HomeMy WebLinkAbout0075 FIRST AVENUE (HYANNIS) - Health 75 FIRST AVE., HYANNIS
TOWN OF BARNSTABLE
`LOCATION SEWAGE # 0 47'�
`VILLAGE 1Q '- � "�' SSESSOR'S MAP & LOT
"'�INS,TALLER'S NAME&PHONE NO f
SEPTIC TANK CAPACITY eo',
r
-LEACHING FAcELr'Y: (type) A T- (size)
NO.OF BEDROOMS , >
BUILDER OR OWNER
PERMIT•DATE: �' .. COMPLIANCE DATE:
Separation Distance Between the:
Mai iinum 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
Ed prof Wetland and Leaching Facility(If any wetland exist
hin 300 feet pf leac 'n aci
`red l;
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LOCATION SEWAGE PERMIT NO.
VILLAGE
IONSTA LLER'S NAME i ADDRESS
® U 1 L D E R OR OMEN ER
DATE PERMIT ISSUED3- 3
DAT E C0MIPLI A N C E ISSUED
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No.83 .l.®.c?/ FxsA...10.00...._
TH F TS
BOARD OF HEALTH
----------------' .Own................OF.................i3armatable----.........................................
Appliratiou for Ui_qpnsal Works Tnntrnrtinn ramit
Application is hereby made for a Permit to Construct ( ) or Repair ( X) an Individual Sewage Disposal
System at:
....71 Fire..!xaj.A.. ......02672..--•-••---------------•--•--......-•---------......-------•-------------------------•-----------
Location-Address or Lot No.
......................mara...•--••---------------------•----•------------•-•--••...._...... ..7.5..Firat..A�ra�.,--Nast..Hyanni spo�.,...MA......Q2 72
Owner Address
LLB B Cesspool Service -.12Q-3iahops-_T=aQe.,...Hyanni,s.,..BA,..-.02.6.0.1__.
Installer Address
dType of.Building Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms....................2......................Expansion Attic ( ) Garbage Grinder ( )
Other—T e of Building No. of persons............................thowers — Cafeteria
Q+ Other fixtures -----------------------------•-- .
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid'capacity......_.....gallons 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 ( ) Dosing tank ( )
aPercolation Test Results Performed bY.......................................................................... Date........................................
,4 Test Pit No. 1......----------minutes per inch Depth of Test Pit.................... Depth to ground water............__-__---.--.
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
----------------------------------•------------------------•----•--------------...------•-•••-----.....-----•---•-------......-----------------•-•-----._----
0 Description of Soil----- Sand-------------------------------------------------------------------------------------------------------
V -•-•-----------•--••-------------•----....-----.........-----------------------------------•-----•----•----------------------•••------••------...--------•--
W --------•-•------ ------------------••-------------•--•-••--------------------------.....•---•-•••----•---------•---------------------•--......--•--------•---------•-•---•-------•--------------------
UNature of Repairs or Alterations—Answer when applicable-----installation__of_a__l.000___gallon_,___pre-cast,
. (fir) peptic tank.
Agreement:
,.The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TLNU 5 of the State Sanitary Code— The undersig ed further agrees not to p the system in
operation until a Certificate of Compliance has b i ued by the b I
e �l..� Cirn = 1-... 1.83.....
-
/ Da e
Application Approved BY f ..• �'�- ••.•----------------------------------------------------•.... 2 8-3-----------
Date
Application Disapproved f the ollowing reasons-----------------•••------•--•--•--------------------------------••-•----•-•---•-------------------•-....._......
--------•--------------------•---....-------•--------------•-----••-••-•------•------.._.......-----•-------------------------•-------•-----------------------•-••---•-----•••------------•-••----------
/ / -------Date
Permit No............ -..1..® ....................... Issued.-_31.2`83
Date
ZP
Fis...��''...!.5.00....
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
........ .......Town...--.....:....OF................. ,arnstable---..........................................
Appliration for UiopouFal Workii Tonoirnrtion ramit
Application is hereby made for a Permit to Construct ( ) or Repair ( =`) an Individual Sewage Disposal
System at:
.....0267?................................................................................................
Locat_on-Address or Lot No.
....iTp1C-3ri CatRF1Tc3 75 �_�5�._A1'.'�.,.�..�:7t'�'f..u��.nr�i 5�S?�¢ -r� •�2U72
...........................•-----•-••................_......._..._ -._..
