HomeMy WebLinkAbout0116 BRISTOL AVENUE - Health 116 Bristol Avenue, Hyannis
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TOWN OF BARNSTABLE Ste?
'4.00l:TION llro �ls�
V�[,LAGE_ oS ASSESSOR'S MAP & LOT ! "-�S G
.�R'S-NAME&PHONE NO. 50
SEPTIC TANK CAPACITY lGd
LEACHING FACILITY: (type)�� 7, S% /T (size)
NO.OF BEDROOMS
BUILDER OR OWNER yy1/d C L�l c
A" fiftNT-DATE: O�'�j .� 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 Facili (If any wetlands exist
within 300 feet of leaching cili Feet
Furnished bu10
'I Y
TOWN OF BARNSTABLE
-,LJCATION
(O' l 4d) A'uc SEWAGE #
VILLAGE_N�jA(IY1IS ASSESSOR'S MAP & LOT Z130
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY /�nn
LEACHING FACILITY: (type) Y� -r (size) &X(O
NO. OF BEDROOMS
BUILDER OR OWNER 6 t�- (n/t✓t t�
PERMITDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of lea chin facility) Feet
Furnished by Fow� 3 ;1 i
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COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
TITLE 5
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 116 Bristol Avenue
Hyannis, MA
Owner's Name: Eric Winer
Owner's Address: P.O. Box 741
South Yarmouth, MA 02664 Map: 291
Date of Inspection: March 8, 2001 Parcel. 130
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
Ns Further Evaluation by the Local Approving Authority
i
Inspector's Signature: Date: March 11, 2001
The system inspector shall sub it 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 1
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Page 2 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 116 Bristol Avenue
Hyannis, kM
Owner: Eric Winer
Date of Inspection: March 8, 2001
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.
4 ^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
I
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: 116 Bristol Avenue
Hyannis, AM
Owner: Eric Winer
Date of Inspection: March 8, 2001
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:
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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: 116 Bristol Avenue r
MA _. -..
Hyannis.
Owner: Eric Winer
Date of Inspection: March 8. 2001
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 !/Z 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 greatenthan 50 feet from a private water
supply well with no acceptable water quality analysis. [This system passes if the we[l wafer 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.]
i
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.
i
K. 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: 116 Bristol Avenue
Hyannis, MA
Owner: Eric Winer
Date of Inspection: March 8, 2001
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
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Page 6 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
INFORMATION
Property Address: H6 Bristol Avenue
Hyannis MA
Owner: Eric Winer
Date of Inspection: March 8, 2001
FLOW CONDITIONS
RESIDENTIAL
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
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] (piped to backyard)
Laundry system inspected(yes or no): No
Seasonal use(yes or no): No
Water meter readings,if available(last 2 years usage(gpd)): 2000- 14 000 gals.; 1999-32,000 gals.
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);_ pd
"Basis of design flow(seats/pers6ns/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 1999-per owner
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
'Ottier(describe):
Approximate age of all components,date installed(if known)and source of information:
Unknown
Were sewage odors detected when arriving at the site(yes or no): No
6
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' Page 7 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 116 Bristol Avenue .
Hyannis, MA -
Owner: Eric Winer
Date of Inspection: March 8° 2001
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: 20"
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: 1000 gal.
Sludge depth: I"
Distance from top of sludge to bottom of outlet tee or baffle: 31"
Scum thickness: 1"
Distance from top of scum to top of outlet tee or baffle: 10"
Distance from bottom of scum to bottom of outlet tee or baffle: 14"
How were dimensions determined: Measuring stick
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 baffles were present The liquid level was even with the outlet invert. There were no signs of leakage.
