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HomeMy WebLinkAbout0354 BEARSE'S WAY - Health 356"-BEARSE'S WAY Hyannis - - - A = 292=01770.01 ;. l' 1: � 3 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENT FAIIf' DEPARTMENT OF ENVIRONMENTAL /yEQ yi ONE WINTER STREET,BOSTON MA 02108 (617)2 2 00 PA '00f 199,;�, WII,LIAM F.WELD Y COXE Governor l Secretary ARGEO PAUL CELLUCCI B 4 B. STRUHS Lt. Governor Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: G 4-Address of Owner: "t—'o-- Date of Inspection: I 1 b\'Al (if different) Name of Inspector: S.yA'Em��� MA , CG7Jot0 y Company Name, Address and Telephone Number: 1A+1{.,r-jty i 1 L��vvt�2�rvvro..v�sz•r�t.._,��-3Q�'1 I�Y`'�1�Y.��, (gyp-. c'1't.l��-i�1 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: X Passes _ Conditionally Passes _ Needs Further Evaluation By the Local Approving Authority _ Fails Inspector's Signature. x,,.�,-�4Z Date: 4 X y Vk—% The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (30) days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. INSPECTION SUMMARY: Check A, B, C, or D: A] SYSTEM PASSES: I have not found any information which indicateXatsystem violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated B] SYSTEM CONDITIONALLY PASSES: One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair, passes inspection. Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain why not. The septic tank is metal, cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 11/03/95) A t� Printed on Recyded Paper `.SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A 0 CERTIFICATION (continued) Prop rty Address `yz�� i Owner Date-of,\Inspectioii '6.1NV � ' B] SYSTEM>CON DITIONALL,Y P SSES (continued) _ ,4a•�.•Sewage'ba" ckup or breakout or high static water level observed in the distributi n box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system II 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 b oken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of'Health/Hea broken pipe(s) are replaced obstruction is removed C] FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HE Conditions exist which require further evaluation by the Border to determine if the system is failing to protect the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAF AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of a surfac water Cesspool or privy is within 50 feet of a borrdd ring vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER HAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: I The system has a septic tank and so' absorption system and is within 100 feet to a surface water supply or tributary to a surface water supply. The system-has a septic tank and oil absorption system and is within a Zone I of a public water supply well. _ The system has a septic tank an soil absorption system and is within 50 feet of a private water supply well. _ The system has a septic tank aWd soil absorption system and is less than 100 feet but 50 feet or more from a private water supply well, unless a well wrier analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from tha(facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 PPm• ,. 3) OTHER (revised 11/03/95) 2 1» SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Owner: Date of Inspection: D] SYSTEM FAILS: I have determined that the system violates one or more of the following failure criteria as fined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to d termine what will be necessary to correct the failure. Backup of sewage into facility or system component due to a/volume logged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground due to an overloaded or clogged SAS or cesspool. Static liquid level in the distribution box above outlet invert ded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6" below invert or availss 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 rivy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 fee of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zo e I of a public well. Any portion of a cesspool or privy is within 5, feet of a private water supply well. Any portion of a cesspool or privy is less t an 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the ell has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic comp unds, ammonia nitrogen and nitrate nitrogen. E] LARGE SYSTEM FAILS: 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 env*ionment because one or more of the following conditions exist: the system is within 4 0 feet of a surface drinking water supply the system is withi/00 feet of a tributary to a surface drinking water supply the system is local d in a nitrogen sensitive area (Interim Wellhead Protection Area (IWPA) or a mapped Zone II of a public water supply well) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 11/03/95) 3 r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 35kA Owner: 'O x Date of Inspection: `.` to Vvl Check if the following have been done: Pumping information was requested of the owner, occupant, and Board of Health. None of the system components have been pumped for at least two weeks and the system has been receiving normal Flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. (J �As built plans have'been obtained and examined. Note if they are not available with N/A. 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. 