Owner Address
W a e 1' Cess ool Service
Installer Address
Type of Building !t Size Lot............................Sq. feet
Dwelling—No. of Bedrooms..................... ..........._._.......Expansion Attic ( ) Garbage Grinder ( )
p,,l Other—Type of Building ............................ No. of persons.......................
..... thowers ( ) — Cafeteria ( )
Pa Other fixtures -------------------------------- -
W
Design Flow............................................gallons per person per day. Total daily flow............................................gallons
.
WSeptic Tank—Liquid*capacity............gallons Length................ Width.'...:----------- Diameter---------------- Depth................
x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area.................:..sq. ft.
Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by........ ••--•-•-•-•••-----•-------•••••-•-----•--••---...--•-••-•-•••--•- Date........................................
Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................
44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
a .-•--- ................•-------------.......------------.................----.........................................................and
0 Description of Soil........`..' .......................................................................................................................................................
x
W
V Nature of Repairs or Alterations—Answer w en applicable.--___installation- of a 1.,00O._ga.11.on, lre-cast
as = ( septic tank.
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with f
the provisions of TITLE: 5 of the State Sanitary Code— The undersigned further agrees no to place the system in
operation until a Certificate of Compliance has ben ' ed by the 4qar,, of h
----- --1--------------
A Plication Approved BY = --- .... .-•-•-•......--------- ---------------- --.....-.-.-.P Date -
Application Disapproved f th ollowing reasons:.......................................................................--.......................................
.........................................................................................................................................................................................................
/ Date
Permit No............ -�`-�-�---....----•-•----------.. Issued....3/ 2/83 to
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
T own Darns table
...................O F....................................................................................
TrrtifirFatr of TomptiFanrr
T��IIT���S ONCE Y- Thai the�n id�ualpSe a eDis�oslySst m'ctru� o` ) or Repaired ( X)
A-Yc ,`3 Ces ooI Sex�v�ce i��ss o s �'e a a n i
bY-------------------•----.----------•-----------.--•---•---------------•-----------------•-------l p�--}-�---------.---.-----•..---•-----------•---•-------•-•----..-..-..------------------------
75 First Ave., West hyannisport, M�AlnsbMV2 - Helen Camara
at-•-••-•---••-••-••---•--••-••----••-----••----••-••--•--•-•••----...•-•-----•----------•..............
—" has been installed in accordance with the provisions of T ,T,LW 1,ry j The State•Sanitar 3YVn described in the
L'� V
P // Y
application for Disposal Works Construction Permit No......___,l..... ...................... dated_....._.._....................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM 3lJ 2/FF3 NOTION SATISFACTORY.
DATE................................................................................ Inspector_
nspector ---- --•----------------------•---------••--•------------•-------•-----------
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
£i3- Town Farnstable
........OF.......................................................•••••........................ 43 15.00
No......................... FEE........................
Diupouul Workii T-1onotrion rruti#
A & Cess ool Service
Permission is hereby granted . ...11......••-----•-•------•-••-•---•••-----•-•-•-•••••••••••---•-••••••-••--••......•................••----
to Con Rea (( x n Individua Se r e al System
�S"CH(zsl ve.P 1166t)llayarm- spo , " t i -- Helen ^amara
atNo..••••••••--•••••-••------•------•-•---••-----••••......-•-•-•••••.-•-•-•.....................-••-•••---------••......--••-•-•-•••......••----•------••-••-••-•--••-••......••-•............
Street $3 r 3/ 2/83
as show/the ca n for Disposal Works Construction Permit No..:.... __.. Dated...............................Board of Health
DATEFORM 12WARREN. INC.. PUBLISHERS _
DATE:_9/29/99_--_
PROPERTY, ADDRESS:_ 75_Firat_gYe-_________-
West Hyannisp.,ort,MassL_
------------------------
On the above date, I Inspected the septic system at the above address.
This system consists of the following:
1 . 1-61x6 ' block cesspool . ( Gray Water ) .�
2 . 1-1000 gallon septic tank .
3. 1-1000 gallon precast leaching pit packed in stone .
Based on my Inspection, I certify the following conditions:
4. This is a title five septic system ( 78 Code ) .
5. The septic system is in proper working order
at the present time .
6. The grey water cesspool must be omitted .
Change plumbing and tie it into the septic system in +� ;f
the front yard .
SIGNATURE:1
Name:_ P .kLacoaber.-J-r------- V .,
Company: Joseph—P . Macomber & Son , Inc .