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:
Comments(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: 116 Bristol Avenue _
Hyannis, AM
Owner: Eric Winer
Date of Inspection: March 8, 2001
TIGHT or HOLDING TANK: None stank 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: gallonstday
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.):
DISTRIBUTIQN...BOX:. None (if present must be opened)(locate on site plan)
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.):
PUMP CHAMBER: None (locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no)
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
8
Page 9 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 116 Bristol Avenue
Hyannis, MA
Owner: Eric Winer
Date of Inspection: March 8, 2001
SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required)
If SAS not located explain why:
Type
✓ leaching pits,number: I -6'x 6'
leaching chambers,number:
leaching galleries,number:
leaching trenches,number,length:
leaching fields,number,.dimensions:
overflow cesspool,number:
Innovativetalternative system -Typetname of technology:
Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation,
etc.):
The pit had 1'6"of water on the bottom. The scum line was at the same,16el. There were nosigns of failure:-The cover was
Y below grade. The bottom to grade was approximately 9.
CESSPOOLS: None (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 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
Page 10 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 116 Bristo!Avenue _
Hyannis, MA
Owner: Eric Winer
Date of Inspection: March 8, 001
Map: 291
Parcel: 130
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.
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10
Page 11 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 116 Bristol Avenue
Hyannis, MA _
Owner: Eric Winer
Date of Inspection: March 8, 2001
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water 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&water contours maps
Checked with local excavators,installers-(attach documentation)
Accessed USGS database-explain:
You must describe how you established the high groundwater elevation:
The bottom ofthe Idach pit to grade was approximately 9' Using the Barnstable topographic map and the Cape Cod Commission
water contours map the maps were showing approximately 20'+/-to groundwater 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 _
DATE: _ 8/23./96
PROPERTY ADDRESS: 1'16 Bristol 'Ave.
Hyannis ,Mass .
02601
On the above date, I Inspected the septic system at the above address.
Thls system conslsts of the following: .-� Rrruvro
1 . 1-1000 gallon septic tank. ..r • SEP 4 1996 �f
2. 1-1000 gallon precast . leaching pit. of r
Based bn my Insoactlon, I certify the following conditions:
1 . This is a title five septic system. ' ( 78. .Gode- )
2. The septic system is in proper -
• working order at "the present time.
3". No repairs are needed at the present time.
SIGNATURr,: G`'(
Name: d_P Rac"omber J
,— r_-------
i
Company: • P;Macomber & Son•_Inc .
Address:
_—Centervill,e AUs__02.63'2 '
Phone:---50.8.J7,5�3338_------ _- I
THIS CERTIFICATION- DOES NOT CONSTITUTE A GUARANTY OR WARRANTY
.IOSEPH P. MACORRBER & SON,. INC.
Tanks-Csupoola-Leaohile'd.
PUmpad & Installed
Town Sewer Connections
P.O. Box 66' Centerville, MA 02632-0066
77.5.33.38 77"412
a ( :,rTImonweolth of Massachusetts
' Executive Office of Environmental Affairs
epartment of
Environmental Protection
W1111a n F.Weld Trudy Cox@
GOVOMW "Clowy
Arpeo Paul Celluocl David 0.Struhs
LL Gowmot ConwJa�lorwr
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A -
CERT•IFICATION
..w
PropertyAddreas: 116 Bristol Ave Hyannis,Mass ., Addreofowner. 198 Race Lane
Date of Inspection;8/23/9 6 (If different) Marstons Mills'- .Mass..
NameofInspector. Joseph P. Macomber Jr. 02648
Company Name,Address and Telephone Number..
J.P.Macomber & Son Inc. Box 66 Centerville,Mass . 02632 508-775-3338
CERTIFICATION STATEMENT
I certify that I have personally iaspoctod the sewage disposal system at this address and that the information reported below is true,accurate
and complete as of the time of inspoction. The inspoction was performed based on nay training and experience in the proper function and
maintena eo of on•aito aowa.•. The system:
f PAa9aS
l:vu�uuua;:.tiy Yulaes .
Needs Furthar Evaluation By the Local Approving Authority
Fails
Inspector's signature:Awl,```/��
The system Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this
inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the
report to the appropriate regional orrice of the Department of Environmental Protection.
The original should be sent to the systew owner and copies sent to the buyer, if applicable and the approving authority.
