HomeMy WebLinkAbout0222 BISHOPS TERRACE - Health 222 Bishops Terrace-_
Hyannis P
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TOWN OF BARNSTABLE
LOCATION S��S,�S•7�— (lC V- SEWAGE #
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VILLAGE_, _ �,�I / / �A>SSESS R'S MAP
& LOT
NAME&PHONE NO. c�
M
C TANK CAPACITY
HING FACILITY: (type) 1'i (size) 1600 !i G 1
NO. BEDROOMS ®2
BUILDER O ✓/.mr1 s ��'bC,y.�
PERMITDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and 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 3 t__o__fffl--eaching fa�'ity) Feet
Furnished by�«��TCJ1a
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No. 6 l Fee OG
THE COMMONWEALTH OF MASSACHUSETTS Entered in co uteri
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS es
4plication for Misposal 6pstem Construction Permit
Application for a Permit to Construct( ) Repair& Upgrade( ) Abandon( ) ❑Complete System [Individual Components
Location Address or Lot No. asZ a i$140PS "Ct�Cl� Owner's Name,Address,and Tel.No.
Assessor's Map/Parcel �� ( I �4A5 I�1���b 7b� «��, ` 1
Installer's Name,Address,and Tel.to. 502-4 7'1 $11-1 Designer's Name,Address,and Tel.No.
CAPEW1b6: &PT60"&S uC
/A
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) gpd Design flow provided gpd
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable)
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 Certificate of
Compliance has been issued by this Board of Hea
Si ned Date 6—�-3—X0I
Application Approved by Date ?��S
Application Disapproved by Date
for the following reasons
Permit No. 2�( S M Date Issued
. . A
No. U t Fee (�L�
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
application for Disposal'16pstrm (Construction VPrmit
Application for a Permit to Construct( ) Repair(�k Upgrade( ) Abandon( ) ❑Complete System [kindividual Components
Location Address or Lot No. ;[;L z al S 14OPS' —rgRM4J5L Owner's Name,Address,and Tel.No.
NYC+ S lZt c gait A A. 3 W od soak, 4�Raue)N
Assessor's Map/Parcel ( 1 Z rt AIJW 1
Installer's Name,Address,and Tel.Iko. Designer's Name,Address,and Tel.No.
C'APGWlb6:r 6NTQ2PQiS6S l.t.G
15 3 CQW0AkW,I A4- tA!%A9 64 P ft-< /A
Type of Building:
Dwelling No.of Bedrooms Lot Size • sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) gpd Design flow provided gpd
Plan Date Number of sheets Revision Date
Title
lip
Size of Septic Tank Type of S.A.S.
i
Description of Soil
s
r 2`
Nature of Repairs or Alterations(Answer when applicable)
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 riot to place the system in operation until a Certificate of
Compliance has been issued by this Board of Healt .
Si ned ( Date —2'3 ;L0I
Application Approved by dl '16 Date / 2'7_ /C
Application Disapproved by Date
for the following reasons
Permit No. 2 r) ( T _ M 7 Date Issued & - a 1 r (J-
---------------------------------------------------------------------------------------------------------------------------------------
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE,MASSACHUSETTS
U_ Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(Y) Upgraded( )
Abandoned( )by c /Ap u_nbL E&�rmjst (P/ LC
at CI XI I S Gt-OP S_ has been constructed in accordance
T� t
with the provisions of Title 5 and the for Disposal System Construction Permit No.>1jr—d'1 t/ dated 3^ f
Installer `#4 GL� Designer M,1A
#bedrooms , Approved desyggflofj ���� gpd
The issuance of his permit shall not be construed as a guarantee that the system wi� function as designed.
Inspector (
No. a( Fee
r(� )v
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS
Misposal *pstem Construction VPrmit
Permission is hereby granted to Construct( ) Repair(X) Upgrade( ) Abandon( )
System located at R;I a �/�a„��(C
and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with
Title 5 and the following local provisions or special conditions.
Provided:Const ctio must be completed within three years of the date of this permit.
Date �n "2 3 Approved by f 4,.
