HomeMy WebLinkAbout0060 BLACKBERRY LANE - Health 60 Backberry Lane A. .
Hyannis-079,
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Commonwealth of Massachusetts L9
. Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
60 Blackberry Lane
Property Address
Barbara A. Westwood
Owner Owners Name
information is H annis ✓ MA 02601 January 14 2016aal
required for every y
State Zip Code Date of Inspection M••
page. Citylrown
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When A. General Information
filling out forms
on the computer,
use only the tab 1. Inspector:
key to move your
cursor-do not David D. Flaherty Jr IRS, REHS
use the return Name of Inspector
key
�� Flaherty Environmental Services
_ _6 I Company Name
P.O. Box 81
Company Address
Yarmouth Port MA 02675
CityrTown State Zip Code
508-362-1657 SI#4713
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection.The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5(310 CMR 15.000).The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
January 15, 2016
Inspectors Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP.The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time.This inspection does not address how the system will perform in the future under
the same or different conditions of use.
t5ins•3/13 a Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17
Commonwealth of Massachusetts
REM
. Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary,Assessments
w 60 Blackberry Lane
Property Address
Barbara A. Westwood
Owner Owner's Name
information is required for every Hyannis MA 02601 January 14, 2016
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® 1 have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
B) System Conditionally Passes:
t
❑ One or more system components as described in the"Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old"or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
' A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
_ a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
60 Blackberry Lane
Property Address
Barbara A. Westwood
Owner Owner's Name
information is Hyannis MA 02601 January 14, 2016
required for every Y ry
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ 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
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M 60 Blackberry Lane
Property Address
Barbara A.Westwood
Owner Owners Name
information is Hyannis MA 02601 January 14, 2016
required for every y ry
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within .
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
"*This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes" or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or.cesspool .
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than 'h day flow
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17
I
Commonwealth of Massachusetts
Title 5 Official Inspection . Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
60 Blackberry Lane
Property Address
Barbara A. Westwood
Owner Owner's Name
information is Hyannis MA 02601 January 14, 2016
required for every Y rY
page. CitylTown State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
Required pumping more than 4 times in the last year NOT due to clogged or
❑ ® obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet.of a tributary to a surface drinking water supply
El E] Area
system is located in a nitrogen sensitive area (interim Wellhead Protection
Area—IWPA)or a mapped Zone II of a public water supply well
If you have answered "yes"to any question in Section E the system is considered a significant threat,
or answered"yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
60 Blackberry Lane
Property Address
Barbara A. Westwood
Owner Owner's Name
information is Hyannis MA 02601 January 14, 2016
required for every y ry
page. Cityrrown State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes" or"no" as to each of the following:
Yes No
® ❑ Pumping information was'provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health. t
® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): 3 Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
. Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
60 Blackberry Lane
Property Address
Barbara A. Westwood
Owner Owner's Name
information is Hyannis MA 02601 January 14, 2016
required for every �Y
page. Cityrrown State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 1
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ❑ No
Seasonaluse? ❑ Yes ® No
Water meter readings, if available last 2 ears usage d '14: 47 gpd; '15:
9 ( Y 9 (gpd)): 30 gpd
Detail:
Sump pump? ❑ Yes ® No
2016
Last date of occupancy: Date
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow (seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17
Commonwealth of Massachusetts
_ Title 5 Official Inspection Form
_ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 60 Blackberry Lane
Property Address
Barbara A. Westwood
Owner Owner's Name
information is required for every January Hyannis MA 02601 J 14, 2016
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information: owner, within the last 5 years
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
60 Blackberry Lane
Property Address
Barbara A. Westwood
Owner Owner's Name
information is Hyannis MA 02601 January 14, 2016
required for every Y rY
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
installed 5/7/1996 per BBOH
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 2.5feet
Material of construction:
i
❑ cast iron 040 PVC El other(explain):
>50
Distance from private water supply well or suction line: feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
joints tight, venting through dwelling adequate, no evidence of leakage
Septic Tank(locate on site plan):
Depth below'grade: 2
feet
i Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
t
If tank is metal, list age: years
• Y
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 1500 gallon
Sludge depth: 21-
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
60 Blackberry Lane
Property Address
Barbara A. Westwood
Owner Owners Name
information is Hyannis MA 02601 January 14 2016
required for every y rY
page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle 32
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
14"
How were dimensions determined?
