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HomeMy WebLinkAbout0253 FIFTH AVENUE (HYANNIS) - Health 253 FIFTH AVENUE,HYANNIS A= 245 038 1 I i a I J. c Commonwealth of Massachusetts Title 5 Official Inspection Form 6 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments, Property Address 1--1'-e /fs ev rd 9ci ✓✓e-I ✓o ON ner Owner's Name/ n/�� information is �eS� �.� tea n 6 /� �d l _— required forevery page. City/Town State Zip Code Date 4 Insp ction Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. tnportant:When A. General Information (� filling out forms �1+ —7��{� on the computer, II _I J use only the tab 1. Inspector: key to move your l cursor-do not G K 4-- 0 Se- use the return Name of Inspector ,�/ - key. z / Company Name go Company Address S / Qd ra -r o , CitylTown State Zip Code 0-Y) C� O-C, Telephone Nu er License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CM R 15.000). The system: Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 1�4 0� �> /o Inspector' 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 !I the same or different conditions of use. p. 6 t9ns•3113 '(i�JeSCifipW lies uafForm'Su x "'� cs^i f � S. oDiSpa15ysiom•Pa�O luf 17 Commonwealth of Massachusetts rA Title 5 Official Inspection Form _ Subsurface Sewage Disposal System �Form /-Not for Voluntary Assessments Property Address ,�G ✓'/'2r ✓'17 CW ner Cw ner's Name ^ h information is �es.� �q 0.1 6 /,2 /o 1 required for every page. City/Town State Zip Code Date o Insp lion B. Certification (cont.) Inspection Summary: Check A,B,C,D or E / always complete all of Section D A) System Passes: I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15,304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined"(Y, N, ND) for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old" or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. "A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND(Explain below): t5ins•3113 1 itte 6 Official lfs p6r ticn F crm.SuAstrt ace Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments )S.3 F1 Property Address a r/'2 t ✓'0 Ow ner Owner's Name / / 1 1 Al1 n information is (�/eS� yahN�sA�// /�/'7 O�`b/°Z required for every page. Cityrrown State Zip Code Date 9f inspbction B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes(cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system Is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑. Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh Ora-3/13 Tide 5 Official InsPec lion Fccm StIbslffare SewageDsposai System•Page 3of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Dlsposal System Form - Not for Voluntary Assessments Property Address Gi r��f r0 O,v ner Ow ner's Name �1 information is W PS 7 a✓r✓IIS od b�; /O required for every page. Cilyfrown State Zip Code Date of Insl1bction B. Certification (cont.) 2. System will fall unless the Board of Health (and Public Water Supplier, if any) determines that the system Is functioning In a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No" to each of the following for all inspections: Yes No ❑ �/ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ E Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool "" ❑ Liquid depth in cesspool is less than 6" below invert or available volume is less than '/z day flow l5im-3113 Tioe 5 Gf ricial Ins pectioi Form Subsu f ace Sewage Disposal System•Paga 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments c 2 S3 "4 vle, Property Address )_ [� a rr2 i r o ON ner O v ner's Name/ es T / / n information is (�✓ /S O✓� � required f or every _ q✓l/1 Y State Zip Code Date of lnspection page. Otyffow n B. Certification (cont.) Yes No ❑ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped ❑ Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ Any portion of cesspool or privy is within 100 feet of a surface water supply or — tributary to a surface water supply. ❑ OT/ Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ l� 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.] ❑ 2-11" The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ lD' The system fi. I have determined that one or more of the above failure criteria exist as described in 310 CM 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ 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 1 regional office of the Department. t5ins 3113 Title5Cfficial inspoc bon Form:Subsulx;e se"aDisposal System-Page 5of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form _ b Subsurface Sewage Disposal System Form -Not for Voluntary Assessments o�S.3 F 70":fti 14V Property Address , Ow ner rani ner's NameW � / information is required for every /� o PS �q✓f�1 iSPJ �� /"t page. Gty[Tow n 011 State Zip Code Dat f inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no" as to each of the following: Yes No ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ Were any of the system components pumped out in the previous two weeks? �❑ Has the system received normal flows in the previous two week period? ❑ Have large volumes of water been introduced to the system recently or as part of this inspection? ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) Was the facility or dwelling inspected for signs of sewage back up? ❑ Was the site inspected for signs of break out? ❑ Were all system components, excluding the SAS, located on site? L� ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? �❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has / been determined based on: Existing information. For example, a plan at the Board of Health. Determined in the field (if any of the failure criteria related to Part C is at issue ❑ approximation of distance is unacceptable) (310 CM R 15.302(5)j D. System Information Residential Flow Conditions: Number of bedrooms (design): Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x #of bedrooms): t5ins•N13 Title 50ffcA Impoxhco F am Sup Ls:rface Sewage 0.sposal System•Page 6of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address ON ner Owner's Name information S ���01115AI Do16 AV page. a 9eiredforevery (town State Zip Code Date of nspe tion D. System Information Description: / trq//o,7 L 7/c g N 4,, rT �loWcllfS�iS /S� s6 col sC / T Number of current residents: / Does residence have a garbage grinder? ElS Yes No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes B No information in this report.) Laundry system inspected? ❑ Yes No Seasonaluse? ❑ Yes BNo Water meter readings, if available (last 2 years usage (gpd)): Detail Sump pump? ❑ Yes No GU✓rev► Last date of occupancy: Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CM R 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non'-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins-3/13 Title 50fficial Inspecticn F arm Sutxirfxa Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address Cw ner Qn ner's Name information is / ,f° `s ct off //� /" 44 (��G��/ required for every page. City/Town State Zip Code Qale Inspe lion D. System Information (cost.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: a Source of information: 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 Sy em: 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/Altemative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other (describe): t5rts 3113 Title 5(Nficial ins pection r orm.SUtMIlface So•vixlo Disposal system-Page 8of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments o2S3 Fye;�4 Property Address G Yr2r ✓O Cw ner Cw ner's Name information is required for every Vl/ �G✓►✓I�s/1oi__ __ page City/Town Stale Zip Code Date Ins i6ection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 99S 60 Were sewage odors detected when arriving at the site? ❑ Yes No Building Sewer(locate