INSPECTION SUAMARY: j
Check A, B, C,or D:
A) SYSTEM PASSES: !
I have not found any inlornintion which indicates that the system violates any of the failure criteria as definod in 310 CUR 15.303.
Any LWure criteria not evaluated am indicated below.
B) SYSTEM CONDITIONALLY PASSES:
Arc) One or more system components need to be replaced or repaired. The system,upon completion of the replacement or ropair,passes
inapccticn. '
Dascribo basis of ua:,:•uiinatioa In all instances. If"a t Z.:_.;:__ '
i ruoltucl, structurally tuisou,..:, shows substantial infiltration or extatratlon,-or tank tails•... .
....;:;,;lion if the exk....:;; .eptic U.4:•a is replaced with a puufurn:ing septic tank a. . ;::vved
:revisrci 11/03i.ti) 1
One Vo1it4r Street . ilorton,Maraac;r I 0i 0 FAX(617) 556-1049 9 Telephone(617)292.5500
SUBSURFACE: SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
ProportyAddreew 116 Bristol Ave Hyannis,Mass. ,
Owner. Joseph White
Date of Inal"'00n:8/23/96
B)SYSTEM CONDITIONALLY PASSES (continuca)
Sewage backup or breakout or huh 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 `
distributions box is levelled or replaced
to The system required pumping more than four tiers u 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
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 IS NOT FUNCTIONING IN A
MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT;
k4* Cesspool or privy is within 50 feet of a surface water
Ato Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt warsh.
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 ENVIRONMENT:
tj!b- The system has a septic tank and soil absorption gystem and is within 100 feet to a surface water supply or tributary to a
surface water supply.
The system has a septic tank and soil absorption system and is within a Zone I of a public water supply well.
AM The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well.
d1D The system has a septic 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 fac.lity and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm
3) ,OTHER P ,
(revised 11/03/95) Z
V '
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(oontinued)
8r'opertyAddress: 116 Bristol Ave Hyannis ,Mass.
Owner. Joseph White
Date of Inspection:$ 23 9 6
D) SYSTEM FAILS:
A) I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. Tha bajb for
this determination is identified below. The Board of Health should be ooatacted to determine what will be necessary to correct tbs.
failure.
do Backup of sewage into facility or system component to an overloaded or clogged SAS or cesspool.
QLa Discharge or ponding of emuent to the surface oAhe ground or surface waters due to an overloaded or clogged SAS or
cesspool.
II�IQ, 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 V2 day flow.
Required Pumping more tluna 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped
Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation.
�1 Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
�Q Any portion of a cesspool or privy is within a Zone I of a public well.
Any portion of a cesspool or privy is within 60 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. ;I
E)LARGE SYSTEM FAILS:
The follow
ing criteria apply to large systems in addition to the criteria above: .(
N Ths system serves a facility with a design flow of 10,000 gpd or ter(L
arge Large System)and the system L a sigaifuant threat to public
health and safety and the environmeot.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
�T 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 liW compliance with the groundwater treatment program
requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for tiuthes information..
(revised 11/03/95) 3 ,
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B ;
CHECKLIST `
PropertyAddr,m 116 Bristol Ave Hyanhis,Mass .
Owner. Joseph White j
Date of Iaspeotion: g/23 9 6 10
Check if the following ha
-/ vv been done:
Pumping information was requested of the owner,ocWAut,and Board of Health.
,,,None during that System oompone4ts have been pumped for at least two weeks and the system has been receiving normal flow rates
th
period. Large volumes of water have not been introduced into the system recently or as part of this inspection, '
built plans have been obtained and examined. Note if they are not available with N/A i
l
facility or dwelling was inspected for signs of sewage back-up,
'k'he system does not receive non-sanitary or industrial waste flow
•k
_.fC The site was inspected for signs of breakout. I
— All system components, eluding the Soil Absorption System, have been located on the site.
2The septic tank manholes were uncovered,opened,and the interior of the septic tank was inspected for condition of bamas or
tees,material of construFtion,dimensions,depth of liquid,depth of sludge depth of acu:u.
