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Home My WebLink About0085 CARLOTTA AVENUE - Health 85 CARLOTTA AVENUE, HYANNIS A= p G V John Grad D.E.P. Title V Septic Inspector 564-6813 . SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORK Address of property Owner's name Date of Inspection PART A CHECKLIST Check if the following have been done: V Pumping information was requested of.-the owner., occupant, and Board of Health. L" None of the system components-have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. As built plans have been obtained and examined. Note if they are not available with N/A. The facility or dwelling was inspected for signs. of sewage back-up. The site was inspected for signs of breakout. J All system components, excluding the SAS, have been located on the / site. ,J 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. J The size and location of the SAS on the site has been determined based on existing information or approximated by non-intrusive methods. . The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of SSDS. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM FART B SYSTEM INFORMATION FLOW CONDITIONS If residential -- number of bedrooms =. number of current residents garbage grinder, yes or_ no 16 laundry connected to system, yes or no V- seasonal use, yes or no - If .nonresidential, calculated flow: - Water meter readings, if available: Atov�� Last date of occupancy GENERAL INFORMATION Pumping records and source of information: ✓1U System pumped as part of inspection, yes or no if yes, volume pumped Reason for pumping: iSeptof 'system ic tank/distribution box/soil absorption system Single cesspool y 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. Source of information: Sewage odors detected when arriving at the site, yes or no r -..'-.....-.......,..�_._,_._-- -•;,.-.-.�-.� -...._-._..-.-.P,4,._.,....•...-,ram.-n.:,mn.n-----s--"--r--.--�,,n f.. .,-•,—�..,._ — ,_.... _ 9 ,:;ZUBSURFACE SEWAGE DISPOSAL SYSTEM IYdBPECTION FORM PART B • �' SYSTEM INFORMATION continued - SEPTIC TANK} (locate on':.site plan.) _.. depth below- grade: material of Vnconstruction: concrete metal FRP other(explain) dim 6nsions: r �, �4 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 U distance from bottom -of scum to bottom of outlet tee or baffle Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in:-relation to outlet invert, structural integrity, evidence of leakage, recommendations for repairs, etc. ) DISTRIBUTION BOX: (locate on site plan) depth of liquid level above outlet invert Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, recommendation for repairs, etc. ) PUMP CHAMBER _ (locate on site plan) pumps in working order, yes or no Comments: (note condition of pump chamber, condition of pumps and appurtenances, recommendations for maintenance or repairs,etc. ) ' 1C SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM. PART B SYSTEM INFORMATION continued 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 and number low Gal 01 leaching chambers and number leaching- galleries and number leaching trenches, numbe_r,. length leaching fields, number, dimensions overflow cesspool, number Comments: (note condition of soil , signs of hydraulic failure, level of ponding, condition of vegetation, recommendations for maintenance or repairs, etc. ) CESSPOOLS (locate on site plan) : number and configuration 41 depth-top of liquid to inlet invert depth of solids layer depth of scum layer dimensions of cesspool materials of construction indication of groundwater inflow (cesspool must be pumped as part of inspection) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, recommendations for maintenance or repairs,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, recommendations for maintenance or repairs,etc. ) 11 ` SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION DORM - PART E SYSTEM INFORMATION Continued SKETCH OF SEWAGE DISPOSAL SYSTEM: . include ties to at least two permanent references landmarks or.- benchmarks locate all wells within. 100 ' �1LC�C I! A A � D � DEPTH TO GROUNDWATER depth to groundwater method of determination or approximation: C }5 12 SUBSURFACE SEEPAGE DISPOSAL SYSTEM INSPECTION FORM PART C _. FAILURE CRITERIA - Indicate yes, no, or not determined (Y.' V, -or ND) . Describe basis of determination in all instances. If "not determined", e;-plain why- not) -; Backup of sewage into facility? Discharge or ponding of effluent to the surface of the ground or surface waters? Static liquid level in the distribution box above outlet invert? Liquid depth in cesspool <b" below invert or available volume< 1/2 day flow? Required pumping 4 times or more in the last year? number of times pumped Septic tank is metal? cracked? structurally unsound? substantial infiltration? substantial exfiltration? tank failure imminent? Is any portion of the SAS, cesspool or privy: below the high groundwater elevation? 1 within 50 feet of a surface water? within 100 feet of a surface water supply or tributary to a surface water supply? i within a Zone I of a public well? within 50 feet of a bordering vegetated wetland or salt marsh (cesspools and privies only, not the SAS) ? within 50 feet of a private water supply well? . 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 analy: for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate. nitrogen. 13 SUBSURFACE -SEWAGE DISPOSAL SYSTEM INSPECTION FORM f - PART D _ CERTIFICATION - Name of Inspector - - Company Name JOHN GRAM Title Y Inspector_ _ Company Address P.O. Box 2119 Teaticket, MA 02536 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 inspection. The inspection was performed and any -recommendations regarding upgrade, maintenance and repair are consistent with my training and experience in the proper function and manitenance of on-site sewage disposal systems. !hfeone: I have not found any information which indicates .that the 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. I have determined that the system fails to protect public health and the environment as defined in 310 CMR 15. 303 . The basis for this determination is provided in the FAILURE CRITERIA section of this form. Inspector' s Signature Date Original to system owner Copies to: Buyer (if applicable) Approving authority tr W v Cro IV —71 77 i 1 � _ +:r — v 4 - Ld F ( ( 1 J i ` 1 k --—: -- -- TOWN OF - BOARD OF HEALTH pSIJBSIIRFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART D CERTIFICATION - p -TYPE OR PRINT CLEARLY- PROPERTY INSPECTED - STREET ADDRESS ASSESSORS MAP, BLOCK AND PARCEL - - OWNER' s NAMEC�(��1 '�` '� - PART D - CERTIFICATION NAME OF INSPECTOR � r Gfac� COMPANY NAME JOHN. GRAC' i eInspector - COMPANY ADDRESS P.O. Box 2119 Street C e , 02536 Town or city State LIP COMPANY TELEPHONE-(41- ( FAX 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 inspection . 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 e : System PASSED The inspection which I have conducted has not found any information which indicates that the 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. System FAILED* The inspection which I have conducted has found that the system fails to protect the public health and the environment in accordance with Title 5 , 3.10 CMR 15 . 303 , and as specifically noted on PART C - FAILURE CRITERIA of this inspection "rm . Inspector Signatures Date CO Z G45 One copy of this certification must be provided to the OWNER, the BUYER ( where applicable) and the BOARD OF HEALTH. * If the inspection FAILED, the owner or operator shall upgrade the system within one year of the date of the inspection, unless allowed or required otherwise as provided in 310 CMR 15 . 305 . partd.doc TOWN OF BARNSTABLE LOCATION CJ� �( n SEWAGE # VILLAGE +- ASSESSOR'S MAP& LOTC;? INSTALLER'S NAME&PHONE NO Q,Scc, SEPTIC TANK CAPACITY 1600 / // LEACHING FACILITY: (type)—1U 6o SS4r)e (size) Co — Co NO.OF BEDROOMS 3 BUILDER OR OWNER (.( PERMTTDATE: Zo -?Z COMPLIANCE DATE; " U- CI Z Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility ¢ Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet ofNac g fac' 'ty) Feet Furnished by 1 s � V4 VO r> zb lr' 0 P S 1 TOWN OF BARNSTABLE _LOCATION SEWAGE # � VILLAGE ASSESSOR'S MAP & LOT vl V g- I fo/ c INSTALLER'S NAME & PHONE NO. Ad SEPTIC TANK CAPACITY /a 6 , LEACHING FACILITY:(type) /d 60 60&4Qv) NO. OF BEDROOMS 3 PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER DATE PERMIT ISSUED: 6,e.L& DATE COMPLIANCE ISSUED: 3 6 - g VARIANCE GRANTED: Yes No g/ � "nS T J p � . �/ '�O �O _ .. t ,^_ 14 $ � dGI $30 00 No.. �:-2.�a Fps............................. THE COMMONWEALTH OF MASSACHUSETTS T BOAR® OF HEALTH TOWN OF BARNSTABLE Appliratiun for Disposal Works Tunutrnrtiun ramit Application is hereby made for a Permit to Construct ( ) or Repair (X ) an Individual Sewage Disposal System at: --_85 Carlotta Ave W. Hyannisvort ...... ..... .--•- _... ..... ...................................•-------..._----------•----•--••--------------.........._---_.. Location-Address or Lot No. Sue White Owner Ad` s a W.E. Robinson Septic Service P O Box 1089 Centervi 1e ..............•-----•--•------ -•--•--•-----------•••----•------- Installer Address 14 Type of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms---3.......................................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( ) dOther fixtures ----------------------------------------------------------------------------•---------=----------•--------....--------••-•-•---------.........._.__.. w Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length---------------- Width-............... Diameter---------------- Depth.........-...... x Disposal Trench—No.____________________ Width.......-............ Total Length.................... Total leaching area....................sq. ft. Seepage Pit No-_------------------ Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by..........................................-•------•--•-------•----•------ Date........................................ 4 a Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 44 Test Pit No. 2................minutes per inch Depth of.Test Pit---:................ Depth to ground water........................ a ------- ------------------ ----•--••-----••--- -----••--•------------•--.....-•--•---•---......................................................... 0 Description of Soil-------------sand---------.........................................................-....................-----------•------•----•-------•-------------------............•--- x w -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- U Nature of Repairs or Alterations—Answer when applicable................................................................................................ a_nstalLing--a._1tQOQ--gal... ank.,D_box,and..1_,00.1.gal-Aeachpit------------•-------------------------------------------•---. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance-with the provisions of TITLE 5 of the State Environmental Code—The undersigned fu ther agrees not to place the system in operation until a Certificate of Compliance has been ' sued Tt rd health Signed .........e 1. / ---- ------ ---------------------------- -------------- ........ ............. Dace Application Approved By ................. �' V.. 3 - f� -"----Dtte Application Disapproved for the following reasons- ................................................. ----- --- --------------- . ----........-----------------............. -------------------- ...... .- q Da re Permit No. ------/ .................. Issued Dare No..� ^a.8� F�s. 3A�AO........... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE App iratuan for Disposal Works Tnnitrnrtinn ramit Application is hereby made for a Permit to Construct ( ) or Repair (X) an Individual Sewage Disposal System at: •..................... ............................................... ......- ....--- Location.Address or Lot No. ..................... ..........-•..........................................•--------•••.............................. Owner Address a W., ..Robinson Septic Service P O Box 1089 Centerville „ - Installer Address Type of Building Size Lot............................Sq. feet 1-, Dwelling—No. of Bedrooms---3......................................Expansion Attic ( ) Garbage Grinder ( ) aa Other—T e yp of Buildin g ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( ) dOther fixtures ..........................-----•------------------••--------------•-----------------------.......................................................... Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No..................... Width..............._.... Total Length-------------------- Total leaching area....................sq. ft. Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date------------ W Test Pit No. 1................minutes per inch Depth of,Test Pit-..-___--------.__- Depth to ground water......................... f=, Test Pit No. 2................minutes per inch Depth of.Test Pit.................... Depth to ground water........................ .........................................-.........................................................•........................................................ 0 Description of Soil............Sand......................0.........-----------••-----------------------------------------......-----------••----•-------••----•-------.._..--------- x U W •------------------------------------------- -------------------------------------------------------------------------------------............................................................... U Nature of Repairs or Alterations—Answer when applicable............................................................................................... nnn ..,-, 1__ r-U --D_lv.�s --aner7 1 1?(� _rr�l 1� c�l**17.t..................... .y _.6_._�c__..... _tia_ ':J.e.^_� ......___� J.............. . . .... ............................ Agreement: t , The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place.the system in operation until a Certificate of Compliance has been issuedsby •e boar of health. { ' .. Signed -�� - ------------- - ---------------------------------------- Application Approved By ..................v..._.......... ..... to -RIP Application ...............Date-----.-...._...- Application Disapproved for the following reasons- ---------------------------------------------------------............................----................................---------- - — r ----------- -------------- �- -__..._-----. ............................... .. Date ..- PermitNo. ------------------------------------------ - Issued -------------------------------------------------------------------- Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Ole>r#tftrate of Cguntpliance THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( X ) b "?�E ... T'- -�- ,�.,.-, nraA S ----------------------------------------------------------------------------- Installer at -------85 Carlotta Ave W. nsport ----------------------------------------------------------------------------- ---------------------------------------------------------- has been installed in accordance with the provisions of TITLE 5 GI-Xh e Srj6Environmental Code as described in the application for Disposal Works Construction Permit No- ------------------------_-.----____......_-.--. dated ..-.--...-.._-----_--..---.................... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. ' DATE � �-� ----- ------------------------------------------- Inspector --------------------------1 '----- ............... -------------------------------- f = - THE - COMMONWEALTH OF MASSACHUSETTS } BOARD OF HEALTH [ 0(1/ TOWN OF BARNSTABLE No......................... FFX....NA0---- Roposal Works Trrnstrnrtiott ]Jrrmit Permission is hereby granted---K -R ...........................................................____ to Construct ( ) or Repair ( X) an Individual Sewage Disposal System at No...85_ a l.ott3.Acre_T!a--Hyanni sp ar#t------------------------------------- 7 Street �'d.�o---------------------------------------................. as shown on the application for Disposal Works Construction Permit N2t�___S'--____ Dated------------------------------------------ ----------------------------- ------------------------------------------------------------------------ Board of Health DATE-------------------------------------------------------------------------------- FORM 36508 HOBBS Q WARREN.ING,PUBLISHERS