AsBuilt Page 1 of 1
L TOWN OF BARNSTABLE
LOCATION , �+LS/Xr1�LS T�"�CeC SEWAGE#�_
i
VILLAGE n� ASSESS 'S MAP&LOT
asp J� Taro? �d-e S
NAME&PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) 1 i OL (size) 16100 qG
NO,OF BEDROOMS
BUILDER OR�OWN`ER"l s ✓tDPy�
PERMTTDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and 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 309A t ofleachn f ty) Feet
Furnished b} - 2C, zy14�y�
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http://issgl2/intranet/propdata/prebuilt.aspx?mappar=251171&seq=1 6/23/2015
5 "(°v` �� �I M — 2�I
°. �� RECEIVED I ? -
TROY WILLIAMS 13
SEPTIC INSPECTIONS OCT 1 12003
Certified by MA Department of Environmental Protection HEALTH DEPT. (508) 385-1300
19 Hummel Drive
South Dennis, MA 02660
-\ COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE, OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
,J
TITLE 5
OFFICIAL INSPECTION FORM— NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 222 Bishops Terrace
Hyannis,MA
Owner's Name: Kathleen Rita Lonergan V
Owner's Address: 32 Thames Street v
Springfield,MA 01104 O
Date of Inspection: October 8,2003
Name of Inspector: . Troy M.Williams
Company Name: Troy Williams Septic Inspections
Mailing Address: 19 Hummel Drive
South Dennis,MA 02660
Telephone Number: (508)385-1300
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my
training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system-
✓ Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: Date: 10 /d f o -3
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of I leatth or
DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000
gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the
DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving
authority.
Notes and Comments
Although system meets the minimum requirements set forth by the Massachusetts Department of
Environmental Protection,certification is not to be construed as a guarantee of future working condition
of system,piping or components. This Inspection represents the conditions of the system on the Date of
Inspection noted above.
""This report only describes conditions at the time of inspection and under the conditions of use at that
time.i his inspection does not address how the system will perform in the future under the saute or different
conditions of use.
Title 5 Inspection Form 6/15/2000 page 1 of
Page 2 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:
222 Bishops Terrace
Owner: Hyannis,MA
Date of Inspection: Kathleen Rita Lonergan
October 8,2003
inspection Summary: Check A,B,C,D or E/&LWAYN 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:
B.. System Conditionally Passes:
One or more system components as described in the"Conditional Pass"section need to be re ced or
repaired.The system,upon completion of the replacement or repair,as approved by the Board of alth,will pass.
Answer yes.no or not determined(Y,N,ND)in the for the folloZentf' of determined"please
explain.The septic tank is metal and over 20 years old• or the septic ta or not)is structurally
unsound,exhibits substantial infiltration or exfiltration or tank failureem will pass inspection if the
existing tank is replaced with a complying septic tank:as approved bylth.
•A metal septic tank will pass inspection if it is structurally sound, t leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
Observation of sewage backup or break o or high static water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken,settled uneven distribution box.System will pass inspection if(with
approval of Board of Health): ,
b en pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
The sys . required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will
pass inspec ' n if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain:
2
Page 3 of 11
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address:
Owner:
222 Bishops Terrace
Hyannis,MADate of Inspection: Kathleen Rita Lonergan
C. Further Evaluation is Aequired3by the Board of Health:
Conditions exist which require further evaluation by the Board of Health in order to determine if the system
is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)th t the
system is not functioning in a manner which will protect public health,safety and the environ ent:
— Cesspool or privy is within 50 feet of a surface water
_ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health(and Public Water S lier,if any)determines that the
system is functioning in a manner that protects the public health fety and environment:
The system has a septic tank and soil absorption syst (SAS)and,the SAS is within 100 feet of
surface water supply or tributary to a surface water su y.
_ The system has a septic tank and SAS an e SAS is within a Zone 1 of a public water supply.
— The system has a septic tank and S and the SAS is within 50 feet of a private water supply well.
The system has a septic tan nd SAS and the SAS is less than 100 feet but 50 feet or more front a
private water supply well**. thod used to determine distance
"This system passes ' e well water analysis,performed at a DEP certified laboratory, for colifotm
bacteria and volat organic compounds indicates that the well is free from pollution from that facility and
the presence o monia nitrogen and nitrate nitrogen is equal to or less than 5 ppm.provided that no other
failure crit a are triggered.A copy of the analysis must be attached to this form.
3. Other:
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Page 4 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 222 Bishops Terrace
Hyannis,MA
Owner: Kathleen Rita Lonergan
Date of Inspection: October 8,2003
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 in overloaded or
clogged SAS or cesspool
N/q 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
-Z Required pumping more than 4 times in the last year V-ndue to clogged or obstructed pipe(s).Number
of times pumped
Any portion of the SAS,cesspool or privy is below high ground water elevation.