The size and location of the Soil Absorption System on the site has been determined based on
approximated by non•iatrusive methods. ezisting information or
AS facilityowner(and occupants,
peals,it different from owner)were provided with information on the proper maintenance of Sub-
Surface Disposal System.
f
n,
(revised 11/03/95)
i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
ProperVAddroeo: 116 Bristol Ave Hyannis,Mass. .'
Owner. Joseph White
Date of Inspeotiou: 8/23/96 '
RESIDENTIAL FLOW CONDITIONS
De•iga IIow: .Zd ens D ���
Number of bedrooms: aZ •
Number of current residents:
Garbage grinder(yes or no):_42D
IAundry connected to system(yea or no)Ye S . .
Seasonal use(yes or no):�19D
Water meter readings,if available• Gd0 f
` I
Last date of occupancy:_ i
f
COMMERCIAL M0TRLlL•
Type of establishment.
Design flow:-VA—gaions/day
Grease trap P?'esent: (yes or no)AY I
Industrial Waste Holding Tank present: (yes or no)-A&
Non•saaitary waste discharged to the Title 5 system: (yes or no) ,4
Water meter readings, if available:
Last date of occupancy:�/�
OTHER:(Describe) .1)h
Last date of occupaary lV J9
GENERAL INFORMATION
PUMPING RECORDS and source of.nformation:.
i
SYstsm Pumped as part of inspection. (yes or no)_ab I'
i If Yes,volume pumped: .Ulg aaRons I
Reason for pumping
TYPE OF SYSTEM
r
Septic pool 11 abaorptiott system "
.V_ Overilow ceaspool
Privy
=A $hared system(yes OF nn) (if Yea,attach ins t
Other(explain)a -previousinspection records,if any)
i
r
i
APPR0)QMATE AGE of all compottenw, date imitalled(if known)aad source of information:
I
Sewage odors detected when arriving at the site: (yes or no)
(revised 11/03/95)
. 6
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C. +
SYSTEM INFORMATION (continued)
Property Address: 116 Bristol Ave Hyannis,Mass.'
Owner: Joseph White
Date of Inspection:g/23/96
SEPTIC TANK• 40
(locate on site plan)
Depth below grade:.?� '
Material of construction: Zoncrete _metal _FRP_other(explain)
Dimensions: V u/
Sludge depth; TF
Distance from top ofdge to bottom of outlet tee or baffle./��,` �
Scum thickness: i
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum.to bottom of outlet tee or baffle. ;
-omments:
;recommendation for pumping, condition of_Puf inlet and
e qutpt tl c tees or baffle. depth of liquid IPvel in relation to outlet Invert,structural
7.rity, eyidengce of leakage. etc.) _
.tl • The t-a-M-3—c �
..
:REASE TRAP. /1/GitX�
locate on site plan)
)epth below grade:;;'V/
Material of consirt.wtionW4zoncrete _metal_FRP_,other(explain)
)imensions•
cum thickness:__;. �fJ
)istance from top yr scum'to top of outlet tee or bafile:JV4—
)istance from bottom of<rum in bottom of outlet tee or 6hie:,
:omments: ti {
ecommendation for pumping, condil-n otinlet and outlet tees or baffles, depth of liquid level in relation to outlet Invert, structural
ite ity, e' 'dence of leakage, etc_
ANiI i,t.1 A_iA�i f
A.
I
Wised 0/15/95) 6
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
ProperyAddnws: 116 Bristol Ave Hyannis,Mass.
O=er- Joseph White
Date of Inspection:8/23/9 6
TIGHT OR HOLDING TANX-d
(locate on site plan) e
Depth below grads:Q[�
Material of constractio acrsts_metal_FRP_other(explain)
AM
Dimensions: - '
Capacity: A 1.4 gallons
Design ilow: oas/day
Alarm leveh,
•
Comments:
i (conditioa o islet tee,condition of alarm and IIoat switches,etc.)
