)�/0 revised 9/2/98 Page 6ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) *ropertyAddress: 81 St . Josephs St . , Barnstable , Owner: Chris S t an d.r ing Date of Inspection:, _ BUIL NG SEWER: (Local on site plan) Depth elow grade:_ Materia of construction:_cast iron_40 PVC_other(explain) Distan a from private water supply well or suction line Diam er Comm nts: (condition of joints, venting, evidence of leakage,-etc.) SEPTIC TANK:_ (locate on site plan) Depth below grade:_) — — — Material of construction: oncrete metal Fiberglass Polyethylene_other(explain) If tank is metal,list age_ Is.age confirmed by Certificate of Compliance_(Yes/No) Dimensions: Sludge depth: Distance from top of sludge to bottom of outlet tee or.baffle: G,) 3 Scum thickness: C Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom.of outlet tee or baffle: How dimensions were determined: .;omments: (recommendation for pumping, condition of inlet and outlet tees oraples, depth o liquid level in relation to outlet invert, structural integrity ) evidence of leakage, etc.) /6«--C Q t, I /. � �- 10 G J ��3 lJ ef GR SE TRAP: (locate n site plan) Depth be w grade:_ Material o construction:_concrete_metal_Fiberglass _Polyethylene_other(explain) Dimension Scum thick ess: Distance fr m top of scum to top of outlet tee or baffle: Distance f om bottom of scum to bottom of outlet tee or baffle: Date of la t pumping: Comment : (recomm ndation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) revised 9/2/98 Page 7of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM v PART C SYSTEM INFORMATION Icononued) 'roperty Address: 81 St . Josephs St . , Barnstable Owrw: Chris Stand.ring Date oflnspection: TIG T OR HOLDING TANK: (Tank must be pumped prior to, or at time of, inspection) hocat on site plan) Depth elow grade:_ Materia of construction:_concrete_metal_Fiberglass_Polyethylene_other(explain) Dime ions: Cape ity: gallons Desi n flow: gallons/day Alar present Ala level: Alarm in working order: Yes_ No De of previous pumping: Co ents: (con ition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX:V (locate on site plan) Depth of liquid level above outlet invert: Comments: (note if level and distribution is equal, evidence�of soli s carryover, evidence of leakage into or out of box, etc.) - PUMP AMBER:_ (locate n site plan) Pumps n working order: (Yes or No) Alarm in working order(Yes or No) Com ants: Ino condition of pump chamber, condition of pumps and appurtenances,etc.) revised 9/2/98 Page 8of11 = SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C ' SYSTEM INFORMATION(continued) 'rop"Address: 81 St . Josephs St . , Barnstable ' Owner: Cr1S S g Date of Inspeecdont�71T1 SOIL ABSORPTION SYSTEM(SAS):_ (locate on site plan,if possible;excavation not required, location may be approximated by non-intrusive methods) If not located, explain: Type: leaching pits, number:_ leaching chambers,number:_ leaching galleries,number:_ leaching trenches,number, length: Z� leaching fields, number, dimensions:_/ 1 :2 3 r overflow cesspool, number:_ Alternative system: Name of Technology: Comments: (note condition of soil, signs of hydraulic failure, I el of 9onding, damp soil, condition of vegetation, etc.) t r CESSPOOLS:_ (locate on site plan) . Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: )epth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater: inflow (cesspool must be pumped as part of inspection) Comments: (note conditi of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY:_ (locate on site plan) Materials of c nstruction: Dimensions: Depth of soli s: Comments: (note Condit' n of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) revised Page 9ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM , PART C SYSTEM INFORMATION,Ieontinued► 'roperty Address: 81 St'.' Josephs St . , Barnstable )wnw: Chris S t ands ing ' Jete of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) 7 i r v e sed 9/2/98 Page 10of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) ` mperty Address: 81 St . Josephs St . , Barnstable owner: Chris Standring Date of Inspection: I7^g NRCS Report name Soil Type_ Typical depth to groundwater USGS Date website visited Observation Wells checked Groundwater depth: Shallow Moderate Deep SITE EXAM Slope Surface water Check Cellar r Shallow wells Estimated Depth to Groundwater L Fe t Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record v Observed Site (Abutting property, observation hole, basement sump etc.) Determined from local conditions Checked with local Board of health Checked FEMA Maps Checked pumping records Checked local excavators, installers Used USGS Data Describe how you established th High Groundwater Elevation. (Must be completed) revised 9/2/98 Page 11of11 --------- ------ ------ Z-e5 ASSESSORS MAP :---W-zg TEST HOLE LOGS wUI �, ;qoo PARCEL : ---------- A SOIL EVALUATOR: FLOOD ZONE: IAVVL"P-7;i-� A5 )T -r�- WITNESS : Z2L�A,/,kM r��/,2E:6 REFERENCE : IlAJ 95 DATE (,J ._ -:_I -. -. O� . J' 1 }.. , 71 -, I o ,.cc lqlMl PERCOLATI 'IATE: G Z 1XIA-4 TH- 1 TH-2 ow 0�1 FLf' Lp()�,T law C) /07 LOCATION M A P qT 5, UTJ Lt7Z-q�D FT vm 0 ---------------------- TF ----------- -------- I D .{ �� - ��. y ___ _� _ � � ��o� CT 7q,o/ 7, - � __ �� - ��:: -_7 EPTI C SYSTEM DES I GN T 4 T-7>, 117,17 05:��CV E-7r -d N, FL0'3 ESTIMATE a 7/�E L, -7,5 3,BEDROOMS AT 110 GAL/DAY/BEDROOM GAL/DAY c- V 19 -F* SEPT I C TANK GAL/-&AY x 2 DAYS GAL ----------- USE GALLON SEPTIC TAN K X E: 30-1 L ABSORPTION SYSTEM 77TX XO to 23 VL IE- IN v SIDE AREA: D , ° Wu BO`TTOM AREA: ,Z�o x pp- 5EPTI C SYSTEM SECTION /, o Fa, lez 00 - - . � iag,6t � ' � 'tjL�.. �ut .l�u}T��,�j t MAX -Al-9 70 t, E 7 00 D-BOX D.0 5Lc /000 GAL ouz_-� SEPTIC TANK 7-11 ni 14 1 + 1 -Poo 3o�- 11/z" 4 19,50 &77-/&/77,E,,S SITE AND SEWAGE PLAN *61 :370,56P LOCATI ON : !ON : H5 E7122- e�LE� Miq PREPARED FOR Ba5 7 Z �A SCALE. DAVID B . MASON 'R5 DATE DBC ENVIRONMENTAL DESIGNS DATE HEALTH AGENT EAST SANDWICH . MA ( 508 ) 833- 2177 Toq D-BOX T -