— Adj Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
— Nl-i Any portion of a cesspool or privy is within a Zone I of a public well.
— 6�U Any portion of a cesspool or privy is within 50 feet of a private water supply well.
— &L,,4 Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from aprivate water
supply well with no acceptable water quality analysis. (This system passes if the well water analysis,
performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds
Indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria
are triggered. A copy of the analysis must be attached to this form.)
o (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as
described in 310 CMR 15.303. therefore.the system fails. The system owner should contact the Board of
Health to determine what will be necessary to correct the failure.
E. Large Systems:
To be considered a large system the system must serve a facility with a design fl of 10,000 gpd to 15,000
gpd•
You must indicate either"yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria a e)
yes no
the system is within 400 feet of a surface drinking w r supply
the system is within 200 feet of a tributary to surface drinking water supply
the system is located in a nitrogen s rtive area(Interim Wellhead Protection Area-1 WPA)or a mapped
Zone 11 of a public water supply ell
If you have answered"yes"to any estion in Section E the system is considered a significant threat,or answered
"yes"in Section D above the 1 e system has failed.The owner or operator of any large system considered a
significant threat under Sec ' n E or failed under Section D shall upgrade the system in accordance with 310 CMR
15.304.The system o should contact the appropriate regional office of the Department.
4
' 'Page 5 of I l
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address:
222 Bishops Terrace
Owner: Hyannis,MA
Date of inspection: Kathleen Rita Lonergan
October 8,2003
Check if the following have been done.You must indicate"yes"or"no"as to each of the followine:
Yes No
✓ _ (`-;aping information was provided by the owner. occupant,or Board of I iealth
✓ Were any of the system components pumped out in the previous two weeks?
✓ Has the system received normal flows in the previous two week period?
✓ Have large volumes of water been introduced to the system recently or as part of this inspection?
_ V/q Were as built plans of the system obtained and examined?(If they were not available note as N/A)
✓ — Was the facility or dwelling inspected for signs of sewage back up
✓ _ Was the site inspected for signs of break out?
— Were all system components,excluding the SAS, located on site'?
✓ _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition
of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum?
_✓ _ Was the facility owner(and occupants if different from owner)provided with information on the proper
maintenance of subsurface sewage disposal systems'?
The size and location of the Soil Absorption System(SAS)on.the site has been determined based on:
Yes no
Vol — Existing information. For example,a plan at the Board of Health.
— Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance
is unacceptable)(310 CMR 15.302(3)(b))
1
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Page 6 of 1
OFFICIAL INSPECTION.FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address:
222 Bishops Terrace
Owner: Hyannis,MA
Date of inspection: Kathleen Rita Lonergan
October k,2003 FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): Z Number of bedrooms(actual): 2
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x k of bedrooms): o
Number of current residents: O
Does residence have a garbage grinder(yes or no): N6
Is laundn on a separate sewage system (yes or no):e!!u (if yeS separate inspection'required)
Laundry system inspected(yes or no): ,vpi
Seasonal use:(yes or no): Yc's
Water meter readings,if available(last 2 years usage(gpd)): u 2-
Sump pump(yes or no): No
Last date of occupancy: H b,>, p7 Oj
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): gpd
Basis of design flow(seats/persons/sgf'etc.'
Grease trap present(yes or no):_
Industrial waste holding tank present(yes or no):_
Non-sanitary waste discharged to the Title 5 syste yes or no):
Water meter readings, if available:
Last date of occupancy/use: -
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information:
Was system pumped as pan of the inspection(yes or no): a
If yes, volume pumped: gallons-- How was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM
✓Septic tank,di5eribulic n W*,soil absorption system
_Single cesspool
_Overflow cesspool
—Privy
_Shared system(yes or no)(if yes,attach previous inspection records,if any)
_Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be
obtained from system owner)
_Tight tank _Attach a copy of the DEP approval
_Other(describe):.
A proximate age of all components.date installed(if known)and source of information:
4 14 14 a
Were sewage odors detected when arriving at the site(yes or no):,Va
6 "4 r
a`
-Page 7 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
222 Bishops Terrace
Owner: Hyannis,MA
Date of Inspection: Kathleen Rita Lonergan
October 8,2003
BUILDING SEWER(locate on site plan) .
