HomeMy WebLinkAbout0094 DUMONT DRIVE - Health 94 DUMONT DRIVE
HYANNIS.
�, ,A -
No- C6) I o Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS
Application for Misposal 6pstem Con urtion Vermit
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon(X ❑Complete System ❑Individual Components
Location Address or Lot No. 9'(* 8 t�A 5® l`I�Tt��Es Owner's Name,Address,and Tel.No.
HYALw K_. P�t�bit
Assessor's Map/Parcel 3 0 7 O 9 �( �v Do- (4VA&)P K
Installer's Name,Address,and Tel.'No. ,SOS—�7--a' 1 Designer's a g Address,and Tel.No.
l', Cv u ` lt*54fl*Zr1
Type of Building:
Dwelling No.of Bedrooms Lot Size 7 q qo — sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) f'i/� gpd Design flow provided A)it gpd
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable)
_--_ A0 4X)A0,o' 6uST I04tr Sf--V tc— 5'YSTV1Z'--
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board of Hea /
Si IdaDate `�' ���'�ol,�('
Application Approved by Date /
Application Disapproved b Date
for the following reasons
Permit No. 2 I(} Date Issued A/)b L-m I q
No.�0 t"! 'o 1 Fee 12 �D THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS
01ppYiration for Disposal .6pstem Construction permit
Application for a Permit to Construct Repair Upgrade Abandon �Complete System Individual Components
PP ( ) P ( ) Pg ( ) (� ❑ P Y ❑ P
Location Address or Lot No. 9 C f DVA44vuT 1>12.1ue Owner's Name,Address,and Tel.No.
Hy,40v'!S PFrL_c1 b*rjN ZA
Assessor's Map/Parcel 307 p v D&I OYAtj P (y
Installer's Name,Address,and Tel. o. S p�,-tEsl a' 71 Designer's Name,Address,and Tel.No.
c�co�lr� �•���d �. N1�,
s c v
Type of Building:
Dwelling No.of Bedrooms Aj er Lot Size _7 '9 qQ ± sq.ft. Garbage Grinder( )
Other ` -Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) kit gpd Design flow provided A)�} gpd
Plan Date Number of sheets Revision Date
Title Y
Size of Septic Tank Type of S.A.S.
Description of Soil
1
Nature of Repairs,or Alterations(Answer when applicable)
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board of Healt '
Signed --- aDate 4—6 "ao i Ll -
. Application Approved by Date
Application Disapproved b Date
for the following reasons
— -- Permit No. I n q Date Issued C/116 /Zfl 1 q
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE,MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( ) Upgraded( )
Abandoned(X)by (�A BEa,,2dT,c CtjTZ72DI1(C ' Ud
at .q4 7 )Mo& r nRI V,F bteAMN 15' has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No.7014"101 dated �' Iq
Installer dAP&W j r)E: Err7MAq fS-f!!C ej C. Designer
#bedrooms Approved design flow A//a , gpd
The issuance of this permit all not be
construed as a guarantee that the system will;0-Inc,tiion as designed.�J, � � �f)
Date Vi' 1 Inspector
v�r
r j,V _ W
No. GQ I Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS
Bisposal bpstem Construction Vermit
Permission is hereby granted to Construct( ) Repair( ) Upgrade( ) Abandon(
System located at 94 OL2U C) Doq l aicd H1/,d�MAM S
and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with
Title 5 and the following local provisions or special conditions.
Provided:Construction must be completed within three years of the date of this permit.
Date Approved by
'i
d..
_ .. - - -- --- -----
Town of Barnstable Barn
r�
Regulatory Services Department AffAmmicae j
4 MY4,C•�B.F I I
���� __ _ _ __ _. . _ Public.Health Division _
_. _
Main200 Street, yannis MA 02601
Office: 508-862-4644 Thomas F.Geiler,Director
FAX: 508-790-6304 Thomas A.McKean,CHO
CERTIFIED MAIL#7012-1010-0000-2848 -0158
March 28, 2013
PETER BARBOZA
94 DUMONT DR IMPORTANT NOTICE
HYANNIS, MA 02601 Map & Parcel: 307- 091
The Department of Public Works informed us that public sewer lines are now
available in your neighborhood. According to our records, your property has a septic
system. This letter directs you to connect your dwelling, at 94 Dumont Dr, Hyannis,
MA, to public sewer on or before 3/30/2015.
The old septic system must be either removed or filled in due to future safety
concerns. This may be done by the same contractor who connects you to the sewer.
Septic Abandonment Permits ($ 25) are issued at the Public Health Division, 200 Main
Street, Hyannis.
Failure to comply with this Board of Health Order may result in a complaint
against you, in a court of law.
For additional information pertaining to the sewer connection, please see the
reverse side of this page.
PER ORDER OF THE B ARD OF HEALTH
Thomas A. McKean,R.S., C.H.O.
Agent of the Board of Health
Cc: Barbara Childs,WPC/Roger Parsons,Town Engineering, DPW
Enc.
