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HomeMy WebLinkAbout0424 BISHOPS TERRACE - Health 424 Bishops Terrace Hyannis P F /� = 250 070 �. i a f a M i B o N ,4. COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION RECEIVED „AP 1---- Ar?Ci"1 APR 12 2005 Gt r _ __. ..�� TOWN OF BARN- -,LE HEALTH TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 424 Bishop's Terrace Hyannis MA 02601 hr<l.Gl. Owner's Name: Kleber Guimaraes Owner's Address: Date of Inspection: April 1 2005 Name of Inspector: (Please Print) James M. Ford Company Name: James M.Ford Mailing Address: P.O.Box 49 Osterville MA 02655-0049 Telephone Number: (508)862-9400 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: April3. 2005 The system inspector shall sub t 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. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page I 9 0 Page 2 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 424 Bishop's Terrace Hyannis. MA Owner: Kleber Guinlaraes Date of Inspection: April 1 2005 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: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined",please 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. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: 2 Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 424 Bishops Terrace Hyannis MA Owner: Kleber Guiniaraes Date of Inspection: April 1 2005 C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: 3 Page 4 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 424 Bishop's Terrace Hyannis, MA Owner: Kleber Guimaraes Date of Inspection: April 1, 2005 D. System Failure Criteria applicable to all systems: You must indicate either"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 ''/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 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 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.] No (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 System: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) Yes No the system is within 400 feet of a surface drinking water supply _ the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes"in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 4 Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 424 Bishops Terrace Hyannis, MA Owner: Kleber Guimaraes Date of Inspection: April 1, 2005 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 this inspection? ✓ _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ✓ Was the facility or dwelling inspected for signs of sewage back up? ✓ _ Was the site inspected for signs of break out? ✓ _ Were all system components,excluding the SAS,located on site? ✓ _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? ✓ _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes No ✓ _ 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)]. 5 Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 424 Bishop's Terrace Hyannis, MA Owner: Kleber Guimaraes Date of Inspection: April 1, 2005 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 2 Number of bedrooms(actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 220 Number of current residents: 3 Does residence have a garbage grinder(yes or no): No Is laundry on a separate sewage system(yes or no): n1a [if yes separate inspection required] Laundry system inspected(yes or no): No Seasonal use(yes or no): No Water meter readings,if available(last 2 years usage(gpd)): Unavailable Sump Pump(yes or no): No Last date of occupancy: Currently occupied COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no) Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Pumped in September 2004-pa tenant Was system pumped as part of the inspection(yes or no): 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) (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): Approximate age of all components,date installed(if known)and source of information: Installed on 3122199-per as built card Were sewage odors detected when arriving at the site(yes or no): No 6 TOWN OF BARNSTABLE Fvv- rt�r r Y�y �ISIl 'S e!( (A �I- 131 _ SEWAGE # ASSESSOR'S MAP & LOTJ SD- O.7 O ! a .'fitiI.LER'S NAME&PHONE NO. SEPT1 TANK CAPACITY I ODU LEACH G FACILITY: (typeQ' S 69 NIC A5►,�cid (size) y I NO. OF BEDROOMS v1-- BUILDER OR OWNER GyiM,aW5 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 by �nSOc� w J FD! IL -C w Sb _ O � o w H �l �' J TO"OF BARNS i ABLE LCCATI�IN �L �� a�S Saar SEWAGE# J V'jiLLAGE ASSESSOR'S MAP&LOT D010 - Tam , (soS INSTALLER'S NAME&PHONE NO. .- f 1.1 m ns /�Acc C � �"��� f,)fll A SEPTIC TANK CAPACITY 6c, I LEACHING FACELITY: (type) �r,�t (size) moo 6u f lre c k�sG NO.OF BEDROOMS C Ael p g,r,� � �—r4 � F64 r FP S* ,S 7J,v e BUILDER OR OWNER SCE Al /yrrC y4 � � Ot-cs Ver, PERMIT DATE: 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 �I Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) AvD Feet Furnished by F � ar © 4v �v �v Page 7 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 424 Bishop's Terrace Hyannis, MA Owner: Kleber Guimaraes Date of Inspection: Apri11, 2005 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction: _cast iron _40 PVC _other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): . SEPTIC TANK: ✓ (locate on site plan) Depth below grade: 6" 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: 1000zal. Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle: 30" Scum thickness: 2" 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: 10" How were dimensions determined: Measuring stick Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels I as related to outlet invert,evidence of leakage,etc.): Tees were present The liquid level was even with the outlet invert. There did not appear to be any sins of IeakaQe. GREASE TRAP: None (locate on site plan) Depth below grade: Material of construction: _concrete _metal _fiberglass _polyethylene _other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Conunents(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): 7 �, Page 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 424 Bishops Terrace Hyannis, MA Owner: Kleber Guimaraes Date of Inspection: April 1. 2005 TIGHT or HOLDING TANK: None (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: _concrete _metal _fiberglass _polyethylene _other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: ✓ (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Even Commments(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 level. J PUMP CHAMBER: None (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no) Commnents(note condition of pump chamber,condition of pumps and appurtenances,etc.): 8 f Page 9 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 424 Bishop's Terrace Hyannis, MA Owner: Kleber Guimaraes Date of Inspection: _ April 1, 2005 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number: ✓ leaching chambers,number: 2-500 gal. chambers w/4'stone(per as built card) leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number: Innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): The chambers were dry and clean. No scum line was present. The bottom to grade was 6' The cover was 6"below grade CESSPOOLS: None (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: i Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: None (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): 9 �.1 i 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: 424 Bishop's Terrace Hyannis. MA Owner: Kleber Guinzaraes Date of Inspection: April 1, 2005 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. LIS Iola 03 'I a al a ay 3 y8 ay y 51 33 10 j Page 11 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 424 Bishop's Terrace Hyannis MA Owner: Kleber Guimaraes Date of Inspection: April 1 2005 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 30+/- feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) ✓ Checked with local Board of Health-explain: topographic and water contours snaps Checked with local excavators, installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: Using Barnstable topographic and water contours nt_ ps the maps were showing approximately 30+/-to ground water at this site. This report has been prepared and the system inspected and passed 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 t COMMONWEALTH OF MASSACHUSETTS EXECUT;I'VE,OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION � a r V TITLE 5 " OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION ;. Property Address: 424 BISHOP TERRACE HYANNIS,MA 02601 M250 P070 Owner's Name: BRAD DAVIS Owner's Address: 424 BISHOP TERRACE HYANNIS,MA 02601 RECEIVED Date of Inspection: 1/24/01 a�;g FEB 0 7 2001 Name of Inspector: (please print) JOHN GRACI t.� Company Name: SEPTIC INSPECTIONS TOWN OF BARNSTABLE Mailing Address: P.O.BOX 2119 TEATICKET,MA.02536 HEALTH DEPT. Telephone Number: 508-564-6813 FAX'508-564-7270 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,ofthe time of the inspection.The inspection was performed based on my training and experience in the proper functio `and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section'1;5.340 of Title 5(310 CMR 15.000). The system: 2;t . X Passes'" - _ Conditionally Passes _ Needs Furt a Evaluation by the Local Approving Authority _ Fails Inspector's Signature: Date: 1/24/01 The system inspector shall submit 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 d or greater,the Y P g p Y Y g gp g 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 _, THE SYSTEM PASSES TITLE V INPECTION. RECOMMEND PUMPING SYSTEM EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFULL LIFE. ""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. k, Title 5 1nCnrrtlnn Fnrm 01'r,11006` I Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 424 BISHOP TERRACE HYANNIS,MA 02601 M250 P070 Owner: BRAD DAVIS Date of Inspection: 1/24/01 Inspection Summary: Check A,B,C;D or E/ALWAYS complete all of Section D A. System Passes: X 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 PASSES TITLE V INPECTION.RECOMMEND PUMPING SYSTEM EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFULL LIFE. B. System Conditionally Passes: _ One or more system components as-described in the"Conditional Pass"section need to be replaced or repaired.The system, upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined"please explain. n/a The septic tank is metal and over 