Depth below grade: /8"f-
Materials of construction: Zcast iron _40 PVC ✓other(explain):
Distance iron;private water supply well or suction line: ivil ---7
Comments(on condition of joints,venting,evidence of leakage,etc.):
Q A[O 4"t. VL+�n .t 7jJ✓ �J r's"
w 3
�• �oloc.k- �s �.�.,.� oft,<..
SEPTIC TANK: ✓ (locate on site plan)
Depth below grade: /y'
Material of construction:concrete_metal fiberglass-_ Polyethylene
_other(explain) —
If tank is metal list age:— Is age confirmed by a Certificate of Compliance(yes or no):—(attach a copy of
certificate)
Dimensions: S''k 9 x G ' io0 C' ,it.
Sludge depth: Y�`
Distance from top of sludge to bottom of outlet tee or baffle: a2 'S
Scum thickness: Alp Iviz
Distance from top of scum to top of outlet tee or baffle: No S c
Distance from bottom of scum to bottom of outlet tee or baffle: .vo c,'J
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.):
�Ant-rfi=Lt l t1 .�alc..� h �n/a1.v._f1r A,.5/
G r w....�y!r rJ ti) %-D v+� �G ti �✓c..S rn o �- !h n .t J 7 J2 Let T G�
GREASE TRAP:_(locate on site plan)
Depth below grade:—
Material of construction:_concrete_metal_fiberglass_�olye lene_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 baffle:
Date of last pumping:
Comments(on pumping recommendations,in and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of le e,etc:):
Page 8 of I I
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
222 Bishops Terrace
Owner: Hyannis,MA
Date of Inspection: Kathleen Rita Lonergan
October 8,2003
TIGHT or HOLDING TANK: (tank must be pumped at time of ins ction)(locate on site plan)
Depth below grade:
Material of construction: concrete metal fiberglas _polyethylene other(explain):
Dimensions:
Capacity: gallons
Design Flo%%: gallons/day
Alarm present(yes or no):
Alarm level: Alarm in working o er(yes or no):
Date of last pumping:
Comments(condition of alarm and at switches,etc.):
DISTRIBUTION BOX: (if present must be opened)(locate site plan)
Depth of liquid level above outlet invert:
Comments(note if box is level and distribution to outl equal,any evidence of solids carrygver. any evidence of
leakage into or out of box,etc.):
PUMP CHAMBER: (locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no):
Comments(note condition of pump chamber,conditio pumps and appurtenances,etc.):
'Page 9 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM-INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
222 Bishops Terrace
Owner: Hyannis,MA
Date of Inspection: Kathleen Rita Lonergan
October 8,2003
SOIL ABSORPTION SYSTEM(SAS):Z(locate on site plan,excavation not required)
If SAS not located explain why:.
Type
leaching pits,number: I - s 6 ' L »mil FN;4. .l ' Ste►, .
leaching chambers,number:
leaching galleries,number:
leaching trenches,number, length:
leaching fields,number,dimensions:
overflow cesspool,number:
innovative/alternative system Type/name of technology:
Comments(note condition of soil,signs of hy
draulic ydraultc failure, level of ponding,damp soil,condition of vegetation,
etc.):
ON
' ICE Lt .�. ;� �,,.y .�ti� d►,- U�.y+ss�-cc,h'o�.,
CESSPOOLS: (cesspool must be pumped as pan of inspection) cate on site plan)
Number and configuration: _
Depth—top of liquid to inlet invert:
Depth of solids layer: _
Depth of scum layer:_
Dimensions of cesspool:
Materials of construction:
Indication of groundwater inflow(yes or
Comments(note condition of soil,si 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 hydrau;f ' re,level of ponding,condition of vegetation,etc.):
11
9
Page 10 of I I
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 222 Bishops Terrace
Hyannis,MA
Owner: Kathleen Rita Lonergan
Date of Inspection: October 8,2003
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.