Q:\SEWER connect\Sample order letters for sewer connection\Form Let3A Sewer hook-up sample 2013.doc
Public Health Division March 28, 2013
ADDITIONAL INFORMATION AND REMINDERS FROM OTHER DIVISIONS:
SAVINGS AVAILABLE/GRINDER PUMP:
A reminder to those of you who need a grinder pump for your connection:
Department of Public Works (DPW) sent you a letter in December 2012 stating the town,
for a limited time of two years, only from the receipt of the DPW letter, would provide
you with the pump at no charge. (This can save you thousands of dollars.) Please note:
You must pay the installation cost through yggr own contractor. Please make your
contractor aware of this, if interested. Also be aware: this is a shorter deadline than
the Public Health Division's deadline on the reverse side of this page.
SAVINGS AVAILABLE/PERMIT FEE:
The Town offers a waiver of the residential sewer connection fee of $420.00 for those
properties that connect within two years of the receipt of the DPW December 2012 letter.
LOANS:
For loan(s) available,-please see the enclosed brochure, or see the town website:
http://www.town.barnstable.ma.us/cdbg (under the "CDBG Programs", see "Sewer
Connection Loan Program). For loan specific questions, you may contact Kathleen
Girouard, Growth Management, at 508-862-4702.
CONTRACTORS:
Information on Licensed Sewer Installers is available on our web site at
www.towii.bariistable.ma.us/Pub]icWoi-ksTech/sewerinstalIers. Contractors, approved to
perform sewer connection work in the Town of Barnstable must obtain and file a Sewer
Connection Permit with DPW-Water Pollution Control Division, 617 Bearse's Way,
Hyannis—contractors, please call Dave Anderson at(508) 790-6244.
FOR ANY QUESTIONS /ASSISTANCE:
Len Gobeil at the Town Manager's Office is available to provide you with direction you
may need in reference to the Stewart Creek Sewer Connections. You may contact him at
508-862-4701.
QASEWER connect\Sample order letters for sewer connectionTorm Let3A Sewer hook-up sample 2013.doc
w, ® TOWN OF BARNSTABLE
LOCATION L.�/ 6^1 ®AyT- "boe, SEWAGE#
iVAAGE ASSESSOR'S MAP&PARCEL
I&4ERSSAME&PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY:(type) (size)
NO.OF BEDROOMS —
OWNER �/L./c� r �,E� B`Z
R£ T DATE: cJ�aZ,�'®� 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
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LO(.TION �L4 rn 7" 'D!!,, SEWAGE #
t V LLAGE N�1 S _ ASSESSOR'S MAP & LOT 307 -OBI/
INSTALLER'S NAME & PHONE NO.
SEPTIC TANK CAPACITY p0 Ca
LEACHING FACILITY:(type) (size)
NO. OF BEDROOMS PUBLIC WATER 7C
OWNER -6 E !�
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes �"
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LOCATLOt�1 SEW�,GE PERMIT KJO. -
091
V-Il..l_pG►E '._ _ �v�cv�.-�.� �JW� S
--IN T-�t`LERS--►J�tJIE -�—ADDRESS— -- - - _ -.
--BUILD-ER S--IJA1./lE --�—ADDR.ESS -- -
--D1�►TE--PERMIT--ISSUEDT_� _1_ _�S—_—____.
s
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No.... Fua..............................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Ow``' �,IA.LSTh,b e-
.. .. OF................... ............. ................................................
Appliratin for Big uiittl orkii Towitrurtion rriuit
Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal
PP Y (?�) P ( ) b P
System at:
C/oL] (y�(� /A�/f// - LMcat/iY[n Address j9V,/ /♦ �//j�?/ (sue./�y�'A ��/�( lL� Lo No.
./ � • ��� �_L � -T5...�X....... 6-_-_/.�.�'.�.1.�...... ../-_..�..• ,�..-=I..(-=_l_V�.f..•--�-�(��!---.-------•---•--------------- .
Owner Ad es
Installer Address
d Type of Building Size Lot-----------------------------Sq. feet
U Dwelling—No. of Bedrooms....... -6...........................Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ----------------------------- No. of persons_-. _®_.______.__ Showers (�) — Cafeteria ( )
Otherfixtures -------•--------------------------•- -•-••------------------------------ ---•------------------------------------
Desi n Flow......••= d2 -- U
W g gallons per person per play. Total daily flow...........................................gallons.
WSeptic Tank—Liquid capacitv-.Q gallons Length................ Width................ Diameter---------....... Depth.__.__---_---
x Disposal Trench—No_ ____________________ Width........_........... Total Length--_---__-_______-_ Total leaching area....elav_-___sq. ft.