GFO
Address' Box 66
-------------------- _
Centerville , Ma__02632-0066 s o �'99
Phone: 508-775-3338 A
THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY
JOSEPH P. MACOMBER & SON, INC.
Tanks-Cesspools-Leachflelds `
Pumped & Installed
Town Sewer Connections
P.O. Box 66 Centerville, MA 02632-006,B
775-3338 775-6412
•
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COMMONWEALTH OF MA�SSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
ONE WINTER STREET, BOSTON MA 02108 (617) 292.6500
TR UD
S
ARCEO PhUL CELLUCCI DAVID B. S
Governor Coma:
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
Estate Of Helen Camara
Proparty Addr as.s: 75 First Ave Namw of owner lfeFiFyr a
Adds"of Owrsa:
�1 ot�LH, npisport ,.Mass , // qq// nc n oa EXT
N.mA of inspector:(Ptaasa Print) Jose1)h9P?I�ar tuber Jr . Hyannis ,Mass . 02601
1 am a DER approved system lnspector purwam to Section 16.340 of 71de 6 (310 CMR 16.000)
cornpar,yNa.-n.: J. P.Macomber & Son Tnr _
Id&%NAddress: Rnx 66 3le ,gass . 02632
T el eptvone N-1,15 0 8 7 7 5—3_n
CERnF1CAnoN STATEMENT
I csruty that I have personally Inspected the sewage disposal system at this address and that the Informadon reported below Is true, occur
and complete as of the time of "paction. The Inspection was performed based on my training and experience In the proper function and
maintsnancs of on•slts sewage disposal systems. The system:
' 4z P83ses
_ Conditionally Passes
Needs Further Evaluation By the ocal Approving Authority
_ fail .t
ins is Siytavue: ,/��� r�V t Date:
pat_
Tha System Inspect hall submit a copy of this nspection report to the Approving Authority (Board of Health or DEP)within thirty (30) da
completing this Inspection. If the system Is a shared system or has a design flow of 10,000 gpd or greater, the Inspector and iris system
shall suomit the report to the approprlate regional office of the Department ohEnvlronmantal Protection. The original should be sent to Zne
system owner and copies sent to the buyer, If applicable, and the approving authority. '
NOTES AND COMMENTS
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revised 9/2/98 Plitt IofII
Iru+ted on Aecyc40 Paper
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (cofrdnued)
Property Addrw:
Owner.
Drte of kupocr;—
LNSPEC710H SUM)AARY: Check A, S, C, or D:
A. SYSTEM PASSES: _
1 have not found any Information which Indicates that any of the failure conditions described In 310 CMR 1-6.303 exist. Any failure
critsdi not evaluated are Indicated below.
COMMENTS: Grey water rec Poptl 1n I:eer- eig he-tts
tanK & pi
in the fron yard . Cesspool is not structurally sound .
S. SYSTDaA COr1DMONALLY PASSES:
yV' One or mots system components as described In the 'Conditional Pass' section need to be replaced or repaired. The system, upon
com;:.:: n of the replacement or repair, as approved by the Board of Health, will pass.
Indicate yes, n,,, or not determined (Y. N, or ND). Describe basis of datermination In all Instances. If 'not determined% explain why not.
The septic tank Is metal, unless the owner or operator has provided the system Inspector with a copy of a Certificate of
Compliance (sttached) Indlcadng that the tank was Installed within twenty (20) years prior to the date of the Inspection; or
t:e septic tank, whether or not metal,Is cracked, structurally unsound, shows substantial Infiltration or exfiltration, or tank
failure Is Imminent. The system will pass inspaction If the existing septic tank Is replaced with a complying septic tank as
approved by the Board of Health.
1q' S swage backup or breakout or high static water level observed In the distribution box Is dus to broken or obstructed pips(s)
or due to a broken, sawed or uneven distribution box. The system will pass Inspection If(with approval of the Board of
Haalth;.
broken pipa(s) are replaced
obstruction Is removed
dlsuibudon box Is levelled or replaced
The system roquired pum*g,-mare than'fourdmas t+•yeardue to broken or obstructed pipe(s). The ryrtwm wittyesr--
Ir.Specdon If (with approval of the Board of Hoaith):
broken plpe(s) are'ropiaced
obstruction Is removed
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revised 9/2/98 Page Iof11 '
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
PropertyAddreas: First Ave West Hyannisport ,Mass .
Owner: I:.—ate Of Helen Camara
Data of inspection: ?9/9 9
C. FURTHER EVAL1.1: ION IS REQUIRED BY THE BOARD OF HEALTH:
4)h_ Conditions 5 Kist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the
public het: safety and the environment.