on site plan): Depth below grade: feet Material of construction: ❑ cast iron 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 f construction: concrete ❑ metal ❑ fiberglass ❑ polyethylene Elother(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: I Sludge depth: 19re•3113 Title 50rficA Inspecfim F mn.StJWL1f xn SFaNV,*)e Disposal System•Page got 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 7 _ �5� / fqC► Ave, Property Address G Ir✓e! ✓r� Ow ner ON ner's Name/ information is (jl/eS� /�J1 �� 0-26�a �O / required for every ��"" ✓1 � page. City/Town State Zip Code Dateof Insp ction D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle Scum thickness r� Distance from top of scum to top of outlet tee or baffle r Distance from bottom of scum to bottom of outlet tee or baffle l�ai Cer/<C How were dimensions determined? rL)le Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): / G v► ly C�✓1� 7�f /✓1 `�Jo C COO Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date 15ns-3113 Title 5 Official Irns per tionForm:SLILC 11l)1.f!Sfaw lei)unosal System•Page 10d 11 Commonwealth of Massachusetts Title 5 Official Inspection Form 's Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address YCI rl-e if ON ner Owner's Name information is esj / �� O�6�� 1� 1 required for every �''r N�j °i' page. City f row n State Zip Code Date/of In pection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No t5ins•3113 TIUe5Officiel Inspec lion Form.Suts�rlaco 60,vocle,Di5posal System-Page 11 of 17 III Commonwealth of Massachusetts Title 5 Official Inspection Form - Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 04 -4k- Property Address - 91:; rretYo Owner owner's Name�,Ie4 L 9, �� .information is �q,�INJ/S�oi � /� �0 � required for every page. Gty/Town State Zip Code Date of spe ion D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): /fin �So/ 0& //0 Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): " If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: l5ins•3113 Titto501ficidirspocticnFumSuO;irtYc -.v.rnUisposaiSystem•Page 12d17 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments p4- 2 Property Address �►rrp t r d Ow net ON ner's Name information is e /PS I �� required for every W page. Cityfrown State Zip Code Dat of nspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where lic water supply enters the building. Check one of the boxes below: hand-sketch in the area below ❑ drawing attached separately Fro� t w a lift 2 - J3 Z 2-7- 93 — -� t,9r%s•3113 TWO 5Officialh,poctlaiFcam S,,lb !oa:;n.vo];C cpusal System•Page 15or 17 Commonwealth of Massachusetts v-- Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address G Ole/V, Cw ner, Cw ner's Nae informa m tion Is es U O.) required for every page. Cilyfrown State Zip Code Date nspe lion D. System Information (cont.) TypeOC ot,c/�r SorJ 7 J�vt� ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches: number, length: ❑ leaching fields, number, dimensions: ❑ overflow cesspool number: ❑ innovative/altemative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): � �w► �� O Ph.eC/ -le 'r__ • V S /1S D✓ A lG a/t G 7<. AVe Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer-- Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ns•3113 ritie501ficial lnspectionForm Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts -= Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address I'le f/'a Ow ner � Information Is Cw ner s Name01 required for every (," &s /T /�1'4 page. City/Town State Zip Code Date of nspe Lion D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t&rna•3113 Tide 5 Of ficiai Iris pection F orm Suteuf:r::o Disposal System-Page 14of V ° Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form -Not for Voluntary Assessments C>2 Property Address eci YIei .�n ON ner O v ner's Name / / .