20 years old* or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old'is available. ND explain: n/a n/a Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): _ broken pipe(s)are replaced _ obstruction is removed _ distribution box is leveled or replaced ND explain: n/a n/a 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 ffie§'Board of Health): _broken pipe(s)are replaced _obstruction is removed ND explain: n/a d F` Page 3 of I 1 .i OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 424 BISHOP TERRACE HYANNIS,MA 02601 M250 P070 Owner: BRAD DAVIS Date of Inspection: 1/24/01 C. Further Evaluation is Required bythe 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 unlei`7130ard 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 withini50 feet of a bordering vegetated wetland or a salt marsh F 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. _ The system has a septic tank and SAS and the SAS is within a Zone I of a public water supply. _ The system has a septic tank and,SAS and the SAS is within 50 feet of a private water supply well. 4: _ 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 n/a "This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compodnds 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. F 3. Other: n/a a Page 4 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 424 BISHOP TERRACE HYANNIS,MA 02601 M250 P070 Owner: BRAD DAVIS C Date of Inspection: 1/24/01 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for alLinspections: Yes No X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool _ X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool X Liquid depth in cesspool is less than 6"below invert or available volume is less than '/z day flow X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped nLa. X Any portion of the SAS,cesspool or privy is below high ground water elevation. X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone 1 of a public well. X Any portion of a cesspool or privy is within 50 feet of a private water supply well. _ X Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [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]]: (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 3 . necessary to correct the failure. E. Large Systems: ; ` To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no X the system is within 400 feet of a surface drinking water supply ,,, is X the system is within 200 feet of a tributary to a surface drinking water supply X the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well 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. ,r d Page 5 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 424 BISHOP TERRACE HYANNIS,MA 02601 M250 P070 Owner: BRAD DAVIS Date of Inspection: 1/24/01 Check if the following have been done.You must indicate"yes" or"no"as to each of the following: Yes No X _ Pumping information was provided by the owner,occupant,or Board of Health I _ X Were any of the system components pumped out in the previous two weeks? X _ Has the system received normal flows in the previous two week period'? X Have large volumes of water been introduced to the system recently or as part of this inspection? X _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) X _ Was the facility or dwelling inspected for signs of sewage back up? X _ Was the site inspected for signs of break out? X _ Were all system components,excluding the SAS, located on site? X _ Were the septic tank manhole's 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? X _ Was the facility owner(and o:Ycupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems . . s. The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no X _ Existing inform ation.'For example,a plan at the Board of Health. X _ Determined in the field ,(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)] S Page 6 of 1 I t OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 424 BISHOP TERRACE HYANNIS,MA 02601 M250 P070 Owner: BRAD DAVIS Date of Inspection: 1/24/01 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):,2 ',Number of bedrooms(actual): 2 DESIGN flow based on 310 CNIR f5:203 (for example: 110 gpd x#of bedrooms): 220 Number of current residents:2 Does residence have a garbage grinder(yes or no): NO Is laundry on a separate sewage system(yes or no):NO [if yes separate inspection required] Laundry system inspected(yes or no):NO Seasonal use: (yes or no): NO Water meter readings, if available(last 2`years usage(gpd)): n/a Sump pump(yes or no): NO Last date of occupancy: n/a COMMERCIAL/INDUSTRIAL Type of establishment: n/a Design flow(based on 310 CMR 15.203): n/agpd Basis of design flow(seats/persons/sgft,etc.): n/a Grease trap present(yes or no): NO Industrial waste holding tank present(yes or.no): NO Non-sanitary waste discharged�to'the Title 5 system(yes or no): NO Water meter readings, if available: n/a Last date of occupancy/use: n/a OTHER(describe): n/a a, `t GENERAL INFORMATION Pumping Records , Source of information: n/a Was system pumped as part of the inspection(yes or no): NO If yes,volume pumped: n/agallons--How was quantity pumped determined?n/a Reason for pumping: n/a TYPE OF SYSTEM X 