1) SYSTEM ', ''_ PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 15.303(1)(b)THAT THE SYSTEM
IS NOT FL, ZONING IN A MANNER WHICkiya-L.PROTECT THE PUBLIC HEALTHAND SAFETY AND-THE ENS MONMENT:
C :_spool or privy is within 50 feet-of surface water
c pool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
2) SYSTEM `• FARL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER.IF ANY)DETERMINES THAT THE SYSTEM IS
FUNCTION, IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: -
4L T system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or
t :cry to a surface water supply.
system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well.
jystem has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well.
1419 s,,stem has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a
t� water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the
:s free from pollution from that facility and the presence of-ammonia nitrogen and nitrate nitrogen is equal to or less
t, 5 ppm. Method used to determine distance r (approximation not valid).-
3) OTHER
revised 9/= 3 Page 3of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTiON FORM
PART A
CERTIFICATION (continued)
Property Address: ' first Ave West Hyannisport ,Mass .
Owner: ce Of Helen Camara
Deft of Inspection: i /9 9
D. SYSTEM FAILS:
You ust Indicate eit .s" or "No" to each of the following:
1 have date: :hat one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this
determinati,. ntified below. The Board of Health should be contacted to determine what will be necessary to correct the failure.
Yes No �.
�/ B:. !aewege iMo facility-or•-sYatem component,due qo en overloa, •J orcloggsd-S:PiS-or•cesspod.
Di or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or
ct
S, iid level in the distribution box bovaroutiet invert due to an overloaded or clogged SAS or cesspool.
•F ,
Li :th in cesspool is less than 6" below Invert or available volume Is less than 1!2 day flow.
21 R pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
N, f times pumped OL•
Zn of the Soil Absorption System, cesspool or privy is below the high groundwater elevation.
Ar cn of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
Z'AAr un of a cesspool or privy is-within a Zone I of a public well.
n of a cesspool or privy is within 50 feet of a private water supply well.
n of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no
ac : water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for
-cc acteria, volatile organic compounds, ammonia nitrogen•and nitrate nitrogen. -
E. LARGE SYSIT!
You must indicate eit :' or "No" to each of the following:
The follow'. a apply to large systems in addition to the criteria above:
AV The systen- , facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public
health and z nd the environment because one or more of the following conditions exist:
Yes. No
Y , is within 400 feet of a surface drinking water supply
_ t -, is-•witi4n 200 feet suefaoadrinkiwg-wat+r.-su pig y•... _ --- .. _. _ ._
_ _� ,;• n is located in a nitrogen sensitive area(Interim Wellhead Protection Area=IWPA) or a mapped Zone II of a public
v: ply well)
The owner or opera! such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional
office of the Depanr„ .,rther information.
revised 9/- Page 4orIll
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
PropertyAddrass: 75 First Ave West• •Hyannisport.,Mass .
Owner: Estate Of Helen Camara
Date of Inspection: 9/2 9/9 9
Check if the following have been dond: You must Indicate either "Yes" or "No" as to each of the following:
Yea N
Pumping information was provided by the owner, occupant, or Board of Health.
_ None of the system-cornpooants.hauabsen pawgsed+ PatJeasi•t++ w weaha and-the•systsm hasbaaagscainingenew l ttow
rates during that period. Large volumes of water have not been Introduced Into the system recently or as part of this
Inspection.
_ As built plans have been obtained and examined. Note if they are not available with N/A.
The facility or dwelling was inspected for signs of sewage back-up.
The system does not receive non-sanitary or Industrial waste flow.
4 _ The site was inspected for signs of breakout.
_ All system components�luding the Soil Absorption System, 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 Soil Absorption System on•the site has been determined based on:
Existing information. For example, Plan at B.O.H.
_ Determined in the field (If any of the failure criteria related to Part C is at Issue, approximation f distance Is unacceptable)
115.302(3)(b))
_ The facility owner.(.and.o_ paj,.Jf diftarerit from.niunarl.v�ers prnuIded wIih intncmasi ►inn+ham p=ls�t��"M ^t
SubSurface Disposal Systems.
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revised 9/2/98 pages orii
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C `
SYSTEM INFORMATION
Property Addresa: 75 First Ave West Hyannisport Mass .