// /y�,f information is (/✓P-5 ��tiv1N�S�o/l' /- 4 required for every 3 page. City/Town State Zip Code I)ate 6f Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: f eel /l 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: pate ❑/ 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: 0-7 / v?s4, Ile c /�/9p S /Is Leo vd�: r t /'O ti✓l C tom- Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5Us•W3 Title 50friaalIns[)ecucnFtirm Ciispcsal System-Page 16d 17 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address ar�et�� Oar ner Ory ner's Name �1 �� 11 n information is (AlLaS'4 1 haul4tr,0oi7C i -i. Da 6"< �� �-7 required for every page Cityffown State Zip Code Date f Inspection E. Report Completeness Checklist L,,�/Inspection Summary: A, B, C, D, or E checked EY"nspection Summary D(System Failure Criteria Applicable to All Systems) completed 3 System Information—Estimated depth to high groundwater 2 Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins-3113 Tide50ffieial lnspocdm Form'. DiSpoSal System.Page 17 of 17 PROPERTY ADDRESS: 253 Fifth Ave -- Hjy nnisQort _Mass___ 02672 ----- ------------------ .I On the above date, I Inspected the septic system at the above address. This system consists of the following: 1 . 1 -1000 gallon Tank 2. 3 Leach. Trenches aft by 15ft Based on my Inspection, I certify the following conditions: This is a Title Five Septic System (78 code ) I I ' I i SIGNATURE-- A4t, I ---- �1� i Name: Jose h P Macomber I Com an : Jose h P Macomber & Son Inc. 10 Address:Box_66___ Centerville Ma 02632 __ Phone:S_5 o B 1 �_3_3_3 8--------- V4N THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY l '•.fJ� I i JOSEPH P. MACOMBER & SON INC. Tanks-Cesspools-Leachflelds Pumped & Installed Town Sewer Connections P.O. Box 66 -. Centerville, MA 02632-0066 775.3338 775-6412 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Address of property Z53 �'�� ra �vF__ ����s ��� Owner ' s name F �1e�+o Date of Inspection JQluE61, t9�5 �19� E71 (9 PART A CHECKLIST Check if the following .have been done: Pumping information was requested of the owner, occupant, and Board of Health. r -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. RA As built plans have been obtained and examined.available with N/A. Note if they are not The facility .or dwelling was inspected for signs of sewage back-up . _. The site was inspected for signs of breakout. All system components, excluding the SAS, have been located on the site. The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid; depth of sludge, depth of scum. The size and location of the 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. 5U vv�w�,�,1L1( ©�_ �Ecou.t.w� GYupATtp�S A.)C*Ck) 2 1 1, - t p S C f—n L -T—P�k 8 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION FLOW CONDITIONS If residential 3 number of bedrooms number of current residents 2 Q-r-Yu'Cmo F;o,Z- A Yeja�,e_S R(o garbage grinder, yes or no . � laundry connected to system, yes or no seasonal use, yes or no If nonresidential , calculated flow: �` 8�n�c-+48c.E � ovvea- Co, Water meter readings, if available: ? S- DOG 3 �0 9ZC—P P)�3GS AV 90 C,A.&_E; Zmo5 ?LOS Last date of occupancy �`O ME GENERAL INFORMATION Pumping records an so rce of information- 0 0 � l tom..►ru [�. �2ruS = S'��, 1 4 is5'Tt•eu System pumped as part of inspection, yes or no if yes, volume pumped Reason for pumping: Type of system —)L_ 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) Other (explain) Approximate age of all components. Date installed, if known. Source of informat •on: �►zA-0GC- �2C,G lP� ZC) ,I6A25 a Sewage odors detected tected when arriving at the site,' yes or no 1 9 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B ` Y SYSTEM INFORMATION continued SEPTIC TANK: tOW (locate on site plan) depth below grade.: 12�� material of construction: _.concrete metal FRP other(explain) dimensions: sludge depth distance from top of sludge to bottom of outlet tee or baffle scum thickness distance from top of scum to top of outlet tee or baffle distance from bottom of scum to bottom of outlet tee or baffle. 