2. I
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2 S'r 2y
32 ,
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'Page 11 of 1 l
OFFICIAL INSPECTION FORM— NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
222 Bishops Terrace
Owner: Hyannis,MA
Date of Inspection: Kathleen Rita Lonergan
SITE EXAM
October 8,2003
'
Slope
Surface water
Check cellar ✓
Shallow wells
Estimated depth to ground water,32. 3'feet
--- Adjusted high ground walcr elevation j9.s'feet
Please indicate(check)all methods used to determine the high ground %%ater elevation:
Obtained from system design plans on record- If checked,date of design plan reviewed:
Observed site(abutting property/observation hole within 150 feet of SAS) --
Checked with local Board of I lealth-explain:
Checked with local excavators, installers-(attach documentation)
Accessed USGS database-explain: /A,...�z y 7_2 a.4 y 3
You must describe how you established the high ground water elevation:
y / �- ✓ h .lit:l :F I"
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. ygy
This report has been prepared and the system inspected as of the date of inspection. This report'is not a
warranty or guarantee that the system will function properly In the future. There have been no warranties or
guarantees,either expressed,written or implied, relating to the system,the inspection and/or this report.
11
BORTOLOTTI CONSTRUCTION, INC. v�
4! SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
Address Propj
CEIVEO '�
Date of Inspec) Map Parce Owner JULores bra ;3 199" "
CHECK IF THE FOLLOWING HAVE BEEN DONE: PART A — CHECKLIST Co�
PUMPING INFORMATION WAS REQUESTED OF THE OWNER,OCCUPANT,AND BOARD OF HEALTH. g
NONE OF THE SYSTEM COMPONENTS HAVE BEEN PUMPED FOR AT LEAST TWO WEEKS AND THE SYSTEM HAS B g
RECEIVING NORMAL FLOW RATES DURING THAT PERIOD. LARGE COLUMES OF WATER HAVE NOT BEEN INTRODUCED INTO
THE SYSTEM RECENTLY OR AS PART OF THIS INSPECTION.
v 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 SITE WAS INSPECTED FOR SIGNS OF BREAKOUT.
ALL SYSTEM COMPONENTS,EXCLUDING THE SAS,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 SAS ON THE SITE HAS BEEN DETERMINED BASED ON EXISTING INFORMATION OR
APPROXIMATED BY NON—INTRUSIVE METHODS.
THE FACILITYOWNER(AND OCCUPANTS,IF DIFFERENT FROM OWNER)WERE PROVIDED WITH INFORMATION ON THE PROPER
MAINTENANCE OF SSDS.
PART B — SYSTEM INFORMATION
RESIDENTIAL FLOW CONDITIONS
�0 No of Bedrooms �� No of Current Residents Garbage Grinder
/y(/ Laundry Connected to System wl' ; easonal Use
NON RESIDENTIAL: V
Calculated flow
WATER METER READINGS,IF AVAILABLE:
P mping Records and Source of Information: GALLONS
OWr�er- 6 -Z
SYSTEM PUMPED AS PART OF INSPECTION? Q IF YES,VOLUME PUMPED = GALS
Reason for Pumping:
TYPE OF SYSTEM:
Septic tank/distribution box/soil absorption system
Single Cesspool Overflow Cesspool Privy
Shared system If yes, attach previous inspection records, if any)
Other(explain) j��7��� V_— "�'4e
Appr ximate age of all components. Date installed,if known. Source of information.
rs
SEWAGE ODORS DETECTED WHEN ARRIVING AT THE SITE?
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B — SYSTEM INFORMATION (Continued)
SE7bbelow
TANK:
Dept grade: !� Dimensions: ,
Material of construction: 4.1-1'Concrets Metal FRP Other}
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:
zS
.-Z
dc
DISTRIBUTION BOX: DEPTH OF LIQUID LEVEL ABOVE OUTLET INVERT
Comments:
PUMP CHAMBER: Pum sin workin order?
Comments:
SOIL ABSORPTION SYSTEM SAS
IF NOT PRESENT,EXPLAIN:
TYPE:, D Q GJ�
Comments:
7 7 L
r a a
CESSPOOLS: Number and configuration
Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer
Dimension of cesspool Materials of construction
Indication of groundwater inflow(cesspool must be pumped)
Comments:
PRIVY:
Materials of construction
Dimensions Depth of solids
Comments:
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B — SYSTEM INFORMATION (Continued)
SKETCH OF SEWAGE DISPOSAL SYSTEM:
INCLUDE TIES TO AT LEAST TWO PERMANENT REFERENCES,LANDMARKS OR BENCHMARKS.