dip stick, tape measure
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
maintenance pumping should be performed every two to three years, inlet&outlet tees good, tank
seems structurally sound, liquid level appropriate, no evidence of leakage
Grease Trap(locate on site:plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
60 Blackberry Lane
Property Address
Barbara A. Westwood
Owner Owner's Name
information is Hyannis MA 02601 January 14, 2016
required for every Y ry
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity:
gallons
Design Flow:
gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
"Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
60 Blackberry Lane
Property Address
Barbara A. Westwood
Owner Owner's Name
information is Hyannis MA 02601 January 14, 2016
required for every Y rY
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened) (locate on site plan):
011
Depth of liquid level above outlet invert
Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
dbox seems level, no evidence of leakage
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No*
I
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
I
*if pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins•3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
_ . Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
, 60 Blackberry Lane
Property Address
Barbara A. Westwood
Owner Owner's Name
information is Hyannis MA 02601 January 14 2016
required for every y ry
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
® leaching chambers ' number: (4)
❑ 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.):
(4) chambers with stone in a 33'x 11'x 26"configuration, soils sandy with gravel, no signs of
hydraulic failure or breakout, chambers dry, vegetation typical (lawn)
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
60 Blackberry Lane
Property Address
Barbara A. Westwood
Owner Owner's Name
information is Hyannis MA 02601 January 14, 2016
required for every ._Y rY
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy (locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
i
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17
Commonwealth of Massachusetts
- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
60 Blackberry Lane
Property Address
Barbara A. Westwood
Owner Owner's Name
information is Hyannis MA 02601 January 14, 2016
required for every y rY
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
A-!
� � - 301 I
z
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments .
w 60 Blackberry Lane
Property Address
Barbara A. Westwood
Owner Owner's Name
information is Hyannis .MA 02601 January 14, 2016
required for every � rY
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
® Surface water
® Check cellar
® Shallow wells
i
Estimated depth to high ground water:' >11
feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: - Date
® Observed site (abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health-explain:
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
You must describe how 9
you established the high round water elevation:
Y 9
hand aughered to 11', no groundwater encountered
i
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form.-Not-for Voluntary Assessments
60 Blackberry Lane
Property Address
Barbara A. Westwood
Owner Owner's Name
information is Hyannis MA 02601 January 14, 2016
required for every y ry
page. Cityrrown State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
i
® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed
® System Information—Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
OWN OF BARNSTABLE
LOC'A.TION 1l�GK��/ �ti� SEWAGE# be
VILLAGE. �`y44,71 p ASSESSOR'S MAP&LOT Zqf-'�79
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY 15'oo G,G L
LEACHING FACILITY: (type).7�) lea OHS �7�(size) i X 3? 02 6
NO.OF BEDROOMS 3
BUILDER OR OWNER
PERMI TDATE: = COMPLIANCE DATE: 7—9��_.
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 l
on site or within 200 feet of leaching facility) VA Feet
Edge of Wetland and Leaching Facility(If any wetlands exist A/
within 300 feet of leaching facility) /U Feet
Furnished by
4ti
' O �
A
00/00
_.
i rA,
t
II
i
I
No. Fee
THE COMMONWEALTH OF MASSACHUSETTS
j PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS
0(ppYication for 33igpo5a[ *pgtem Congtruction Vermit
Application is hereby made for a Permit to Construct( )or Repair( �On-site Sewage Disposal System at:
Location Address or Lot N . Ow7r's/N e,Add ss and Tel.No.
ro girr�� S 6Dl��r��'6er✓' /y. h` �v/r� ,5
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
Type of Building:
Dwelling No.of Bedrooms Garbage Grinder
Other Type of Building 8SI e�'G� No. of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow /Z 11P gallons per day. Calculated daily flow 330gallons.