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. ) Fr- 2EP4�c� wt �tVT DISTRIBUTION BOX: (locate on site plan) Lo IQGm 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. ) _ 1c� - 5 C>1� out L CTS 7006,,H KbX PUMP CHAMBER• btu E (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. ) • 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B 11 SYSTEM INFORMATION continued I 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: 2 5k2.T ; IS7.s 3 5 a tg�• 1 Type -- X'3 = 225 -'5 F pC leaching pits and number leaching chambers and number leaching galleries and number leaching trenches, number, length T2.EryCj�� yoee leaching fields, number, dimensions Lpn3c overflow cesspool, number Comments: (note condition of soil, signs of hydraulic failure, level of pondirig, condition of vegetation, recommendations for maintenance or repairs,etc. ) __ LOQKI> e (U -TCOO LDNQ ', 1COvU Vk-/'C>fL4(DLkL, 9/�lLL90_(--T CESSPOOLS (locate on site plan) : number and configuration (� depth-top of liquid to inlet invert depth of solids layer depth of scum layer dimensions of cesspool materials of .construction indication of groundwater: inflow (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) `��I dQ C 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. ) ' i 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM �. PART B SYSTEM INFORMATION continued SKETCH OF SEWAGE DISPOSAL' SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100 ' S t C �-r-t-►ac�c G c� -To 1-*,y6-7�---AA IV I 15 L CAct-k L-C c�C�TZ-1 L S D 0 GROUNDWATER S�r � - - ' � epth to ground ter'� s'S -rip '�r method of determination or Aar�Nximation: v 1 jLLOI-" i %u6 AjTjp Sa 9=L_ Z, 7 ' F-Q-O,-tn T2 P csE 'TZZ E -[--\ ►` F7 --� � '�C7 T'Th�n n (��= 'T i? F1l Y' �. -tf� 6 �c�,�� WAI= 1 N 12 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C FAILURE CRITERIA Indicate yes, no, or not determined (Y, N, or ND) . Describe basis of determination in all instances. If "not determined" , explain why not) Backup of sewage into facility? Discharge or ponding of effluent to the surface of the ground or surface waters? Ned Static liquid level in the distribution box above outlet invert?-• ' i ' . Liquid depth in cesspool <6" below invert or available volume< 1/2' day flow? D Required 'pumping 4 times or more in the last year? number of times pumped �0 Septic tank is metal? cracked? structurally unsound? substantial infiltration? substantial exfiltration? tank failure imminent? Is any portion of the SAS, cesspool or privy: ,W below the high groundwater elevation? within 50 feet of a surface water? within . 100 feet of a surface water s upply. ,or tributary to a surface'; water supply? within a Zone I of a public well? within 50zVfeet of a bordering vegetated wetland or salt marsh (cesspool's 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? ff .the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile Qrganic compounds, ammonia nitrogen ) and nitrate nitrogen. TOWN OF BOARD OF HEALTH SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART D - CERTIFICATION -TYPE OR PRINT CLEARLY- PROPERTY INSPECTED STREET ADDRESS Z5 Z) lkj a %1 EST YA LX\1 Ls?O 0--T ASSESSORS MAP, BLOCK AND PARCEL # OWNER' s NAME PART D - CERTIFICATION NAME OF INSPECTOR 7E (7U-i2 S U L L k V ,4�\rQ �E COMPANY NAME C0"O r +-T-p�tV T- -To l-.c-011A S1,,U c. COMPANY ADDRESS IL Street Town or City State ZIP COMPANY TELEPHONE ( ) - FAX CERTIFICATION STATEMENT I certify that I have personally inspected the sewage• disposa-1 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 one: NQ System PASSED F 1 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 , 310 CMR 15 . 