LOCATE ALL WELLS WITHIN 100'
To t)l
DEPTH TO GROUNDWATER: DEPTH TO GROUNDWATER
METHOD OF DETERMINATION OR APPROXIMATION:
oe
r
Ge
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C — FAILURE CRITERIA
(Indicate Y—yes N—no ND—not determined.Describe basis of determination.If"not determined",explain why not)
_/I/ Backup of Sewage into Facility?
Discharge or ponding of effluent to the surface of the ground or surface waters?
Static liquid level in the districution box above outlet invert?
AIIA Liquid depth in cesspool, 6"below invert or available volume, 1/2 day flow?
_ V Required pumping 4 times or more in the last year? Number of times pumped
Septic tank is metal?cracked?structurally unsound?substantial infiltration?substantial exfiftration?
! tank failure imminent?
! Is any portion of the SAS,cesspool or privy, below the high groundwater elevation?
— / Within 50 feet of a surface water?
i
Within 100 feet of a surface water supply or tributary to a surface water supply?
Within a Zone I of a public well?
/1 Within 50 feet of a private water supply well?
Within 50 feet of a bordering vegetated wetland or salt marsh (cesspools&privies only, not the SAS)?
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
col'Iform bacteria,volatile organic compounds,amonia nitrogen and nitrate nitrogen.
I
PART D — CERTIFICATION !
I
INSPECTOR: ROBERT J. BORTOLOTTI ADDRESS: 765 WAKEBY ROAD, MARSTONS MILLS it
COMPANY: BORTOLOTTI CONSTRUCTION INC. MA 02648 (508) 771-9399
CERTIFICATION STATEMENT
I
!!I CERTIFY THAT I HAVE PERSONALLY INSPECTED THE SEWAGE DISPOSAL SYSTEM AT THIS ADDRESS AND THAT THE INFORMATION
REPORTED IS TRUE,ACCURATE AND COMPLETE AS OF THE TIME OF INSPECTION. THE INSPECTION WAS PERFORMED AND ANY
RECOMMENDATION REGARDING UPGRADE,MAINTENANCE AND REPAIR ARE CONSISTENT WITH MY TRAINING AND EXPERIENCE
IN THE PROPER FUNCTION AND MAINTENANCE OF ON—SfrE SEWAGE DISPOSAL SYSTEMS.
�i
'i CHECK ONE:
1 HAVE NOT FOUND ANY INFORMATION WHICH INDICATES THAT THE SYSTEM FAILS TO ADEQUATELY PROTECT PUBLIC j
HEALTH OR THE ENVIRONMENT AS DEFINED IN 310 CMF 15.303. ANY FAILURE CRITERIA NOT EVALUATED ARE AS
STATED IN THE"FAILURE CRITERIA"SECTION OF THIS FORM.
I HAVE DETERMINED THAT THE SYSTEM FAILS TO PROTECT PUBLIC HEALTH AND THE ENVIRONMENT AS DEFINED IN
310 CMR 15.303. THE BASIS FOR THIS DETERMINATION IS PROVIDED IN THE"FAILURE CRITERIA"SECTION OF THIS
FORM.
'i
INSPECTOR'S SIGNATURE:
—72
DATE:
I ORIGINAL TO SYSTEM OWNER,COPIES:BUYER(if applicable),APPROVING AUTHORITY
it
No2.7�2----- Fps : ............_
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
!`i I l .....oF...........
- r� 1 .....................
2Sl .fit li.ration for 1 usal f
�� � urks Tonstrurtion Prrutit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
, v 1� � �...............s. :� c 1� .0....... C .-••-----...-•-•-............__......--••----•...........--•-•--•---........._..__..
LgGati4ft Address —1'-L or Lot No.
..... .L. 1113. .....b.. r— '........................... .......-........_.......-................. ............._.._.........._.._•-••--.............
1;���,pC fi
O�y�r ,^ Address
./V.�� ....:.. 1. /..(J1 .��..5.:..................... .... ............ ................
Installer Address
UType of Building Size Lot............._______________Sq. feet
�--� Dwelling—No. of Bedrooms.................
...........................Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building ______.___._ No. of persons..................... Showers
a g ................ --------._.._ ...------- ------- ( ) — Cafeteria ( )
d Other xtures . --�a
W Design Flow____._.._ _0............__YY...._.,_�..,gallons per person per day. Total daily flow............a�`.........................gallons.