Owner: Estate Of Helen Camara
°"'of Inspection: 9/2 9/9.9
FLOW CONDITIONS
RESIDENTIAL:
Design flow: 1/h g•p•d./bedro
Number of bedrooms(d ig ): Number of bedrooms lactual):1
Total DESIGN flow
Number of current residents:
Garbage grinder(yes or not:
Laundry(separate system) as r no):_, If yes, sepamtsInspection.required --.
Laundry system Inspected es or no)
Seasonal use lass or no):
Water meter readings,if available (last two year's usage(gpd):
Sump Pump(yes or no): ,}-Q��
Last date of occupancy: Q
COMMERCIALANDUSTRIAL:
Type of establishment:
Design flow: 49/i apd ( Based on 15.203)
Basis of design flow
Grease trap present: (yes or no)
Industrial Waste Holding Tank present: (yes or no)A
Non-sanitary waste discharged to the Title 5 system: (yes or no)&
Water meter readings,if available:
Last date of occupancy:_JX
OTHER:(Describe) WA
Last date of occupancy:
GENERAL INFORMATION
PUMPING R CORDS and jour of Information:
System pumped as part of I pection: (yes or no)_.o
If yes, volume pumped: gallons
Reason for pumping: kw
TYPE OF YSTEM
Septic tank/dissributicrHbvxlsoil absorption System
Single cesspool
Overflow cesspool
Privy
Shared system (yes or no) (if yes, attach previous inspection records,if any)
I/A Technology etc.Attach copy of up to date operation and maintenance contract
A.�ry Tight Tank _Copy of DEP Approval
Other
► eO TFrJ1GE of ell components date installediif known).qnd source o#4n(oxmotion-
Sewage odors detected when arriving at the site: (yes or no)Z0.
revised 9/2/98 Page 6ofII
F3 S-
` LOCATION SEWAGE /PERMIT N0.
VILLAGE
� ll
I N S T A LLEIt's NA PRE i ADDRESS
�✓ U
SUILDER OR OWNER
DATE PERMIT ISSUED
33- � �
DATE C0M ►LIANCE ISSUED
U ,
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
PropertyAddre": 75 First Ave West H,yanni sport ,Mass .
Owrw: Estate Of Helen Camara
Data of Irupection:9/2 9/9 9
BUILDING SEWER:
(Locate on site plan)
Depth below grade:
Material of construction: cast iron Z40 PVC_other(explain)
Distance from pri ate wa er supply well or suction line 0 '1_
Diameter
Comments: (condition of joints, venting, evidence of leak"a,•etc.)
stemPear1I '
SEPTIC TANK: lQX qri LoN.5
(locate on site plan)
Depth below grade:
Material of construction: concrete AmetalpZ&Fiberglass�v4PolyethyleneN'A other(explain)
If tank Is Inetal, list age_W Js.age.confumed by Certificate of Compliance&& (Yes/No)
Dimensions: FW11111.te
Sludge depth:_a 1
Distance from to f sludge to bottom of outlet tee'ortaffie:�� —
Scum thicknessp
Distance from top of scum to top of outlet tee or baftle:ri"
Distance from bottom of scum to bottorp of outlet ee or baffle:_,
How dimensions were determined:
Comments:
(recommendation for pumping, condition of inlet and outlet tees or-baffles, depth of liquid level in relation to outlet invert, structuroHntegrity,
evidence of leakage, etc.) Pump tank every 2-3 years " TnlAr & autl®t t6e6
are in place .The tank ; g gt•rj1rf ij-r 11Tsgal4d and sheies fte
evidence e£ !eakase . -
GREASE TRAP:
(locate on site plan)
Depth below grade:
Material of constructions(/.�iconcreteVAmetaVl Fiberglass.( Polyethylene other(explain)
AM
Dimensions:
Scum thickness:__ ./
Distance from top of scum to top of outlet tee or baffler
Distance from bottom of scum to bottom of outlet tee or baffler
Date of last pumping:
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level In relation to outlet invert, structural integrity,
"dance of leakage, etc.)
Grease trap is not pregant
revised 9/2/98 Page 7or11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(contirwed)
Property Address: 75 First Ave West HXanni sport ,Mass .
Ownw: Estate Of Helen Camara
Date of Inspection`9/2 9/9 9
TIGHT OR HOLDING TANK:4,j>&(Tank must be pumped prior to, or at time of, inspection)
(locate on site plan)
Depth below grade:bw
Material of constructionAL4concret"—o metaW2AFiberglasso rVolyethylenwWother(explain)
N
• Dimensions:
Capacity: d2&gallons
Design flow: M gallons/day
Alarm present
Alarm level: Alarm in working order:Yes,44� No?JV
Date of previous pumping: _
Comments:
(condition of inlet tee, condition of alarm and float switches, etc.)