Plan Date Number of sheets Revision Date
Title 6467iG w
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 df Title 5 of the E 'ron ental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued by s o d f e
�. Signed Date ��y
Application Approved b
Application Disapproved for the following ieasons
Permit No. z:�� `Date Issued `"��
THE COMMONWEALTHS OF MASSACHUSETTS Z 41f—4�1 7 JD
PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
.x.
i
Certificate of Compliance
THIS IS TO CERTIFY,that the,On-site Sewage Disposal System installed( )or re aired/replaced( on '
by 6O/YeZel�/ -6!MuS for geq
as has been constructed in accordance .
with the provisions of Title 5 and the for Disposal System Construction Permit No.9 dated �f.� '
Use of this system is conditioned on compliance with the provisions set fort below:
c_7 b--�
No. " 2 `4 7 9 Fee ! O
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
3kgo5al *pgtem Construction Permit
Permission is hereby grantedpca— �Ol^ O Cm�SJ�uG�`/dam
to construct( )repair( )✓)an On-site Sewage System located at 4 .l aGle 'e'e'Sza
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.
All construction must be
completed within two years of the date below.
Date: �'" / % 49 Approve,
F No. 1� - Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
Application for Mig ogal * gtem Congtruction pern�it
Application is hereby made for a Permit to Construct( )or Repair( V)an On-site Sewage Disposal System at:
Location Addre s or Lot N . Own is N e,Add ss and Tel.No.
6e!�d� �a,
i
Installer's Name,Address,and Tel.No. 7 7/ Designer's Name,Address and Tel.No.,
Type of Building:
Dwelling No.of Bedrooms Garbage Grinder(14W
Other Type of Building S) eW No.of Persons Showers( ) Cafeteria
Other Fixtures
Design Flow 1
g /�l� gallons per day. Calculated daily ow gallons.
Plan Date Number of sheets RevisionfDate
Title 64e-l-e,11 g& 4
Description of Soil C ar
Nature of Repairs or Alterations(Answer when applicablg,)q_..,7_)tit�
27
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-?wee �i ' ar✓�ovH
Date last inspected: - t
Agreement: k
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions'o Title 5 of the E 'ron ntal Code and not to place the system in operation until a Certifi- '
cate of Compliance has been issued by s o�atd f e '` f
Signed � << " Date
Application Approved b
Application Disapproved for the following reasons
Permit No. ,• � � Date Issued '9!5� I
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CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL
WORKS CONSTRUCTION I'ERNIFF (WITHOUT DESIGNED PLANS)
hereby certify that the application for disposal works
construction permit signed by me dated 2/Zf/4 , concerning the
property located at Ga �l�G1Lbvr�'�'/�j, meets all of the
following criteria:
• There arc no wetlands within 300 feet of the proposed septic system
• There are no private wells within 150 feet of the proposed septic system
• The observed groundwater table is 14 feet or greater below the bottom of the leaching facility
• There is no increase in flow and/or change in use proposed
• There are no variances requested or needed.
SIGNED : DATE: .
LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER
IAttach a sketch plan of the proposed system. Also if the licensed Installer posesses a certified plot plan,
this plan should be submitted].
PAR ] Real Estate System - General Property Inquiry] Help [ ]
Parcel Id: 249 079- - Account No: 158304 Parent :
Location: 3 BLACKBERRY LANE Neighborhood: 50AC Fire Dist : HY
Devel Lot :, 11 Lot Size : . 38 Acres
Current Own: WESTWOOD, BARBARA A State Class : 101
60 BLACKERRY LANE No. Bldgs : 1 Area: 2110
Year Added:
HYANNIS MA 2601
Deed Date : 050196 Reference : 10198075
January 1st : WESTWOOD, BARBARA A Deed MMDD: 0596 Deed Ref : 10198075
Comments :
Values : Land: 27700 Buildings : 69400 Extra Features :
Road System: 60 Index: 129 (BLACKBERRY LANE ) Frntg: 110
Index: ( ) Frntg:
Control Info: Last Auto Upd: 020997 Status : C Last TACS Update : 072696
Land Reviewed By: Date : 0000 Bldgs Reviewed By: ML Date : 0691
Tax Title : Account : Taken: Account Status : Hold Status :
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` 14SS OASMAPtOE`<
PARCEL N0: ---=
Commonwealth of Massachusetts ��.