WSeptic Tank—Liquid capacity.�(.� _gallons Length________________ Width................ Diameter................ Depth................
x Disposal Trench—No.____________....{{ dth.................... Total Length.................... Total leaching area.......,............sq. ft.
3 Seepage Pit No.... 'eter____________________ Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ) Dosing tank ( )
aPercolation Test Results Performed by......................................................................... Date.........................................
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to-ground water______________________--
f3� Test Pit NcE 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
ODescription of Soil,>-• _rA�_�._?--•••C9--2==-.-q-a.....-------------------------------------------------------------------------- ---------------------
x
V .--------------------------•---------..-.----...----------------._...------------------._...-•-•---------•--------•---------••--------...---------•----------------------------------._..._..•---••---••-
W
U Nature of Repairs or Alterations—Answer when applicable.................................................._.............................................
_...---•---------------------------------•------••-•---------------------•---....._..............--•------•--•---.__.....-------.._..---------------------------------•-------------------------•---••--
Agreement:
The undersigned agrees to install the afor escribed Individual Sewage Disposal System in accordance with
the provisions of Article XI of the State Sanit y ode—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance he n issued by t bar f healt .
Signe ••--•-•-._......
Date
Application Approved BY----•---•---•••••--•-----------•-----•-------•----•-.:=-- -_..._
Date
Application Disapproved for the following reasons-------------------------------------•--------------------------------•---------••--••------•--•-•--.......---•--
....................................................----------- •-----------•--••--------------.........................................................................................•.........
Date
PermitNo.......... ......................................... Issued............:...........................................
Date _
No....... -------------- FE .......................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
...............1.1�60,Lj.....OF...............4�.ar.
Apphrativa for Disposal Mork, Tonotrurtion run fit
Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal
System at: .7,
..........
...................... ..................................................................................
Location.-Address or Lot No.
� 11 i I J-4.
.....4.... ........................... ............ ....................................................................................
4 Oner Address
L ................... ..................................................................................................
...........
Installer Address
U
.Type of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms..............:. .-;:_._.._.........Expansion. Attic Garbage Grinder
........
P-4 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. 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 ( )
Percolation Test Results Performed bv.......................................................................... Date_.._......................._._......_...
Test Pit No. 1................minutes per inch Depth of Test Pit_-__........__.._... Depth to ground water___-____-____-__-._-_-_.
f� Test Pit No. 2................minutes per inch Depth of Test Pit..__.._............. Depth to ground water-__-_._______--_-_.._.
-- .......... ........................................................................................................
0 Description of Soil.... .241.o�1..6. ......%�.. Alt. ---_----------------------------------------------------- --------------------------------------------------
U .........................................................................................................................................................................................................
W
17" ........................................................................................................................................................................................................
U Nature of Repairs or Alterations—Answer when applicable._..............................................................................................
................................................................................ ............................. -----------------------------------------------------------------------------------------
Agreement:
The undersigned agrees to install the aforodescribed Individual Sewage Disposal System in accordance with
the provisions of Article XI of the State Sanitary . ode—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has b.4n issued by t�e,boafd)Df healt e
e
Signed ... ..................... ....................... ...... ....Date .... ..
ApplicationApproved By................................... ............................................................. .......................................
Date
Application Disapproved for the following reasons:.................................................................................................................
.........................................................................................................................................................................................................
Date
PermitNo......................................................... Issued........................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
4 0.
'A').4j...........OF......
;AO.-C.....................
(9rdiffrate of Toutphattre
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed or Repaired
\.L............ -------------------------------------------------------------------------------------------------------
Of
.......................... ---_--------
at.. lk
has been installed in accordance with the provisions of Article XI of The Stateanitz--S try 7o as described in the
application for Disposal Works Construction Permit No...a X... .. ................... dated......... ------ ........
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 HEALTH
2
.......... ........OF............j—
..................... 41)No_::� ... . ...... FED_.il, ...................
Disposal Mork. T'lloustrurtion Pgrutit
Permission is hereby granted....._.. ... 4. ............................................................
to 'Construct or Repair an individual Sewage Disposal System
e
. ...at No..4,,.42 ....... .........�k
as shown on the application for Disposal Works Construction Permit No.._ D a ted..... _,, ?I/n-7---—-------
.........................................................I.........................................
Board of Health
DATE............................................................... ................
FORM 1255 HOBBS & WARRFN, INC.. PU8L!SHr_RS