Seepage Pit No..................... Diameter-------------------- Depth below inlet-------------------- Total le liing area--_-..-.--.--___-sq. ft.
z Other Distribution box ( ) Dosing tank ( ) yob'`SQl Ar -
Percolation Test Results Performed by------------------------------------------- ...........rc__!�T. Date---------------------------------------
-- -
Test Pit No. 1----------------minutes per inch Depth of "Pest Pit.................... Depth to ground water..-.-.-----.------.--_
�Tq Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water..............•---------
--------------------------------------------------------------------------------------------------------------•--------•-------•----------•---------•-••-----
O Description of Soil---=--------------••-- .. ._............ ._....
---------------------------- o .
------ -- ----
o y"
w -- '�w/--------�-- ------
UNature 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 furth a ees not to place the system in
operation until a Certificate of Compliance has been ' s y th and of healt .
Signed 1_ ------ ----•• --------•-
Date
ApplicationApproved BY------ -------------------•--•--•--•--•-•--••------•---•--•-•--......--------------------
Date
Application Disapproved for the following reasons--------------------------------------------•--..............--•-•-----------------•---•----•-•----------------•-
--•-•----------------------------------------------------------------------
Date
Permit No.----19•24....-•---------•----•---------------- Issued..-- �� ------.
�7 Date
No.... ••--'• Fnic..............................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
'J/4 A rc ;--,r/> C.
_... .... . .OF................................... ........................ ....................
Appliration -for Bi,q oottl Ourks Tutuitrurtion Vrru it
Application is hereby made for a Permit to Construct (/.) or Repair ( ) an Individual Sewage Disposal
System at:
..--••--•-•------•------------------•----'-•---------....._...------------------------------•---•- ---•--•-•••-•--•--•-••••••-•--•••-•--•--•-•-••-•---•••--•-•••••-•••••-•--•-••-•---._..._••-•-•---
Location_Address or Lot No.
--------------------------•--------'..--------'-------------------._..-----•-----'-•---•-•• •----•-•••••-••--•-•-•-••••-•-------•---•••-••-••---•-•'...•••--••••-••••-••-••••---•...---•-•--..
Owner Address
W
Installer Address
Type of Building Size Lot----------------------------Sq. feet
U Dwelling—No. of Bedrooms--------------------------------------------Expansion Attic ( ) Garbage Grinder ( )
per, Other—Type of Building --------------------_------- No. of persons..___.___-___-___________.__ Showers ( ) — Cafeteria ( )
o' Other-fixtures ------------------------------- -
_----------•------- ------------ ..............
W Design Flow_.__..___%--------------------------------gallons per person per day. Total daily flow--------- __-__u_______________._.__.-.gallons.
Gd Septic Tank—Liquid capacit &-�� Ugallons Length---------------- Width-----_._.-.-. Diameter---------------- Depth..--__.__.___.
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 ('O Dosing tank ( ) ��' ' �'� r' F'f`46
'-' Percolation Test Results Performed b '�"'
W y-------- ----------------------------•----.:.. ...-------- Date
Test Pit No. 1________________minutes per inch Depth of 'Pest Pit.................... Depth to ground water........-__-._--__._-...
44 Test Pit No. 2................minutes per inch Depth of Test Pit____________________ Depth to ground water........................
P4 •----------------------------•--•-••---------------•----•-------------•----•----•----•---••----••-••.........................................................
0 Description of Soil--------------------------------------------------------------------------------------------------------------------------------------------- -------_----------------
W S/y/ e, 16 . � �
--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
UNature 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 been issued by the board of health.
Signed...................................................................................... ................................
�� ADate
ApplicationApproved By........ ............. •---•-•-•-•--•--•------•----•--•---------------------••••-•--••••-•••••••• .........................................
Date
Application Disapproved for the following reasons_________________________________________________________________________________________________________________
•-_._••--•-_.---•--_-_...-•••--•-••-•-------•--------------------•---•-...••--••-•-••--•-••-••-----•••-•-•------•-•••---__-----•••--....•-•••---••-••---•••-••-•--•-•••••••-•••---------•--_....•-_••••-
_ Date
Permit No.••••-�•1/ ---------•--•.-••-----•••-•----'-'-- Issued.---- .. l --••.�.5._.-
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TUGS./'�..........OF........../tr�sZ fr��fjL w
..................................................
Trrtif ira#r of (Soutphaurr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed or Repaired ( )
by------------------- ---A?.(,ISA-Y-•-- --C O-�--•----•----•---------.............................. ----------•----•----•----------------------------------------------••--------•---------._..
/ Installer /
atI---- ✓-tip ldL !" •--------•---------------------••------•--------•-•-----•---•--•-------•--•-•---•-•-•-•-------------
has been installed in accordance with the provisions of Article XI of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No--------IA/Z....................... dated------%............. ......................
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 OF HEALTH
_} `I ..........................................O F................ ................................
No......................... FEE........................
BiopoottlA.
ork Conofrnrioatrrnti
Permissionis hereby granted.....................................----•------•...._.._..•----------••••---•--••-•-•-•--•-•......----------•••••--•-•-•-•--•--...••••••-•-
to Construct ( �) or R pair ( ) an Individual Sewage Disposal System
at No............ T " Olt i t
Street
as shown on the application for Disposal Works Construction Permit No...........r ....... Dated.................................7.........