303 , and as specifically noted on PART C - FAILURE CRITERIA of this inspection form. Inspector Signature Date 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.do • r SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM PART D CERTIFICATION Inspector : Peter Sullivan PE Location : 253 Fifth Ave. W. Hyannisport Date : June 6,1995 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 disposai systems. 'I have not found any information which indicates1hat the system fails to adequately protect public health or the environment as defined in 310 CMR 15303 . Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form. Please note the summary of recommendations as presented in this form. Lastly please note 310CMR:15.302 Criteria for Inspection(1) "The inspection is not designed to provide information to demonstrate that the system will adequately serve the use to be placed upon it by the new owner. " 1 truly yours Peter Sullivan PE d Distribution: Original to system owner Buyer Board of Heath TOWN OF BARNSTABLE LC,-AT?"�v 053 r-/r_7'N Avg . 'SEWAGE# 85-3 VILLAGE 14YRn/6//5 Pole ASSESSOR'S MAP &LOT INSTALLER'S NAME&PHONE NO. 6, 110Tn1 iYR�=_ 38:- 940- SEPTIC TANK CAPACITY /500 G-,9 L 56 Ix /Z, LEACHING FACILITY: (type) ,5 (size) ` C 8 ' &J NO.OF BEDROOMS 5 5T �� BUILDER OR OWNER FC L/Sae e-rd C PERMITDATE: /Z_ S - 45 COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist , within 300 et of leachin facility) / 5 t Feet Furnished by i C,A iZ iEx151. GAR Cil o® TOWN OF BARNSTABLE LOCATION a". 'SEWAGE # VILLAGE (,V. ASSESSOR'S MAP & LOT INSTALLER'S NAME & PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY:(type) (size) NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: W 4 . e y No. /, Fe .�. THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 21ppfication for Bigozar *pgtem Conotruction Permit Application is hereby made for a.Permit to Construct( )or Repair(K,)an On-site Sewage Disposal System at: Location Address or Lot No. Owner's Name,Address and Tel.No. 253 FiFTN F}vE. J�P4A_J.,j6POR_T FELI58c,�To �, /3�}2I2C—!�e Installer's Name,Address,,and Tel.No. Designer's Name,Address and Tel.No. /Ll.C. A/G_zJ7`t'2E R.O. &OX (047 P•o. Box 115 02675 385--9407 Nr¢12y00 PoeT 194 621-75 3L2-8/31 Type of Building: Dwelling No.of Bedrooms Jr Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 55 gallons per day. Calculated daily flow 6,5 D gallons. Plan. Date 11- ZO- `/S� Number of sheets / Revision Date Title Description of Soil 6,0C Pz-R, Nature of Repairs or Alterations(Answer when applicable)R-ttAi-a vC- C-',jC15T• -S Y_S7�Zd L(�/fEP-6 ,f'OLI64B� A-AjT� f�sTRu- /1 1 SD O 6A1, S; ? 7� B a �` f D '5 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 Certifi- cate of Compliance has been issued b this Board of ealthh. Signed C Date Application Approved by - Application Disapproved for the Ilowing reasons Permit No. 7;L, f o V Date Issued , f+- ,,,v:ie+b." ,.,:_ 9'^'.,7J}"^'�' ..rs--.a,.r�'K� •a'i:tr+'..` a ,.y � r �,ra;n.. ,,, ..,.�, �� ..",off"1�... .w'/^-.+r.�.r�•Y'��"^4f'r"'-`,Y',�,.¢"T:. 1 Fe No. —) D.7 �' e _ iTHE COMMONWEALTH OF MASSACHUSETTS t PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS 2pplication for Migagat *ps�tem Con!5tructton Perl ''ttt £ Application is hereby made for a Permit to Construct( )or Repair(X)an On-site Sewage Disposal System at: Location Address or Lot No. Owner's Name,Address and Tel.No. A 2S3 r-IF7"H qVE'., HeIJA AJ6PaeT FEG l58E,eTo G, bft�=���o �----~ Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. G.&,2 F R.O. awx 647 0,0. $ox tilt ,ea+ feel . `o267S 385-9407 N�,�yov �6,eT �f� 6z��5. 3G2=8131 ! 1 Type of Building: Dwelling No. of Bedrooms Garbage Grinder( ) Other Type of Building No. of Persons Showers,( ) Cafeteria( ) Other Fixtures r/ 1 a d 1 Design Flow 55 gallons per day. Calculated daily flow ��S5 gallons. ,. Plan Date /!