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 existing information or approximated by non-intrusive methods. he facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of Sub- urface Disposal System. i (revised 11/03/95) 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 3Sy s� 3S(o P�av sus c+ao� Owner: W Date of Inspection: 'FLOW CONDITIONS RESIDENTIAL: Design flow: !ALko allons Number of bedrooms: Number of current residents:: Garbage grinder(yes or no):_UD Laundry connected to system (yes or no):-�Ap�. Seasonal use (yes or no):I Water meter readings, if available: tilN Last date of occupancy: �� COMMERCIAUI N D USTRIAL: Type of establishment: Design flow: gallons/day Grease trap present: (yes or no)_ Industrial Waste Holding Tank present: (yes or no)_ Non-sanitary waste discharged to the Title 5 system: (yes or no)_ Water meter readings, if available: Last date of occupancy: OTHER: (Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: S,�S��vr� tvteds �tY1�D�t�iA System pumped as part of inspection: (yes or no)_ If yes, volume pumped: ¢allons 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) Other(explain) APPROXIMATE AGE of all components, date installed (if known) and source of information: Sewage odors detected when arriving at the site: (yes or no) tiC� (revised 11/03/95) 5 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: Lk.)%Ncq_ Date of Inspection: SEPTIC TANK:�, S (locate on site plan) Depth below grade: L T�4P1a' Material of construction: Y,concrete _metal _FRP —other(explain) Dimensions: ILX-O M.\ Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) T¢v�-,_r��s :�r�p T<< ' t►��ac�— (),o prv, c-4C- any%lck "Q P+ I k Lei(�— rk:Ti a-� �4 c,�.r.1�. �e� �]C4 IV C_ „I c Q - S— ' isc�At'2 GREASE TRAP:_ (locate on site plan) Depth below grade: Material of construction: _concrete _metal _FRP —other(explain) Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) (revised 11/03/95) 6 I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 3 Sti S5l0 Owner: Date of Inspection: t 1 Lam`5 SOIL ABSORPTION SYSTEM (SAS):4e,!) (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: Type: 1 leaching pits, number: a 1 toxto P� leaching chambers, numbed:_ leaching galleries, number: leaching trenches, number,length: leaching fields, number, dimensions: overflow cesspool, number: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,etc.) x -4-11 S WWI S 0 — h CESSPOOLS: (locate on site,plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer. Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater: inflow (cesspool must be pumped as part of inspection) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY:20 (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) (revised 11/03/95) 8 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: SS-\ 3-31., Owner: Date of Inspection: TIGHT OR HOLDING TANK: JO (locate on site plan) Depth below grade: Material of construction: _concrete _metal _FRP —other(explain) Dimensions: Capacity: Gallons Design flow: Gallons/day Alarm level: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX:-.*Z.s (locate on site plan) Depth of liquid level above outlet invert: Comments: (note if level and distribution is equal, evidence of solids car over, evidence of leakage into or out of box, etc.) c, .1.1J .�b�.3 t cr, . a.o�,�� S �U t w ik3 f ,._, CA- PUMP CHAMBER:+) (locate on site plan) Pumps in working order:(yes or no) Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) (revised 11/03/95) 7 I' f. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 3Sy �l 35(n g� cts Owner: 4.:1 kovc, .__ Date of Inspection: t SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' ' 3g4 3S l� P63- ��� Sy y IA 5- 5 DEPTH TO GROUNDWATER - Depth to groundwater: ',LO feet method of determination or approximation: U.5. `O �L y (revised 11/03/95) 9 TOWN OF BARNSTABLE a 94 _ �' • LOCATION SEWAGE # '1 3 q VILLAGE�greas �\`Q, ASSESSOR'S MAP 6t LOT*A?A - loTll/7-� INSTALLER'S NAME & PHONE NO.e4--.Aow \ •��C -\LS F SEPTIC TANK CAPACITY /a,50 r LEACHING'•FACILITY:(type) (size) NO. OF BEDROOMS 4 ; "',-PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER o ra►O �`eZ 1 rO tJ DATE PERMIT ISSUED: ® o� D DATE .COMPLIANCE ISSUED: �/ /7 VARIANCE GRANTED: Yes No X I kv M 8 No ...... ....... ............._............ THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH ..'�. ...........o rig.... S..... .........................................................•- Appliratinn for Dispusal Workii C>znnstrurtiun ramit Application is hsyeby made for a Permit to Construct ( ) or Repair (X an Individual Sewage Disposal System at: 0 - = ---------- -...... ------------- Location-.Address S� � or Lot No. o A ..... .......V................. ....................................................................... ... ......... Owner Addres`(� Installer Address 7 Type of Building , Size Lot............................Sq. feet �. Dwelling—No. of Bedrooms................:...........................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) G4 Other fixtures --------------------------••-.. . . W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity.............gallons Length................ Width................ Diameter................ Depth...:............ x Disposal Trench—No. .....................Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area...................sq. ft.- Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date........................................ a Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth-to ground water_-_-_----____-__---__-_. (14 Test Pit No. .2................minutes per inch Depth of Test Pit.................... Depth to ground water----------_............. Ix •--•----•-•------------ -------------------•----------------------....................