-----------------------------------------------------------------•----•••-•••--•-•-••--•--••••••----•---
Board of Health
DATE.............. '-----
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
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COMMONWEALTH OF MASSACHUSETTS
d
Title 5 Official Inspection Form
Not for Voluntary Assessments
ye Subsurface Sewage Disposal System Form
Inspection results must be submitted on this form. Inspection forms may not be altered in any way.
A. General Information
1. Property Information: MAP 307—PARC 092 ova
94 DUMONT DRIVE - HYANNIS, MA 02601
Property Address.
BARBOZA, PETER
Owner's Name
94 DUMONT DRIVE
Owner's Address
HYANNIS MA 02601 ,
City/Town State Zip Code ,:_ r_;
SEPTEMBER 25, 2006
Date wt y
2. Inspector:
4 7D
JAMES D. SEARS
Name of Inspector y'
in
A & B CANCO c;
Company Name
350 MAIN STREET
Company Address
WEST YARMOUTH MA 02673
City/Town State Zip Code
508-775-2800
Telephone 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 16.340 of Title 5(310 CMR 16.000). The System:
7 Passes ❑ Conditionally Passes El Fails
® Needs Further Evaluation by he Local Approving Authority Q
pector's 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.
Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 1 of 16
1
COMMONWEALTH OF MASSACHUSETTS
d
Title 5 Official Inspection Form
o�. Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
D. Certification (cont.)
94 DUMONT DRIVE
Owner's Address
HYAN N I S MA 02601
City/Town State Zip Code
BARBOZA, PETER
Owner's Name
SEPTEMBER 25, 2006
Date of inspection
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:
NOTE: SYSTEM INSPECTED WITH CAMERA DUE TO DEPTH OF SYSTEM & LOCATION.
B) System Conditionally Passes: N/A
One or more system components as described in the"Conditional Pass"section need to be replaced or
Repaired. The system, upon completion of the replacement or repair, as approved by the Board of
Health,will pass.
Answer yes, no or not determined (Y, N, ND)in the for the following statements. If"not determined,"
please explain.
® The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
compliance indicating that the tank is less than 20 years old is available.
ND Explain:
i
i
COMMONWEALTH OF MASSACHUSETTS
d
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
B. Certification (cont.)
94 DUMONT DRIVE
Owner's Address
HYAN N I S MA 02601
City/Town State Zip Code
BARBOZA, PETER
Owner's Name
SEPTEMBER 25, 2006
Date of inspection
B) System Conditionally Passes (cont.): N/A
® Observation of sewage backup or break out or high static water level in the distribution box due to
broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass
inspection if(with approval of Board of Health):
® broken pipe(s)are replaced
® obstruction is removed
distribution box is leveled or replaced
ND Explain:
The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
® broken pipe(s)are replaced
® obstruction is removed
ND Explain:
C) Further Evaluation is Required by the Board of Health! N/A
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
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
Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 3 of 16
COMMONWEALTH OF MASSACHUSETTS
d
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
B. Certification (cont.)
94 DUMONT DRIVE
Owner's Address
HYAN N IS MA 02601
City/Town State Zip Code
BARBOZA, PETER
Owner's Name
SEPTEMBER 25, 2006
Date of inspection
C) Further evaluation is required by the Board of Health (cont.): N/A
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
indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less that 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.
3.Other:
i
Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 4 of 16
COMMONWEALTH OF MASSACHUSETTS
4 Title 5 Official Inspection Form
d
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
B. Certification (cont.)
94 DUMONT DRIVE
Owner's Address
HYAN N IS MA 02601
City/Town State Zip Code
BARBOZA, PETER
Owner's Name
SEPTEMBER 25, 2006
Date of inspection
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
® r 2� 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 leaching 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:
® 0 Any portion of the SAS, cesspool or privy is below high ground surface water elevation.
N/A Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary
to a surface water supply.
® N/A Any portion of a cesspool or privy is within a Zone 1 of a public well.
® N/A Any portion of a cesspool or privy is within 50 feet of a private water supply well.
® N/A 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.]
YES No
® The system is a cesspool serving a facility with a design flow of 2000 gpd— 10,000 gpd.
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.
Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 5 of 16
COMMONWEALTH OF MASSACHUSETTS
a w Title 5 Official Inspection Form
d
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
B. Certification (cont.)
94 DUMONT DRIVE
Property Address
HYANNIS MA 02601
City/Town State Zip Code
BARBOZA, PETER
Owner's Name
SEPTEMBER 25, 2006
Date of inspection
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: N/A
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
ElM 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.
Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 6 of 16
COMMONWEALTH OF MASSACHUSETTS
d
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
C. Checklist
94 DUMONT DRIVE
Property Address
HYAN N I S MA 02601
City/Town State Zip Code
BARBOZA, PETER
Owner's Name
SEPTEMBER 25, 2006
Date of inspection
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, including 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:
® 0 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(5)].
Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 7 of 16
COMMONWEALTH OF MASSACHUSETTS
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Title 5 Official Inspection Form
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Subsurface Sewage Disposal System Form
D. System Information
94 DUMONT DRIVE
Property Address
HYAN N IS MA 02601
City/Town State Zip Code
BARBOZA, PETER
Owner's Name
SEPTEMBER 25, 2006
Date of inspection
Residential Flow Conditions:
Number of bedrooms(design): 2 Number of bedrooms(actual): 2
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 220
Number of current residents: 3
Does residence have a garbage grinder? ® Yes No
Is laundry on a separate sewage system?[if yes separate inspection is required] ❑ Yes No
Laundry system inspected? Yes ❑ No
Seasonal use? ® Yes No
Water meter readings, if available(last 2 years usage(gpd)):
Sump pump? ® Yes No
Last date of occupancy: PRESENT
Commercial/Industrial Flow Conditions: N/A
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:
Last date of occupancy/use:
Date
Other(describe):
Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 8 of 16
COMMONWEALTH OF MASSACHUSETTS
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Title 5 Official Inspection Form
Not for Voluntary Assessments
p, Vev
Subsurface Sewage Disposal System Form
D. System Information (cont.)
94 DUMONT DRIVE
Property Address
HYAN N I S MA 02601
City/Town State Zip Code
BARBOZA, PETER
Owner's Name
SEPTEMBER 25,.2006
Date of inspection
General Information
Pumping Records:
Source of Information: N/A
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)
® Tight tank. Attach a copy of the DEP approval.
® Other(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 No
Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 9 of 16
COMMONWEALTH OF MASSACHUSETTS
a
Title 5 Official Inspection Form
Not for Voluntary Assessments
91 ye�`oW
Subsurface Sewage Disposal System Form
D. System Information (cont.)
94 DUMONT DRIVE
Property Address
HYAN N IS MA 02601
City/Town State Zip Code
BARBOZA, PETER
Owner's Name
SEPTEMBER 25, 2006
Date of inspection
Building Sewer(locate on site plan): ✓
0
Depth below grade: 5
feet
Material of construction:
® cast iron 13 40 PVC ® other(explain)
Distance from private water supply well or suction line:
feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
Septic Tank (locate on site plan): ✓
Depth below grade:
feet
Material of construction:
® concrete metal ® fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age:
years
Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) Yes ® No
--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Dimensions: 1000-GAL PRE CAST
Sludge depth: 4"
Distance from top of sludge to bottom of outlet tee or baffle 26"
Scum Thickness 1"
Distance from top of scum to top of outlet tee or baffle 12"
Distance from bottom of scum to bottom of outlet tee or baffle 17"
How were dimensions determined? ASBUILT, TAPE&SLUDGE JUDGE
Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 10 of 16
COMMONWEALTH OF MASSACHUSETTS
4 w Title 5 Official Inspection Form
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Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
D. System Information (cont.)
94 DUMONT DRIVE
Property Address
HYANNIS MA 02601
City/Town State Zip Code
BARBOZA, PETER
Owner's Name
SEPTEMBER 25, 2006
Date of inspection
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid
levels as related to outlet invert, evidence of leakage, etc.):
TANK AT WORKING LEVEL, OUTLET BAFFLE — COVERS AT GRADE.
NO SIGN OF LEAKAGE OR OVER LOADING.
TANK AT 5' BELOW GRADE.
Grease Trap (locate on site plan): N/A
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
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): N/A
9 9 ( P P P ) ( p )
Depth below grade:
Material of construction:
concrete ❑ metal ® fiberglass ® polyethylene other(explain)
Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 11 of 16
COMMONWEALTH OF MASSACHUSETTS
R Title 5 Official Inspection Form
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Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
D. System Information (cont.)
94 DUMONT DRIVE
Property Address
HYANNIS MA 02601
City/Town State Zip Code
BARBOZA, PETER
Owner's Name
SEPTEMBER 25, 2006
Date of inspection
Tight or Holding Tank (cont.) N/A
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 a copy of current pumping contract(required). Is copy attached? ® Yes ❑ No
Distribution Box (if present must be opened) (locate on site plan): ✓
Depth of liquid level above outlet invert 0
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.):
D-BOX IS 16" X 21" —6 '/z ' BELOW GRADE.
NOTE: BOX NOT DUG UP OR OPENED DUE TO DEPTH.
INSPECTED WITH CAMERA— LOOKS GOOD.
NO SIGN OF OVER LOADING OR SOLID CARRY OVER.
NO SIGN OF OVER LOADING IN LEACHING.
Pump Chamber(locate on site plan): N/A
Pumps in working order: Yes No
Alarms in working order: Yes ❑ No
Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 12 of 16
COMMONWEALTH OF MASSACHUSETTS
4 m Title 5 Official Inspection Form
d
0` Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
D. System Information (cont.)
94 DUMONT DRIVE
Property Address
HYANNIS MA 02601
City/Town State Zip Code
BARBOZA, PETER
Owner's Name
SEPTEMBER 25, 2006
Date of inspection
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
Soil Absorption System (SAS) (locate on site plan, excavation not required): ✓
If SAS not located, explain why:
NOTE: LEACHING INSPECTED AT D-BOX WITH CAMERA.
BOX SHOWS NO SIGN OF OVER LOADING OR SOLID CARRY OVER.
Type:
® leaching pits number:
® leaching chambers number:
leaching galleries number:
® leaching trenches number, length:
® leaching fields number, dimensions: (2)AT 18'
® 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.)-
LEACHING IS (2) PIPE FIELD 18' LONG UNDER STONE DRIVE AROUND 6'
BELOW GRADE.
Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 13 of 16
COMMONWEALTH OF MASSACHUSETTS
N Title 5 Official Inspection Form
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e� Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
D. System Information (cont.)
94 DUMONT DRIVE
Property Address
HYAN N I S MA 02601
City/Town State Zip Code
BARBOZA, PETER
Owner's Name
SEPTEMBER 25, 2006
Date of inspection
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): N/A
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
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation,
etc.):
Privy (locate on site plan): N/A
Materials of construction:
Dimensions
Depth of solids
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation,
etc.):
I
Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 14 of 16
r
M
COMMONWEALTH OF MASSACHUSETTS
a Title 5 Official Inspection Form
d
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
D. System Information (cont.)
94 DUMONT DRIVE
Property Address
HYAN N I S MA 02601
City/Town State Zip Code
BARBOZA, PETER
Owner's Name
SEPTEMBER 25, 2006
Date of inspection
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.
' fN
ISJ_
I
---tip
COMMONWEALTH OF MASSACHUSETTS
z Title 5 Official Inspection Form
d
Not for Voluntary Assessments
J v
Subsurface Sewage Disposal System Form
D. System Information (cont.)
94 DUMONT DRIVE
Property Address
HYAN N I S MA 02601
City/Town State Zip Code
BARBOZA, PETER
Owner's Name
SEPTEMBER 25, 2006
Date of inspection
Site Exam:
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to NO ground water: 14
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 you established the high ground water elevation:
NOTE: LOT HIGH, LEACHING AREA AND 8' ABOVE ROAD.
TEST HOLE BESIDE TANK 14' NO WATER.
i
Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 16 of 16
c
v
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
r
a DEPARTMENT OF ENVIRONMENTAL PROTECTION
r
5Q lk
/� 350 MAIN STREET
��"� WEST YARMOUTH,MA
508-775-2800
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 94 DUMONT DRIVE
HYANNIS,MA 02601
Owner's Name: EBERT,JOSEPH 0 Of)
Owner's Address: 94 DUMONT DRIVE JA
HYANNIS,MA 02601 S�2C> S�
Date of Inspection PAY 11,2001 <�d,
Name of Inspector:(please print) JAN ES D.SEARS yOt t �c:2- o
O,A j
Company Name: A&B Canco
Mailino Address: 350 Main Street <�
West Yarmouth,MA 02673
Telephone Number: 508-775-2800 -
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:
X Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
inspector's Signature: c,« r 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 tot
he 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 1
Page 8 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 94 DUMONT DRIVE
HYANNIS,MA 02601
Owner: EBERT,JOSEPH
Date of Inspection: JULY 11,2001
TIGHT or HOLDING TANK: N/A (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:
Material of construction: concrete metal fiberglass polyethylene other(explain)
Dimensions:
Capacity: gallons
Design Flow: gallons/day
Alarm present(yes or no)
Alarm level: Alarm in working order(yes or no):
Date of last pumping
Comments(condition of alarm and float switches,etc.):
DISTRIBUTION BOX: X (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: 0
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.,):
DISTRIBUTION BOX IS 16"X21",6%'BELOW GRADE.ONE LINE IN,TWO LINES OUT.NO SIGN OF
OVERLOADING SEEN IN BOX. RECOMMEND THAT DISTRIBUTION BOX HAS RISERS INSTALLED WITH
COVER TO WITHIN 6"OF GRADE.
PUMP CHAMBER: N/A (locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no):
Continents(note condition of pump chamber,condition of pumps and appurtenances,etc.):
i
}
Title 5 Inspection Form 6/15/2000 9
Sep-05-01 14: 54 BARNSTABLE HEALTH DEPT 5087906304 P.02 t
Town of Barnstable
Regulatory Services
BA"STAec.e. Thomas F. Geiler,Director
MAM
�$pTf0jA'0r Public Health Division
Thomas McKean,Director
367 Main Street, Hyannis,MA 02601
Office: 508-862-4644 Fax: 508-790-63Q4
DATE: O ��
SSO A4 rrU�d—
cv Y �Cv , 1010 U '7
RE:
The Bamstable Health Division has reviewed the Title 5 septic inspection form for the
above referenced property. The following comments listed below are deficiencies j
according to 310 CNIR 15.300 and the Town of Barnstable Health regulations. Please re-
inspect the system, if.necessary, complete a new report form or revise the pages pertinent
to the deficiencies listed and resubmit the report to this office within fourteen (14) days:
L{ w.p r1CL G'r
v—o Ck .
sep,dg_f.doc
1
I
COMMONWEALTH OF MASSACHUSETTS
= EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
n r
DEPARTMENT OF ENVIRONMENTAL PROTECTION
yr
RECEIVED
350 MAIN STREET
WEST YARMOUTH,MA
508-775-2800 o i n . 2001
TOW',J1 uNRNSTABLE
TITLE 5 HEALTH DEPT.
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 94 DUMONT DRIVE
-HYANNIS,MA 02601
Owner's Name: EBERT,JOSEPH
Owner's Address: 94 DUMONT DRIVE
HYANNIS,MA 02601
Date of Inspection JULY 11,,2001
Name of Inspector:(please print) JAMES D.SEARS
Company Name: A&B Canco
Mailing Address: 350 Main Street
West Yarmouth,MA 02673
Telephone Number: 508-775-2800
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:
X Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: Qn��-� 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 tot
he 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.
Tide 5 Inspection Form 6/15/2000 1
Page 2 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 94 DUMONT DRIVE
HYANNIS,MA 02601
Owner: EBERT,JOSEPH
Date of Inspection: JULY 11,2001
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes: X
I have not found any information which indicates that any of the failure criteria described in 310 CMR
15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below.
Comments:
B. System Conditionally Passes: N/A
One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.
The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass.
Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined"
please explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,
exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing
tank is replaced with complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
Observation of sewage backup or break out or high static water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval
of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will
pass inspection if(with approval of the Board of Health)"
broken pipe(s)are replaced
obstruction is removed
ND explain:
Title 5 Inspection Form 6/15/2000 2
r
Page 3 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(CONTINUED)
Property Address: 94 DUMONT DRIVE
HYANNIS,MA 02601
Owner: EBERT,JOSEPH
Date of Inspection: JnY 11,2001
C. Further Evaluation is Required by the Board of Health: N/A
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 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 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:
Tide 5 Inspection Form 6/15/2000 3
Page 4 of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(CONTINUED)
Property Address: 94 DUMONT DRIVE
HYANNIS,MA 02601
Owner: EBERT,JOSEPH
Date of Inspection: JULY 11,2001
D. System Failure Criteria applicable to all systems: N/A
You must indicate"yes"or"no"to each of the following for all inspections:
Yes No
X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded
or clogged SAS or cesspool
X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
X Liquid depth in leaching is less than 6"below invert or available volume is less than%day flow
X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped
X Any portion of the SAS,cesspool or privy is below high ground water elevation
N/A Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a
surface water supply
N/A Any portion of a cesspool or privy is within a Zone 1 of a public well
N/A Any portion of a cesspool or privy is within 50 feet of a private water supply well
N/A Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis. (This system passes if the well water
analysis performed at a DEP certified laboratory,for coliform bacteria and volatile organic
compounds indicates that the well is free from pollution from that facility and the presence of
ammonia nitrogen and nitrate nitrogen is equal or less than 5 ppm,provided that no other
failure criteria are triggered. A copy of the analysis must be attached to this form.)
NO (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as
described in 310 CMR 15.303,therefore the system fails. The system owner should contact
the Board of Health to determine what will be necessary to correct the failure.
E. Large Systems: N/A
To be considered a large system the system must service 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
"ves"in Section D above the large system is 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.
Title 5 Inspection Form 6/15/2000 4
Page 5 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 94 DUMONT DRIVE
HYANNIS,MA 02601
Owner: EBERT,JOSEPH
Date of Inspection: DULY 11,2001
Check if the following have been done. You must indicate"yes"or"no"as to each of the following
Yes No
X Pumping information was provided by the owner,occupant,or Board of Health
X Were any of the system components pumped out in the previous two weeks?
X Has the system received normal flows in the previous two week period?
X Have large volumes of water been introduced to the system recently or as part of this inspection?
X Were as built plans of the system obtained and examined?(If they were not available note as N/A)
X Was the facility or dwelling inspected for signs of sewage back up?
X Was the site inspected for signs of break out?
X Were all system components,excluding the SAS,located on site?
X Were the septic tank 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
X 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)has been determined based on:
Yes No
X Existing information. For example,a plan at the Board of Health.
X Determined in the field(if any of the failure criteria related to Part C is at issue approximation of
distance is unacceptable)[310 CMR 15.302(3Xb)]
Title 5 Inspection Form 6/15/2000 5
Page 6 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 94 DUMONT DRIVE
HYANNIS,MA 02601
Owner: EBERT,JOSEPH
Date of Inspection: JULY 11,2001
FLOW CONDITIONS
RESIDENTIAL
Number of Bedrooms(design): 2 Number of bedrooms(actual): 2
DESIGN flow based on 310 CUR 15.203(for example: 110 gpd x#of bedrooms: 220
Number of current residents: 1
Does residence have a garbage grinder(yes or no): NO
Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required]
Laundry system inspected(yes or no): YES
Seasonal use(yes or no): NO
Water meter readings,if available(last 2 years usage(gpd)):
Sump pump(yes or no) NO
Last date of occupancy: PRESENT
COMMERCIALANDUS TRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203):
Basis of design flow(seats/persons/sgft,etc.):
Grease trap present(yes or no):
Industrial waste holding tank present(yes or no):
Non-sanitary waste discharged to the Title 5 system(yes or no):
Water meter readings,if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information: N/A
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
X Septic tank,distribution box,soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system(yes or no)(if yes,attach previous inspection records,if any)
Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be
obtained from system owner)
Tight tank Attach copy of the DEP approval
Other(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
Title 5 Inspection Form 6/15/2000 6
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 94 DUMONT DRIVE
HYANNIS,MA 02601
Owner: EBERT,JOSEPH
Date of Inspection: DULY 11,2001
BUILDING SEWER(locate on site plan): N/A
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 onsite plan): X
Depth below grade: 5'
Material of construction: X 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: 1,000 GALLON PRE CAST
Sludge depth: 2"
Distance from top of sludge to the bottom of outlet tee or baffle: 28"
Scum thickness: 1"
Distance from top of scum to top of outlet tee or baffle: 11"
Distance from bottom of scum to bottom of outlet tee or baffle: 18"
How were dimensions determined: ASBUILT AND TAPE
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as
related to outlet invert,evidence of leakage,etc.):
TANK 5'BELOW GRADE. COVERS AT GRADE. OUTLET BAFFLE,NO SIGN OF OVERLOADING SEEN
IN TANK.
GREASE TRAP(located on site plan) N/A
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.):
Title 5 Inspection Form 6/15/2000 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: 94 DUMONT DRIVE
HYANNIS,MA 02601
Owner: EBERT,JOSEPH
Date of Inspection: DULY 11,2001
TIGHT or HOLDING TANK: N/A (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:
Material of construction: concrete metal fiberglass polyethylene other(explain)
Dimensions:
Capacity: gallons
Design Flow: gallons/day
Alarm present(yes or no)
Alarm level: Alarm in working order(yes or no):
Date of last pumping
Comments(condition of alarm and float switches,etc.):
DISTRIBUTION BOX' X (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: 0
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.,):
DISTRIBUTION BOX IS 16"X21",6%'BELOW GRADE. ONE LINE IN,TWO LINES OUT.NO SIGN OF
OVERLOADING SEEN IN BOX.
PUMP CHAMBER: N/A (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.):
Title 5 Inspection Form 6/1 i/2000 8
Page 9 of 1 I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 94 DUMONT DRIVE
HYANNIS,MA 02601
Owner: EBERT,JOSEPH
Date of Inspection: JULY 11,2001
SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required)
If SAS not located explain why:
Type
leaching pits,number:
leaching chambers,number:
leaching galleries,number
leaching trenches,number,length
X leaching fields,number, dimensions: 2
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.)
LEACHING IS TWO LINES WITH STONE.LEACHING IS UNDER STONE DRIVEWAY.NO OVERLOADING
SEEN IN LEACHING.
CESSPOOLS' N/A (cesspool must be pumped as part of inspectionxlocate 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: N/A (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.)
Title 5 Inspection Form 6/15/2000 9
Page 9 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 94 DUMONT DRIVE
HYANNIS, MA 02601
Owner: EBERT,JOSEPH
Date of Inspection: JULY 11,2001
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.
It r��d
a
S'
Title 5 Inspection Form 6/15/2000 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: 94 DUMONT DRIVE
HYANNIS,MA 02601
Owner: EBERT,JOSEPH
Date of Inspection: DULY 11,2001
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to no groundwater 1.4 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:
Observation 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 you established the high ground water elevation:
LOT HIGH.LEACHING AREA 8' ABOVE ROAD.TEST HOLE BESIDE TANK 14'NO WATER.
Title 5 Inspection Form 6/15/2000 11
Town of Barnstable
Regulatory Services
1V Y
* BARNSTABLE,
9 MASS. $ Thomas F. Geiler,Director
�
1639. ♦0 ATEo Public Health Division
Thomas McKean,Director
367 Main Street, Hyannis,MA 02601
Office: 508-862-4644 Fax: 508-790-6304
r
DATE: l� G
RE:
T y pvk—
The Barnstable Health Division has reviewed the Title 5 septic inspection form for the
above referenced property. The following comments listed below are deficiencies
according to 310 CMR 15.300 and the Town of Barnstable Health regulations. Please re-
inspect the system, if necessary, complete a new report form or revise the pages pertinent
to the deficiencies listed and resubmit the report to this office,within fourteen(14) days:
a
sepdef.doc