�ewt et�l�it lTS '
i
DISTRIBUTION BOX:jVQ'4V
(locate on site plan)
Depth of liquid level above outlet invert: 4)
Comments:
(note if level d distribution is ual,evidence of solids carryover,evidence of leakage into or out of box,etc.)
• y
PUMP CHAMBER:f e r
(locate on.site plan) '
Pumps in-working orr:(yps or no)_"
I
Comments:
(note of pump chamber,condition of pumps and appurtenances,etc.)
-- /7 ssf.ylP.wTs
(revised 11/03/95) 7 `'; �•: °i
• I"
%k 1 J,
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
.4
PropertyAddrom 116 Bristol Ave Hyannis ,Mass
Owner. Joseph White "
Date of Inspection:$/23/9 6 ;
SOIL ABSORPTION SYSTEM(SAS):,
(locate on SIN pla4 if Poe-11 ;excavation not required,but may be approximated by non latrusive msthods)'
If not 6termined to be present,explain:
; r
Pits,number—L :
Imebing chambers,number: 3 '�f •,� ,...
kachin galleries,number:
leaching trenches,number,leagth:
leaching fields,number,diions ,
overflow cesspool,number:
Commants:(note condition of soil,signs of hydraulic failure,level of po a,a� condition of vegetatiop etc.)
Sand & Gravel•No ai ns of h draulic fa��ure or ponQQling,
is normal.. No repairs needea a e presen lme.
CESSPOOLS:/lJX?—
(locate on site plea) t
Number and configuration:
Depth-top of liquid to inlet invert: Af
Depth of so.-W layer.
Depth of acw"layer
Dimensions of cesspool /1/A
Material of construction: 4)4
Indication of groundwater. > i
• inflow(oesapool must be pumped as part of inspegf o}:)
Comwats: condition of soil,signs of hydraulic failure;level of pondiag,oo dition of vegetation,etc.) L j
!Ue
PRIVY:
(locate on site plan)
Material of construction: /U Dimensions• lU/9
Depth of solids: IVA)
omnents��noottee condition of soil,sips of hydraulic failure,level of pondiag,condition of vegetation,etc.)
(revised 11/03/.95)• 8
SUBSURFACE SEWAGE DISPOSAL SYSTEM 'INSPECTION ,FORH
PART B
SYSTEM INFORMATION continued
SKETCH OF SEWAGE L=SPOSAL SYSTEM:
include ties to at least two permanent references landmarks. or benchmarks`. . '
locate all wells within 100'
Hyannis Water Companyy
`• 775-0063'
loo
DEPTH TO ROUNNATER
-5 depth to groundwater
m,tkgd
- ''of determin ;ion-.orpprox
'a. . at�i-o.'n:
w -
ui t; orf. fil' e Y, a'
tthe n s i67 t -77
..�' •.A rr r .;
. W
U) �7
THE COMMONWEALTH OF MASSACHUSETTS
DEPARTMENT OF .ENVIRONMENTAL PROTECTION
BE IT KNOWN THAT -
Yoseph P. Macomber Jr. .
Has satisfied the Department's qualifications as required and is hereby
authorized to use the title
CERTIFIED TITLE 5 SYSTEM INSPECTOR
as provided in 310 CMR 15.340 and Section 13 of Chapter 21A of the
General Laws. Issued by The Department of Environmental Protection.
June 8, 1995
Acting Director of the ' ' ion of Wate=Pollution Control
rV
TOWN OF Barnstable BOARD OF HEALTH
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM = PART D•- CEIiTIF1CATION
�•'•TiM�T•SS7f�T.1iR�T.TT17..T.1R'RiH►IAA/r71Tf>IRTllT7;-M1'►r+itTlf7tTRrT71R,AAtf7R�R1A7fttf/7 qtt
-TYPE OR PAINT CLEARLY-
. .
PROPERTY INSPECTED
STREET ADDRESS _ 116 Bristol Ave Hyannis,Mass. '
ASSESSORS MAP, BLOCK AND PARCEL #
OWNER's NAME _Joseph White
.tttttR�
'. PART D - CERTIFICATION
NAME OF INSPECTOR _ Joseph-P` Macomber. Jr.
r
J.P.Macombe & udh' Inc.
COMPANY NAME '
COMPANY ADDRESS Box 66 Centerville,Mass. 02632
Street Town or City State LIP
COMPANY TELEPHONE ( � 75 - 3338 FAX ( 508 .) 790 1578
CERTIFICATION STATEMENT
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 .inspeotion . The inspection was performed and any
recommendations regarding upgrade, maintenance , and 'repair are consistent .
with my training and experience in the proper function and maintenance of on-
site sewage disposal systems.
Check one: •' ,
XXXXXXXXXXX Systeui PASSED " t
The inspection which' I have conducted has not found any information
which indicates thatithe system fails to adequately protect public
health or the environment as defined in 310 CMR• 15. 303, Any failure
criteria not evaluated are as stated in the FAILURE CRITERIA section of
this form.
Syst,7m FAILED*
The inspection which:-I have conducted has found that the system fails to
protect the E-)ublic health and the environment in accordance with .Title
6 , 310 CMR 15 . 3031 and as specifically noted on PART C' - FAILURE
CRITERIA of this inspection form.
• r
Inspector Signature' Date 8/26/96
..�
One copy of this ificati6h must -be provided 'to the OWNER, the BUYER
(-where applioablq) and the DOARD OF HEALTH
* "If the inspection FAILED, the owner or•"'operator shall upgrade the system. •
within' o'ne Year of the date of the inspection, unless allowed or required
otherwise as provided in 310 CMR 16 . 305 .
Ise!) _
No.......... •I ._..... Fxa... ..(/..... ..........
THE COMMONWEALTH OF MASSACHUSETTS
ABOARD F HEAD
�� 7i�/� f//........OF...
F.... . L� ...��. ...........
9L
Appliratiun -fur Biipuuttl 10orks Cnunutrurtiun Prruid
Application is hereby made for a Permit to Construct ( ) or. Repair ( ) an Individual Sewage Disposal
System at:
Location-Address ----------- � or Lot"N ---�-----�-------�------�---•-----
T o.
/ 5 ......... S
y Address
¢�_._./... •-- ................................ ..•--......................-•--•-.................................._.....----•-...................
Installer Address
Type of Building Size Lot y.13�.__.Sq. feet
Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
A4 Other—Type of Building No. of persons............................ Showers ( ) — Cafeteria ( )
P4 Other fixtures
W Design Flow- S—'_Q-------------------------------gallons per person per day. Total daily flow....j;;..GTI...........................gallons.
WSeptic Tank/_Liquid capacity/,017jl_gallons Length---------------- Width................ Diameter................ Depth................
x Disposal Trench—No..................... Width-----._ ota;�enh---..........___._.. Total leaching area.._.....__......_...sq. ft.
Seepage Pit No_____________/-- Diameter..... th e Total leachingarea........._......_.sq. ft.
Other Distribution box ( ) Dosing tank ( ) d 3= �V
aPercolation Test Results Performed by................................................... --••••-•••-•---•••-•-- 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........................
................................................•-------•-•-----•--..................---•--....._......-•--••-----...-•-•--............•--._...•---.....-----
O Description of Soil...... ...............
x -. ----------- --•- -- --------------------- --------
W
----------------------- -. --- -- `'"--.--=-----
------------ • .-
V Nature of Repairs or Alterations—Answer when applicable...____........................................................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article XI of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has be issue by the board of health.
tgn . ..-• ........ ....... •- ...............................
Date
Application Approved By..-- -- .. . ... .... �-------•-------•----- •-------� ......
Date
Application Disapproved for the following reasons:.................. .............•-----•-----•-•-------•--------.........••--•------.....---------........------
•.............................................................•-•-•-------•---•••-•----•-••-•....•--•----...........-----•--•---......._..--••--•--....-•-------•--------.............------........-----
/ .........................
Date
PermitNo--------------------------------------------------------- Issued....�-�--f-- --. -
Date
N00 ..jm.......
Fick ..............
THE COMMONWEALTH OF MASSACHUSETTS
BOARD H EA1 •r. ... . . ..
...OF.
.... .............
Appliration -for IN-4pniial Morko Tonfitrurtion Vinnift
Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal
System at:
...... ..........&.�A ......41.r..............
......................................................................
Location-Address I No.
.............................g / f
<V.j..i9A.
0*ner Address
............sm............ . . ............................ -------------------------------------------------------------------------------------------------
Installer Address
Type of Building Size Lot_/Y'_'..03_/V....Sq. feet
Dwelling—No. of Bedrooms......._.._. ...............................Expansion Attic Garbage Grinder
aOther—Type of Building No. of Persons............................ Showers ( ) — Cafeteria
Otherfixtures .....................................................................................................................................................
Design Flow._.ro-------------------------------gallons per person per day. Total daily flow....ar,44FIV...........................gallons.
04 Septic Tank Liquid capacity/AOIV.gallons Length................ Width................ Diameter..._............ Depth................
17
Disposal Trench—No. .................... Width....... ota Len th__ rea....................sq. f t.
Seepage Pit No............. Diameter....../ ;v leaching aarea..................sq. f t.
... th e Total leachin
Other Distribution box Dosing tank
Percolation Test Results Performed by.......................................................................... Date-----------.....---------------.........
Test Pit No. 1----------------minutes per inch I Depth of Test Pit.................... Depth to -round water....__._............_...
Test Pit No. 2................minutes per inch Depth of Test Pit.............____... Depth to ground water_............_.._._.....
....... ----------*------------------------------------------------------------------*------------------------------------------------*------------------
0 Description of Soil........................................................................................................................................................................
U .......................................................................................................................................................................................................
W
........................................................................................................................................................................................................
Z
U Nature of Repairs or Alterations—Answer when applicable.................................................................................................
............ .....
Agreement
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article XI of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has bevi�-'ssu e by the board of health.
AA,
ign ... . ... .....
....... . . - ----- - ........ .....................
Date
Application Approved By.. -----------'/---?.�.74......�.
----------------------
Date
Application Disapproved for the following reasons:.................. ............................................................................................
.......................................................................................................................................................t.................................................
Date
PermitNo......................................................... Issued........................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD a IF HEALT)A
.
.. .. ...............OF a-
atifiratr of Tompliatta
1 16 TO PTI
.
I `the In *vidual Sewage Disposal System constructed /--)-`or Repaired
_---- . I . .. . . ..... .. ............... -
--------------------------------------------------------------------
n ler
at....... ....
... .. ........ .. . ....................................................................................
has been installed in accordance with the provisions of I of The State Sanitary Code a5 desc�..-..-...._....
d in the
7
application for Disposal Works Construction 0----- ....
Permit N ........0..................... dated ..!!! 00
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 HEA
................. ...........
No...... ........ ........OF.. FEE...AV...........
Di_svniml rkii, Qlanfit rti it it
Permissionj*j.,4aWby granted----!!nn... ... .. ....... -------- ...... ..... .. . .......... ........ ....................................
to Co nsA c t or an I IvidAa-I e" sal yst
at No..
�a*--- .. . .... . . ... ..... ... .... .... .............. ................
street
as shown on theapplkation for Disposal Works Construction r it N .. ..... . ed----- .. ...... .......................
.. . ..........................
oar o He �
DATE....../ / ,4'
......................................
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
BY DATE SUBJECT . . SHEET NO. OF
CHKD. BY DATE ............... .., . JOB NO.
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l_OC&.TION : SEWiiCjE PERMIT UO,
IWSTQLLER 5 1 &ME ADDRESS
13U1LDER 5 Q &MF- ADDRESS
Jrl-
Dt►TE PERKA T ISSUED
DATE COMPLI &MCE. ISSUED : 1'a=7-4g�
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