-•-------...-•-•--------------•--•-------.......................... ODescription of Soil.............. � '' -----.....•--•---•-----•------•---------------------------------•-•---------••---------------------------•------------- x U -----------------------•-•--------•--••••-•-------......----•--•--..._..---------------•-••-•-•-••-----•••••-•--------- ------------------------•--- ....._..-----------•--------------•------•-----•-.....----•----------••----•-------•---•-------•--:--------•--•--------•---------------•------••--•--•-----•--•--- V Nature of Repairs or-Alterations—Answer wh applicable,_... .'5 ���___.___�......... .. . ....�4�� Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of'TT p of the State Sanitary Code— The undersigned fur r agrees not to place the system in operation until a Certificate of Compliance ha en issued by the�oarXo,,hf ea h7- SSig: ...�."a....._� '.. r•---....�. Application Approved By-•-•-•-- •-•-•---- e - Date Application Disapproved for the following re ons:---••--•-••••...-•--•-••--......••••-•-•-••---••••••••-••••---••••----•--------••-•••.........................- --•-••-•-•••-•••-•••-••--•----•••----••-••-•---••-•-••-••-----•---•---•----•--••--•..._..-•-•••----•...--.•-••-•••--•-•---•••----••••----••-•-----•-••-•••-••••••••••••••••----•-----••-•••-•••••-•-..... Date i Permit No.----.U�Q...6............. � .-••-••----•--- Issued_........!`�...Z7 b ,` ........................ Date Fizic THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH . `�....................0 .. �J.S......1............................................................ Appliration for Disposal Works Tontntrtion Famit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at C G`r ��S ........... ......... -- -......a2 a !..... r .--- - ............. __..._.._ o ZLoAddress or Lot no. �.. _._ . ............ ..Z... ©to.............. ...........S.5�...`�:e_ .:r:._ ......_._. .4:.. Owner � ( Address �.- .- - -- •• ................. • ...... t Installer Address Type of Building Size Lot..............:.............Sq. feet U Dwelling—No. of Bedrooms...........................................Expansion Attic ( ) Garbage Grinder ( ) PL4Other—T e of Building No. of persons............................ Showers — Cafeteria Q' Other fixtures .----•-----------------•-------. . W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid'capacity.._.........gallons Length................ Width................ Diameter---------------- Depth................ x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water......................... 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ W - - ODescription of Soil........�-�.`- ...\••�-•----•----•-------------------------------------------------------------- --- ----•-------.---- --............... x W x ---•---• -------------------•--••-----------•---•-------------•••--•----------------------•-•......----• -•--•••--•-•--•--•••••--•-••-•-•--••-••--••---•---•------•••••- U N ture of Repairs or Alterations—Answer when applicable__ firs_ _.) ....._.� _S_°.............r�i��.� 1................�•�•x•••-•---••� d 5. 4�-...�................!:7:A......... `6 - Agreement: The undersigned agrees to install)the aforedescribed Individual Sewage Disposal System in accordance with the provisions of T TT s� p 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance ha e n issued by the board of health. Signe `-�- \ a? 1 ...�f Date t Application Approved B kCi 1. �._..•.•................... .................."-2� PP PP Y --- ---- Date Application Disapproved for the following re ons:--•---••---•••--...•--•-••-•••--•••••--•-•-•-•-•----•-••••-•-••••-•-----••••••-•--•---••-----•-•--•---•---•---- ........-••-•-•--•-•.................••-•••••-••••-•••--•----•---•-••--••......••........--•--•••--•-•---••-•-•••-----•-••--••---•-•-------•-••. ..... Date Permit No..... L.:. ja:a.L: --------...-•-- Issued. `'--z Date THE COMMONWEALTH OF MASSACHUSETTS �j�� BOARD OF HEALTH VI�...................OF..............�.��..N 5............................................. Qrrtif iratr of f91intph atta TFj,�S IS TQ CERT FY,T at the Individual Sewage Disposal System constructed ( ) or Repaired ( ) (. by - ' ' .............. ,...... Installer has been installed in accordance with the provisiol s f TTT11Z 5( The State Sanitary Code as described in the application for Disposal Works Construction Permit No. .(,:__1--�- 3-1�--------------- dated...... Z..7- -_Y�.__..._.. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED.AS A GUARANTEE THAT YHE SYSTEM-WILL F , 10� S I•SFACTORY. DATE................ ......................................... Inspector.................................................................................... THE COMMONWEALTH OF MASSACHUSETTS /I BOARD OF HEALTH �.,� r' , .lv S t ._ ( � 3 U OF......................................................... ........................ ""� NO. ..�2 •............ FEE...........v:..w Dispati al orkn_r TDonstrnrtion rrntit Permission is hereby granted---.• ------ Cj-f�.k..•---------------•-••----..._.......--------•--------.........---•--....-•-•--- to Construct ) or Repair ( ) an I dividual Sewn q Disposal System' at . •-- Street �,b _?1' as shown on the application for Disposal Wor s onstruction Permit No..............`....Dated.......................................... W L ` DATE...... .. Boar of Health FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS