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Home My WebLink About0112 CONNEMARA CIRCLE - Health 14,2-Connei ara- Crcle ----- - ---- --- -- - --- _ . . Hyannis - — — 1� \� A=290 138 o ° o i g ° o I u ° 0 �1 `u 1 ° ° ° o 0 , TOWN'OF BARNSTABLE OCATION ��C=.QT:!1Y�� . ja,,.0�� SEWAGE# VILLAGE 5�-- ��1� ASSESSOR'S MAP&PARCEL 6 ON NAME&PHONE NO. SEPTIC TANK CAPACITY AgC1S LEACHING FACILITY:(type) (size) G, NO.OF BEDROOMS OWNER �nSQri"b�n . P�DATE:�1T Z 1�� COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY � co EXECUTIVE OFFICE OFbAc;tiUSETTS EN DEPARTMENT OF E VIRONr,IE��' 'FAIRS NVIRONMENTAL PROTECTION TITLE S OFFICIAL INSPECTIONON FORM SUBSURFACE SEWAGE FOR VOLUNTARY DISPOSAL,SY TEFORM ASSESSMENTS PART A CERTIFICATION Property Address: Owner's Name: Owner's Address: Date of lmp fttion: Name otlnspector: lease rint) Company Name: j Ming Address: Ck- _ Q umber. phone N Tele ,.� CERTIFICATION STATEMENT I certify that I have personally inspected �. below accurate the sewage disposal system at this address and complete as of the time of the inspection.The • and that th training e in the proper function and �pection was �°rmahon reported approved system inspector pursuant to Section 13 qp o jye Son site 310 sewage �O d bas on arty CMR I disposal sYs .I am a DEP The s tem: Passes Conditionally Passes Needs Further Evaluation b Fails Y the Local Approving authority Inspector's Signature: The system inspector shall sub Date: DEP)within 30 days of complettiintg y Y of this inspection report to the Approving gpd or greater,the ' inspection.If the system is a shared system o has Authority e�°azd of Health or inspector and the system owner shall submit the report to the a DEP•The original should be sent to the system owner design flow 1of 10,000 authority. and copies sent to the buyer,appropriate regional otEce of the :f applicable,and the approving Notes and Comments _ "Y�C`1 C\rl tC_ This report only describes conditions at the time of inspection and under t time. This ofuse inspection does not address how the system will perform in the f conditions use. he conditions Of muse d that future under the same or different Title 5 inspection Form 6/1512000 page 1 . OFFICIAL INSPECTION FORM ' S�SURFACE SEWAGE FOR VOLUNTARY ASSESS OSAL SYSTEM INSPECTION FOB T3 CE PART A RTIFICATION(continued) Property Address: Cp f we-c1 ckc ,. C {- Owner: L ` Date ofInspectl a: 2 In+Pectloa Summary; Check A,B,C,D or 9/ALW_AYJ complete all otSectloa D A. System passes: I have not found any information which indicate 15.303 or in 310 CMR 15.304 exist,An s that.any of the failure criteria described in 310 CMR y failure criteria not evaluated are indicated below. . Comments: B. .System Conditlon .aUy Passes. . or more system components as described is the'• ��d' MOW upon completion of the Conditional Pass"section need to be replacement or repair,as approved by the Board of Health., ds Answer �:will pasa. L Yea no or determined(Y,p�)is the for the following statements, If hot determined"please unsound,The septic tank is meta(aad over 20 years old*or the s exhibits substantial • tration os exfiltration or septic tank(whether��or not is existing tank is replaced with a co lying s tank failure is imminent,System will structurally 'A metal septic tank will p� • septic tank as approved by imminent Board of Health. Pass inspection if the on indicating that the tank is less msleC ' if it is structurally souad,.not leaking than 20 Y-"1 old is available. / g if.Certificate of Co mplience ND explain: i Observation of sewage backup or break out or hi obstructed pipe(s)or due to a broken, static water level in the distribution box due to broken or approval of Board of Health): settled or,uaev�n distribution box. System will Pass inspection if(with ob broken,"Pipe(s)are re ced struchon is removed — distribution box is leveled o replaced ND explain: The system required p�iunping more than 4 Pass inspection if(with aP royal of the Board of Heath)es a Year due to broken or obstructed P i \ Pe(s). The system will broken pipe(s)are replaced obstruction is removed .'VD explain: ' T:No C Tnennr►inn Rnrrn�i�ennnn 2 . OFFICIAL INSPECTION FORM_NOT FOR VOL SUBSURFACE SEWAGE DISPOSAL SYSTEM IN,I,SPE�CT�SESSMENTS CERTI FICATION(continued) PART A ION FORM � Property Address: I 'C�, i i Owner: Date otInspec C• Further Evaluation Is Required by the Board of Health: \editions exist which require further evaluation b �B is failing to protect public health.safety or the environmenty. Board of Health in order to determine if the system 1• System will pass unless Board of Health determines in accords / system Is not incdoning in a manner which wf"protect public health,th 310 CMX 13303 1 ' ( )(h)that the safety and the envli'onmeat: Cesspool os is within 50 feet of a-stnfac water �f Cesspool or ppr'iv within SO feet of a bordering vegetated / fed wedand or a salt marsh 2. System will fail unless the Board of ealth(and Public VVst6,zZ r Su Ilex system is tbnctioning ins manner that prot is the public h al pp 'if any)determines that the f th,safety and environment: The system has a septic tank and soil ab ' surface water supply or to option system(SAS)and the SAS is within 100 feet of a butary to a surface wate{supply. _ The system has a septic tank and SAS and,the<\ .is within a Zone 1 of a public water supply. The system has a septic tank and S and�e SAS�>s within SO feet of a Private _ The system has a septic tank and Sa P to water supply well, private water supply well'e, Metho used t de S�Js l�� 100 feet but 50 feet or more from a determine distance ��.. *This system passes if the welFwater analysis, bacteria and volatile organic 6 Y s,performed at a DEP certified laboratory, the presence of ammo �o�indicates that the well is free for coliform failure criteria are ammonia nitrogen and nitrate nitrogen is equal ti or less m pollution from that facility and 8g� A copy of the analysis must be attached to this fo`rm, m,provided that no other 3. Other: / Ti►lo � lnannrlinn l:nrnnl/1G/7/�/�/� 3 OFFICIAL INSPECTION FORM SUBSURFACE INSPECTION FORM—NOT FOR VOLUNTARY ASSES DISPOSAL SYSTEM INSPECTION ASSESSMENTS PART A CTION FORM CERTIFICATION(continued) Property Address: D Owner: Date of Inspectio : D. System Failure Criteria applicable to all systems: You MM indicate"yes-or"no"to each of the following for aLispections; Yes IBackup of sewage into facility or system component due to overload Discharge or ponding of etilueat to the s overloaded or clogged clogged SAS or cesspool �e°f�ground or s du to a or cesspool L Static liquid level in the distribution box above outlet Face waters overloaded or cesspool et invert due to an overloaded or clogged Liquid depth is cesspool is less than 6"below invert ��3A3 or Of rimed P�Pmg mOfa than 4 times in the last yer or available volume is less than%day flow � Pumped�. �Qadne to clogged or obstructed 4Any Portion of the PiPe(s).dumber Any Portion of cesspool cesspool Or�ry is below high ground water e water SW PmY is within loo feee of a surfine water supply ajy �-b„ Y portion of a cesspool �Y to'a surface Any Portion of a cesspool or Privy s within a ZOnO 1 of s public weLL Y portion of a cesspoolPiny within �50 feet of a private water. or privy is less than 100 feet but roPPIY weLL mPP1Y well with no acceptable water quality anal greater than SO feet from a performed at a DEP certl8ed laboratory, ��. IThia system passes If the well Rate water lndicata that the well L Qree b'om Pollution from that bacteria a and volatile organic compounds ter a nitrogen and nitrate nitrogen is equal to or less than S are M facility and the presence of ammonia �V� triggered.A copy of the analysis must be attached to this�>ru ended that no other is criteria (Yes/No)The system a 1 I have de described in 310 CMR 15.303 fnniaed that one or more of the above failure criteria exist as Health to determine , therefore the system fails.The system owner should contact the Board o what will be necessary to correct the failure. f E. Large Systems: To be considered a large system the system must serve'yes or ,no. g a facility with a deal n tlo gpd. You must indicate either' w of 10,000 gpd to iS,000 (The following cr i ria a st each of the following; Play 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 trib\ e tary fo"a.surface drinlang water supply the system is located in a nitrogen serisit&e area\ Zone IT of a public water sup eu (menus..\llhead Protection Area_ P IWPA)or a mapped If you have answered"yes"to an � \ " yquestion in Section E the system is cow defied a significant"Yes"in Section D above the large system has failed.The o significant threat under Section E or failed under Section D shall u gtuficant threat,or answered l 5.304.The system owne should contact the a wrier or operator of anyl'arge system considered a y upgrade the system in accordance with 310 cA4R / appropriate regional office of the Department Ti►�o c rnonnrtinn Rn...,F/I v7nnn 4 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS ' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: CO>1n Owner. Date of Inspee on: 1 ( t 7 / Check if the fonowinit have been done.You must indicate'eyes"or"no"as to each of the f Y s ollowm No�L Pumping information was provided by the owner,occupant;Of Hoard of Health . Were any of the system components _ / pumped out is the previous tv& weeks? Has the system received normal flows in the previous two week penod? were,as built p lana of large volumes of water been introduced to the system recent! / Y or as part of this inspection? the system obtained and examined?(N they were not available note as N/A Was the facility or dwelling ) / g 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 of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge an o the condition depth f 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 Soll Absorption System(SAS)on site has been de Y¢S no fined based on. Existing information.For example,a plan at the Board of Health. ;L _ Determined in the field(if any of the failure criteria related to P is unacceptable)[310 CMR 15.302(3)(b)J art C�s at issue approximation of distance Title i lnonnrlinn Rnnm b/1 ii7nnn - 5 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY A SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION F Sr'IENTS PART C FORM SYSTEM INFORMATION Property Address: Owner: Date of Inspectloqqig RESIDENTIAL FLOW CONDITIONS Number of bedrooms(design):—�L Number of DESIGN now based on 310 13.203 for example: )' Number of current residents: ( xample: 110 gpd x of bedrooms):2_?(� Does residence have a garbage grinder(yes or no):11D Is laundry on a separate sewage system(yes or no): 4 ( if Laundry system Inspected(yes or no):1a Yes separate inspection required) Seasonal use:(yes or no dl Wad meter readings,if available(last 2 years usage(gpd)); Sump pup(yea or no):= Last date of occupancy: �( COMMERCLUANDU TRIAL Type o 1ishment: Design flow on 310 CAS R 13.203 : Basis of design flow ) Q1°`t Grease trap present(yes or opersona/sq�etc.): Industrial waste holding tank r.ao _ � o ).. Nor-sani he .-�..-. Lary waste discharged to t _Title Water meter readings,if available:' ten(yes or no): Last date of occupancy e: OTHER(describe): \� Pumping Records GENERAL MFORMpTTON Source of information: - W89 9 d Ify�vowp� P thainspection(yesorno): Reason for pumping: quantity lions(Flow was quantity Pwriped determined? tJ E OF SYSTEM Septic tank distn butien box;Single cesspool soil absorption system ._ Overflow cesspool Privy _Shared system(yes or no) if yes, attach previous inspection records,if any) _Innovative/Altermtive technology.Attach a copy of the current operation and maintenance obtained from system owner) Tight tank contract(to be gh _Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known))and source of information: (\ Were sewage odors detected when arriving at the site (yes or no): t Z() T:/ln f rnena�finn ;/7nnn 6 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C FORM SYSTEM INFORMATION(continued) Property Address: Owner: Date of Inspec on: L O j6� WELDING SEWER(locate on site plan) Depth below grade: 14 — n Materials of constriction: cast iron ,�40 PVC Distance from private water supply well or suction line:other(explain): Comments(onfonditiOu of joints,venting, w J evidence o leakage,e : IC i SEPTIC TANK;_(locate on site plea) - - - Depth below ,� t` grade: 2`� Material of constnucion:fcoacrete_metal —otlur(explain) — _polyethylene If tank is metal fiat age:— Ia age confirmed b certificate) I Y a Certigcate of Co Dimensions: I/ K Ci (0 00 c I chance(yes or no):_(attach a copy of Studge depth:— Dime from top of s dge to bottom Scum thickness: of outlet baffle: tee or bae:-- _ �� Distance m to of scum to <<P top of outlet tee or baffle: of scum to b — ` Distance frfroom bottom bottom of ou et t or baffle: t '� How were dimensions determined; Comments one - v ( P�nver rewdence of aka, Wet and outlet tee or baffle conditto s as related to oltlet invert,evidence of 1 aka n, tructural y c, c p,etc.): ' integrity,liquid levels GREASE TRAP:_(locate on site plan) Depth below grade:._ Material of construction: concrete (explain); — — tat_fiberglass_polyethylene_other Dimensions• Scum thickness: Distance from top of sc m o top of outlet tee or baffltr_ ; m Distance from bottom of scu to bottom of outlet.tee Date of last pumping:_ Comments(on pumping recommell ors,inlet and outlet tee or baffle conditi structural roteon, as related to outlet invert,evidence of leakage,etc.): BritY,liquid levels Tiflis � fncnnrlinn G'nrrn F/��/7nnn 7 OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION ION FORM PART C CTION FORM SYSTEM INFORMATION(continued) Property Address: l�"� Owner: Date of In pecti n: TI or HOLDING TANK: (tank must be Pumped at time of' Depth below �Pectton)(locat9 on-n grade: Material of construction:__c rite fiberglass Dimensions: --P9�Y tal yleae_ o�explain): Capacity, lions�'`�� *M Flow: Gallo y Present(Yea or no):- - -- - - Alarm level: Al Date of last pumpin R`O�g°�(yes or no):_ Comments(c a of alarm and float switc hes,etc.): D197RMUTION BOX: (ifpresent must be opened)(locate on site plan) Depth of liquid level above ou e Comments(note if box is level and distribution to out e leakage into or out ofbox,etc.): rice of solids c arryover,any evidence of pL7*"L BER:_(locate on site plan) Pumps in working order(yes or no): Alarms in worldng order(yes or no):—. Comments(note conditioa�of---' chamb ~� '�-'----- pump er, condition ofpumps and appurtenances— ,etc.), I Titlo fncnnrfinnP .mF/1�j,)AAn i g i i OFFICIAL INSPECTION FORM_NOT F SUBSURFACE SEWAGE DISPOSALSTEM IN ORVOLUNTARY ASSESSMENTS PART C SPEC1`ION FORM SYSTEM.INFORMATION(continued) Property Address: sc. Owner: Z - Date of Inspec n; Z SOII,ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why. ./ i�BP�.number:�. 1�Ov eaclung chambers,numbs!; - - - - - =leaching galleries,number. leaching trenches,number,kngtb; leaching fields,number,pensions: overflow cesspool,number. :nnovative/altm=dve system Co�nta(note condition of soil,sib of h name of omology; etc.): Vie,level ofpondin l� C l l S+�mP soil, condition of vegetation, V e 6 e- ; b a. 1 plc c CESSPOOLS:,(Cesspool nwst be Piped as part of iaspectionxlocate on site plan) Numb4ln4,configura don: Depth—top ofli d to inlet invert: Depth of solids la Depth of scum layer.. Dimensions of cesspool: Materials of construction: 7_, Indication Of groundwater inflow Comments(note condition of so' ( e3`or no�__ d,signs ofh,draulic failure,level Of po -din coadi4ioa of vegetation,etc.): PRIVY% (locate on site plan) Materials of construction: / Dimensions: ` Depth of solids: Comments(note condition of soil si$nofhydaulic fail , level of ponding,condition of(egetation, etc.): ure T'No � incnantinn i:n..n��/�nnn 9 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner: - Date of Insp a: I 2 SIZTCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent 1c&reaoe lmub&rks or benchmarks,Locate all wells within 100 feet locate where public water supply eaters the building. -9 0� in OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner: L Date of linspec on: SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water, feet Please ialicate(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: Checked with local excavators,installers-(altach dtation Accessed USGS database-explain: )2 (�� • Cj 1. Y In must dlqcnlm how yo established high groin water elevation:SW f S T410 4/1 ti ��F F v v 6&05L f3c�iL VEA T��y C OnofPI,F,#T,b 7V o 4 1' ti 0 O jJ