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) _Tight tank Attach a copy of the DEP approval Other(describe): n/a Approximate age of all components,date installed(if known)and source of information: NEW FIELD IN 99 Were sewage odors detected when arriving at the site(yes or no): NO r, Page 7 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE.SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 424 BISHOP TERRACE HYANNIS,MA 02601 M250 P070 Owner: BRAD DAVIS ` Date of Inspection: 1/24/01 t BUILDING SEWER(locate on site plan) ' Depth below grade: 12" Materials of construction:_cast iron X40 PVC_other(explain): n/a Distance from private water supply well or suction line: n/a Comments(on condition of joints,venting,evidence of leakage,etc.): TOWN WATER SEPTIC TANK: X(locate on site plan) Depth below grade: 6" Material of construction: Xconcrete' metal_fiberglass_polyethylene other(explain)n/a If tank is metal list age: n/a Is age confirmed by a Certificate of Compliance(yes or no): NO(attach a copy of certificate) Dimensions: 1000G L 8' 6" H'5 7".W 4' 10"" Sludge depth: 1" Distance from top of sludge to bottom of outlet tee or baffle:33" Scum thickness: 0" Distance from top of scum to top of outlet tee or baffle: 6" Distance from bottom of scum to bottorn'of outlet tee or baffle: n/a How were dimensions determined: MEASURED 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 SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND.RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG'THE SYSTEM'S USEFULL LIFE. GREASE TRAP:_(locate on site plan) Depth below grade: n/a Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a Dimensions: n/a Scum thickness: n/a Distance from top of scum to top`of outlet tee or baffle: n/a Distance from bottom of scum to bottom of outlet tee or baffle: n/a 'Date of last pumping: n/a Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leaAage,;.etc.): n/a 1 7 Page 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 424 BISHOP TERRACE HYANNIS,MA 02601 M250 P070 Owner: BRAD DAVIS ? Date of Inspection: 1/24/01 TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: n/a Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a Dimensions: n/a Capacity: n/a gallons Design Flow: n/a gallons/day Alarm present(yes or no): N/A Alarm level: N/A Alarm in working order(yes or no): NO Date of last pumping: n/a Comments(condition of alarm and float switches,etc.): n/a DISTRIBUTION BOX: X(if present m+ast be opened)(locate on site plan) Depth of liquid level above outlet invert: LEVEL WITH BOTTOM OF PIPE 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 DISTRIBUTION BOX'IS STRUCTURALLY SOUND. PUMP CHAMBER: _(locate on site plan) Pumps in working order(yes or no): NO Alarms in working order(yes or no):NO Comments(note condition of pump"chamber,condition of pumps and appurtenances,etc.): n/a i Page 9 of I I k OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 424 BISHOP TERRACE HYANNIS,MA 02601 M250 P070 Owner: BRAD DAVIS Date of Inspection: 1/24/01 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required) If SAS not located explain why: n/a Type n/a leaching pits, number: n/a 500 GALLON LEACHING ..leaching chambers, number: 1 CHAMBERS leaching galleries, number: n/a n/a leaching trenches, number, length: n/a n/a leaching fields, number: n/a n/a overflow cesspool, number: n/a n/a =cs innovative/alternative system n/a `'. Type/name of technology: n/a Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation,etc.): THE LEACH FIELD APPEARS TO BE FUNCTIONING PROPERLY,THE SYSTEM SHOWS NO SIGNS OF FAILURE. CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: n/a Depth—top of liquid to inlet invert: n/a Depth of solids layer: n/a Depth of scum layer: n/a Dimensions of cesspool: n/a Materials of construction: n/a Indication of groundwater inflow(yes or no): NO Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): n/a PRIVY: (locate on site plan),:r Materials of construction: n/a 't Dimensions: n/a Depth of solids: n/a Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): n/a 4 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: 424 BISHOP TERRACE HYANNIS,MA 02601 M250 P070 Owner: BRAD DAVIS Date of Inspection: 1/24/01 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. }1 g6A 'I V p g C D . AA ` s � sp 33 in Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 424 BISHOP TERRACE HYANNIS, MA 02601 M250 P070 Owner: BRAD DAVIS Date of Inspection: 1/24/01 SITE EXAM _Slope _Surface water _Check cellar Shallow wells Estimated depth to ground water 12+feet Please indicate(check)all methods used to determine the high ground water elevation: NO Obtained from system design plans on record-If checked,date of design plan reviewed: n/a NO Observed site(abutting property/observation hole within 150 feet of SAS) NO Checked with local Board of Health-explain: n/a NO Checked with local excavators, installers-(attach documentation) YES Accessed USGS database-.explain: n/a You must describe how you established the high ground water elevation: USGS MAPS AND CHARTS- 12+FEET i. I ' I - (3/ No. �......�.s� Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS 01pprication for Miopaar *pgtem Construction Permit Application for a Permit to Construct( )Repair( )Upgrade( Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. Y/ y a i 0 �t Owner's Name,Address and�Tel.No. ?-er ra G C, Ica l� i� .Sets Q 1e/� 1J Assessor's Map/Parcel�6—(3 v (3 76 Installer's Name,Address,and Tg1.No. J J —60 Designer's Name,Address and Tel.No. �AtvvlC5 cLacr PO /3o)c G s /-_o r,-s7a(r ma. o ac yy Type of Building: `� Dwelling No.of Bedrooms C ` Lot Size sq.ft. Garbage Grinder( ) Other Type of Building eFC Aej T•`ce I No.of Persons Showers( ) Cafeteria( ) Other Fixtures 11,, Design Flow O)OL6 gallons per day. Calculated daily flow �3 gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank /6Q0 . Type of S.A.S. _/re C 71,U0 Ste• 6� lPli c :,.� C u rvt w e l/ ST6. 1 e 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 jitle 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued#y this Board of Health d _ Signed Date •S-'fs J Application Approved by i Date Application Disapproved for the following reasons Permit No. —l 3Z Date Issued S ' No.7 dr, �y Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLES Yes MASSACHUSETTS r. application for Migpooal *pztem Couttruction Permit A hcation for a Permit to Construct Re air �,.),Upgrade( Abandon( ) ❑Complete System ❑Individual Components pp. (. ). P ( P Y Po Location Address or Lot No. �� i S 0. f Owner's Name,Address and Tel.No. �"i J4i5l � ;,t S S a /tmu4k Assessor's Map/Parcel :;LS6 _ (376 10 Installer's Name,Address,and Tel.No. — 00 /S Designer's Name,Address and Tel.No. t Z-Q ✓✓I f S C1',Q C r!n1 PO Box G S� /—o riftr- q It tea- 6 Dr Iel Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) 'j Other Type of Building No.of Persons Showers( Cafeteria( ) Other Fixtures Design Flow r)� gallons per day. Calculated daily flow 3•S gallons. Plan Date Number of sheets Revision Date Title Size of Septic Ta>nk J560 . G� Type of S.A.S. Ire C 7" �- 6al, /Pc+e .'iJ 6 C' a ►vt ,.f ;/ STv-0 C Description of Soil i 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 Certifi- cate of Compliance has been issued y this Board of Health. Signed - Date Application Approved by Date Application Disapproved for the following reasons Permit No. 199-131 Date Issued a y / S ' 5 --------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS w Certificate of (compliance � THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( Repaired( )Upgraded( ) Abandoned( )by at q Z i 3 6: Yr_77 a CP iLs has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. — dated 3 / S_` 9 7 . Installer Designer 4. 1 n The issuance of this per-mi shal.not be,1ofiUstrued as a guarantee that the sy/t m wi 1 unc ion s design Y�ted./�tl Date i Inspector M ✓/t � --------------------------------------- No. — Fee \ THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS i� ogar otem Congtruction Permit Permission is hereby granted to Construct(Lj Rem( )Upgrade( )Abandon( ) System located at �/ Z 4/ 2✓r.• &e, and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of thisjVrrmt. Date: Approved by r 1/6/99 NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. - �sd- ova CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERTNUT (WITHOUT DESIGNED PLANS) I, C 1 CcC f , hereby certify that the application for disposal works construction permit signed by me dated 2—/.f - , concerning the property located at o�7 61'S A6(�5"' �Cr C meets all of the following criteria: • The failed system is connected to a residential dwelling only. There are no commercial or business uses associated with the dwelling. • The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch. • There are no wetlands within 100 feet of the proposed septic system • There are no private wells within 150 feet of the proposed septic system • There is no increase in flow and/or change in use proposed • There are no variances requested or needed. • The bottom of the proposed leaching facility will not be located less than five feet above the ma,�dmum adjusted groundwater table elevation. (Adjust the groundwater table using the Frimptor method when applicable] • If the S.A.S. will be located with 250 feet of any vegetated wetlands, the bottom of the proposed leaching facility will not be located less than fourteen(14) feet above the maximum adjusted groundwater table elevation, Please complete the following: A) Top of Ground Surface Elevation(using GIS information) B) G.W. Elevation 2(� +the MAX.High G.W. Adjustment. DIFFERENCE BETWEEN A and B p21 SIGNED : DATE: �/ U (Sketch propo ed plan of system on back]. q:health folder:cert �_ � � -? �Jl ,� �i �� L� / i I �\\� 'mil _�� ��. 1 ��0 � I i i� •� �� f' i J � � 9 l � `M �. �� � �--.,, 4 � � i � ` 5 -� s �, t rew �► q. c 13/ � �,) An�s lad a/W/V y _ r TOWN OF BARNSTABLE � � r LOCATION L i, D�S 1 Pr4-c SEWAGE # VILLAGE VA NP ASSESSOR'S MAP &LOT � D ' INSTALLER'S NAME&PHONE NO. Gi m C� 4 C C (S�'�f' - C O/A SEPTIC TANK CAPACITY '1-co II LEACHING FACILITY: (type) (size) NO.OF BEDROOMS �= %3.-j /_eL�r I�tr STJN BUII.DER OR O WNER .���, Sa tOcc 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) d Feet Edge of Wetland and Leaching Facility(If any wetlands exist. /�� Feet within 300 feet of leaching facility) . Furnished by 1 Yoe ` r7 t� ( � 5 + � 113 0 0c