ExecuWe Office of Environmental Affairs_ John Grad
D.E.P. Title V Septic Inspector
- Department of P.o. Box-2119 --
Invironmental Protection Teaticket, MA 02536 -
_ WUllam F.Weld
- (508) 564-6813
@oremor _
Trudy Cote _ - 08�cntery,EOEA f If
____---David B.Struh;._—_
Oommaaroner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM L / 1996
PART A o
CERTIFICATION lr 42,11'Ate
Property Address: 0 51c1ck e_CT j Lfh 14y;AAI5 ��• Address of Owner:
Date of Inspection: `a 5 (if-different)
Name of Inspector:
Company Name, Address and Telephone Number:
CERTIFICATION STATEMENT
I.certify,that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate
and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems. The system:
_ Passes
_ Conditionally Passes
4/Needs Further Evaluation By the Local Approving Authority
Fails
Inspector's Signature: Date:
i
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, floe of i0,000 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 ;ne system owner and copies sen; to tier bu)er, if app:icable and the appro,ing au:F.ority.
INSPECTION SWA MARY:
Check A, B, C, or(D
A] SYSTEM PASSES:
I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303.
Any failure criteria not evaluated are indicated below.
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 8/15/95) 1
One Whiter Stree s Boston,Mssasehusstts 02108 • FAX(617)SMIC49 9 TNaphone(617)292-SS00
0 Primed on Recycled Paper
w _
• SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM _
PART A.-
CERTIFICATION (continued)
Property Address:
'Owner: ._
- Date of Inspection:
-Bj SYSTEM CONDITIONALLY PASSES (continued) -
Sewage backup or breakout of high static water level observed in the distribution box is due to broken or obstructed
pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the +
Board of Health):
broken pipe(s) are replaced
obstruction is removed -
distribution box is levelled or replaced _
The system required pumping more than four times a year due to brokerror obstructed pipe(s). The system will pass
inspection i0with approval of the Board of Health):-
broken pipe(s) are replaced
obstruction is removed
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 the
public health, safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM 1S NOT FUNCTIONING IN A MANNER
WHICH WILL PROTECT THE PUBLIC HEALTH AND 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 APPROPRIATE) DETERMINES THAT
THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE
ENVIROIkIENT:
InP >%5ipm na> a >eUUC tan'K an dun dUtorpUon systen, end U
I
surface water supply.
_—.T-he s%s!P ha, a septic tank and soil absorption system and is within a Zone I of a public water supply well.
The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well.
The sy;tern has a sep:ic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water
supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is
free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5
PPm•
D) SYSTEM FAILS:
I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis
for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct
the failure
Backup of sewage into facility or system component due to an overloaded or dogged 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.
(revised 8/15/95) 2
2:p.
',SUBSURFACE SEWAGE DISPOSAL,SYSTEM INSPECTION FORM.
PART A _
CERTIFICATION (continued)
-Property Address: :• -
Owner: - -
Date-of.Inspection:
DJ SYSTEM FAILS (continued):- `.'.
N St"tic.'liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. _.
1 -Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow.
N . ' Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped-
AZAny portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation.
Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
IVL ' Any portion of a.cesspool or privy is within a Zone I of a public well.
/U Any portion of a cesspool or privy is within 50 feet of a private water supply well.
Any.portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no
acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for
coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
El LARGE SYSTEM FAILS:
The following criteria apply to large systems in addition to the criteria above:
The design flow of system is 10,000 gpd or greater (large System) and the system is a significant threat to public health and safer
and the environment because one or more of the following conditions exist:
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,
The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program
requiremTnts of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.