— Zo- IS Number of sheets x/ Revision Date � Description of'Soil SEA' P-LA,y i • 1 11� Nature of Repairs or Alterations(Answer when applicable)RCAto v& akJvT .sY.STEk lC1WE46 Date last inspected: 'M 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 Certifi- cate-of Compliance has been issued by this Board of-Health.At ' Signed Date /Z—S 9 S Application Approved by I — Application Disapproved for the ollowing reasons i Permit No. 7 Date Issued =--- ___ ___ __—____---,---� THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-sq Sewage Disposal System installed( )or repaired/replaced(x)on �� by /P MP�I Ze for 1S , A has been construct din ac ordance, with the provisions of Title 5 and the - r Disposal System onstruction Permit No dated �_d Use of this system is conditioned on compliance with the provisions set forth below: - - a No. Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Migw6al bpotem Congtructiou Verna Permission is hereby granted to -44 a%_ flit c— to construct( )repair( )an On-site Sewage System located atT C/ J and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. All construction must be completed within two years of the date below. Date: Approved by i TEST ROLE LOG - — � DATE: IVOW'/. TEST BY: WELLER& ASSOC. WITNESS:-- PERC RAT ' Q ' E. � .Z- i+-r�../�s-v Q-A/ 4 4,0 a �-, . � +. ; ; , ' GocJ.JT�'•` �'CiJ2�•IuY-�9 /�.�07� .�C�?Ti Q bl 0 p� oRs ; f 75 c;�2o u•�.o Gu.+47E.sZ Gi��.c/Ldc u S . - ` � � Q ��� _:r��!��._�:—.,y,�� � _ W/7f1i.�/ TES GGv.S� i•�,O.L?r.�%y/T'Y r----- c / DESIGN DATA ✓ A r Y"', Q" ^6.r ��.°A r }.;../ DAJlY FLOW:�O)_t5zz,✓��'. 1 SEP'I'ICTANK: 5'S® xzaa%= //vo USE:. 'f ' i �, •l os `�'/ i ` LEACHING FACILITY: USE: r� iY6 i 1` CAPACITY: . —• d�� ter' I `� �`\ ! �! SIDEWALL:436- 7>= /aa,� / ti .' �J— `� !'t� BOTTOM: 5&x/Z R.,j� 1/97.3 i` / I ! �( `i N '- .<^ lT'• Gr TOTAL: �t�Ar � jay (! � � �^° "�,.f'�r„ c- r/ I�-,*, s�riM .^-•- s. ""^�b� ^ rC...x/1.�.." '�„� `� o + i ,> �4 «� F ...a- .........,...>.,>...,..... .-..,._..,.w...>.�....» f�J £T...'.—. '�cv'� ..�/.�'+�.;��...i-! f✓. �al'St`�,>, i 2YA:d:;�.�,,.t. � 4�!�:�rl�1�::'^R+i z ,�-,."f isA�: j. 4.r""4 Y .ry > a- -• � ...A - .�Q G?,:.,7� t%e:.�.•'7 e..4=' :F"J �.:•:ar.. r �•�r �_ fs,o.41,,�-.,,,�,,,,� _�••�'�. .r..�ty�._J�....'r'�—:.�- J � .. :.-'—c" ''... ..*^.r /. - /. J -�..�- - - ,.�.«..,...v.. _ .." ram.. - � `a---� _� r PIPE TO BE LAID 2 A ,R OF 3ro"PEASTONE �. C t �P i, T •.N, OVER `3/4 J D1;ST'ROUTIONBO\ STONE'..4J LAF-+^'UND TOP OF FOUND. -51 f. ALL PIPE TO EPVC Q 4 7>I Scx a�Pvc RAISE ALL AP.?LICA,$LE MANHOLE � .1r�./,�%'+�,+'��fi��' 's��.I �p,az: � .' COVERS TO WITHXIS b" .OF FINISH GRADE THIS SYSTEM IS NOT DESIGNED FOR l0 TIC USE OF A GARBAGE DISPOSAL / .. SEWAGE, SYSTEM PROFILE r GENERAL NOTES ` r'' J! ° SI'TE SE WACaE PL , I• CONTRACTORTO BE RESPONSIBLE FOR THE T a ` ` LG CATION OF ALL UTILITIES,ABOVE AND FOR ', c!t�, U. !!)ER GROi�"ND,PRIOR TO ANY CONSTRUCTION OIL EXCAVATION. ?. INr;TALLATION OF SEPTIC SYSTEM TO BE IN PREPARED FOR ' z COMPLIANCE,WITH 310 CMR 15.00:TITLE V. ! . O'A OF K" 3. THIS PLAN IS NOT TO BE USED FOR PROPERTY DANJC:E. 'G• - SRAM' LINE DETERMINATION. T 7� �p < , ��,�/ �+ CIVIL r i /5'CAM. .7 r-.DA7[TE: /Y 4Pe— ez . � .:? _ i�� �No.326(86C� N �q- s„,y �'���..��-.�z�'�• (.t�.•'TiY .9.�.1 Y �.�/Ti9/.4/i.✓/9�7 �/iPT�/�o WELLER & ASSOCIATES P. O. BOX 119 YARMOTJTHPORT, MA. 0?675 (508) 362-8131 APPROVED BY: I -------------, 0 - M J J Q � 0 o � J �{ e v I z I r.... E:l i v � I I I i d1 J 4 v� z� I i � I /� —� - //; /��� / i�, i G I d .i t ��� ",.fi IT f �� ` N I It � � �, � I � , , \� � 3 1+\� �\`1� �` i \ �� I �� . \ \� �: N e `\ � \ i Y . _�, =fir _ _ i O_ 4 t 3 a 0 i d V" � I I �, ` = � I i * / ii I � � � ' I i i I ' j / Ili ' � ` � ; � i � , i � � � � I , I i �, J I — i �, k I t ! � __ j i i � � � , i � I � , ; i � ; I , i � � � i � � I i � �; ' � � � � , � i � � i i i � ' j is h x � I i ; i . 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