(revised 6/15/95) 3
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART_B
_— .. CHECKLIST
Property Address: - -
Owner. - .
Date of Inspection:
Check if the f Ilowing have been done: _
mping information was requested of the owner, occupant, and Board of Health. -
gone 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.
Al As built plans have been obtained and examined. Note if they are not available with N/A.
Y_Te facility or dwelling was inspected for signs of sewage back-up.e system does not receive non-sanitary or industrial waste flow
Y/he site was inspected for signs of breakout.
II 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
✓The fa-;';nv i(rWioro- irnm ownP•' were orovided.with information on the proper maintenance of Sub
Surface Disposal System.
4
(revised 8/15/95)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C _
SYSTEM INFORMATION `
Property Address:
Owner:' .. -
Date.of Irispection: _
--. FLOW CONDITIONS
RESIDENTIAL: :.
Design flow: gallons._.. . _
Number of bedrooms: 11 -
Number-of current residents
Garbage grinder (yes or no : NO
Laundry connected.to system oe or no):
Seasonal use.(yes or 0 -
.Water meter readings, 1(available:
Last date of occupancy:
COMMERCIAL/INDUSTRIAL:
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: syi+e-m C /lG )
System pumped as part of inspection: (yes or no)_
If yes, votMe pumped gallor5
Reason for pumping:
TYPE OF SYSTEM
Septic tank/distribution box/soil absorption system
ingle 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)_
(revised 8/15/95) 5
;t
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C- -
SYSTEM INFORMATION (continued)
Property Address: -
Owner - -
Date of Inspection:
SEPTIC TANK: 11A
(locate on site plan)
Depth below grade: - -
Material of construction: _concrete _metal _FRP —Other(explain)
Dimensions: -
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:—
Comment s
(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.)
r
GREASE TRAP:
(locate on site plan)'
Depth belo,.ti• grade:
Material of construction: _concrete _metal _FRP —other(explain)
Dimensions:
Scum tnic�ne �.
Distance from top of scum to top of outlet tee or baffle:
Dic!a^.ce from botto- ni rt' .r^ hottom of outle! tee or battle:
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 8/:5/95) 6
_ -
- SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM.INFORMATION (continued) -
Property Address: _
Owner: - -
- Date of Inspection:. i
TIGHT OR HOLDING TANK:jOA --
(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:_&'IA
(locate on site plan`
Depth of liquid level above outlet invert:
Comments:
mote if levei and distrlbulfun eyudi, el'-UefSCE u; e�:dence of leakage into or out of box, ex.)
PUMP CHAMBER: /=0
(locate on site plan)
Pumps—in working order.(yes or no)
Comments: -
(note condition.of pump chamber, condition of pumps and appurtenances, etc.)
(revised 8/15/95) 7
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM }
PART C.
_ SYSTINFORMATIO.EM. N (continued)
-
.Property Address:. -
Owner: — -
Date of_Inspection: '
SOIL ABSORPTION SYSTEM (SAS):
(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:
leaching-pits, number:
leaching'chambers, number:_
leaching galleries, number:
leaching trenches, number,length:
leaching fields, number, dimensions:
overflow cesspool, number:
Comments: (noteconditi n of soil, signs of hydraulic failure, level of ponding, condition of vegetation,etc.)
H d cc ,,U " 6C r<<t) vftC
CESSPOOLS: Y
(locate on site plan)
Number and configuration:
Depth-top of liquid to inlet invert: le"
Depth of solids layer: 611
Depth yof scum layer: "
Dimensions of cesspool: Y.
Materials of construction: is D
indication of
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: �✓f _
(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 8/15/95) 8
SUBSURFACE SEWAGE-DISPOSAL SYSTEM INSPECTION FORM
SYSTEM INFORMATION (continued) _ z
-Property Address-.' -
Owner . -
Date of Inspection: _
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100` -
An
.4A 3�
�C 7�p
DEPTH TO GROUNDWATER
Depth to groundwater: , /l� feet /
method of determination or approximation:
(revised 8/15/95) 9