11grit or holding tanks are not present
DISTRIBUTION BOX:/"
(locate on site plan)
Depth of liquid level above outlet invert:
Comments:
(note,lf level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) — —
Distribution box is not nrpepnr
PUMP CHAMBER:&�Ve
(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.)
Pump chamber is not present ,
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revised 9/2/98 Page 8of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
yAddr.s,:75 First Ave West Hyannisport ,Mass .
Owrw: Estate Of Helen Camara
Date of 4ispecdon: 9/2 9/9 9
SOIL ABSORPTION SYSTEM(SAS).1-1
(locate on site plan,If possible: excavation not required,location may be approximated by non-Intrusive methods)
If not located, explain:
Type:
leaching pits, number:
leaching chambers, number: '
leaching gallerles,number:
leaching trenches,number;an gth:
leaching fields, number, dims lions:
overflow cesspool,number:
Alternative system:X1 /J
Name of Technology: (41V
Comments:
(note condition of soil, signs of hydraulic failure,level of ponding, damp soil, condition of vegetation, etc.)
Loamy sand to mPdj ttm fine (2and.No signs of; hydr-atiiie
normal .
s nry. house has been vacant since 99
CESSPOOLS:
(locate on site plan)
Number and configuration:
Depth-top of liquid to Inlet Invert:
Depth of solids layer:
— YJPV
Depth of scum layer: PAN
Dimensions of cesspool:
Materials of construction:
Indication of groundwater: lub
inflow(cesspool must be pumped as part of inspection)
Did not =ttm= r•ac nni Cnsspgo3 Js dpy Handles grey water only
Cess ool is shaky . Said he woultitie it into the septic system out fr&VT
Commen s:
(note condition of soil, signs of hydraulic failure,-level of.ponding,condition of-vegetation, etc.)
esSDO0 s d y
PRiVY:1�0e
(locate on site plan~
Materjals of constructign: AM Dimensions: 4/4
Depth of solids:
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation;etc.)
Privy is not nrPGPnfi
revised 9/2/98 Page 9of11
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4 SUBSURFACE SEWAGE DISPOSAL SYSTEM&SPEcnON FORM
PART C
SYSTEM WFORMA nowcomk&wd)
P, yAd&.". 75 Firs't Ave West Hyannisport ,Mass .
Owr-••: Estate Of Helen Camara
9/2 9/9 9
SKETCH OF SEWAGE DISPOSAL SYSTEM: .
Include des to at least two permanent reference landmarks or benchmuks
locate all wells wlthln 100' (Locata where publlc water supply comas Into house)
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revised 9/2/98 Fitt 10of11
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 75 1st Ave. West Hyannisport ,Mass .
Owner: Estate Of Helen Camara
Date of Inspection: 9/2 9/9 9
NRCS Report name
Soil Type_
Typical depth to groundwater
USGS Date website visited
Observation Wells checked
Groundwater depth: Shallow Moderate Deep _
SITE EXAM Slope
Surface water
Check Cellar
Shallow wells
Estimated Depth to Groundwaterf��Feet
Please indicate all the methods used to determine High Groundwater Elevation:
_I/Obtained from Design Plans on record
t/ Observed.Site(Abutting propert observation hole, basement sump etc.)
V
Determined from local conditions
Checked with local Board of health
Checked FEMA Maps
Checked pumping records
_ZChecked local excavators, installers
Used USGS Data
Describe how you established the High Groundwater Elevation. (Must be completed)
Used water contours map .
Gahrety & Miller Model
12/16/94
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'V
revised 9/2/98 Page 11of11
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TOWN OF Barnstable BOARD OF HEALTH
SUBSU[tFACF SEWAGE [)I DISPOSAL SYSTEM IN9PF�CTION FORM - PART D .- CERTIFICATION
-TYFL OR PRINT CI.EARLY-
PIIOPERTY INSPECTED
STREET ADDRESS _75 First Ave WPet
ASSESSORS MAP, BLOCK AND PARCEL # _Z(, 7C) i 7
OWNER' s NAME _Helen T,_ U ma rn
PART D - CERTIFICATION
NAME OF INSPECTOR jr).- -ph P Mncnmhor, Ir
COMPANY NAME J. P.Macomber & S`on Inc .
COMPANY ADDRESS Box 66 Centerville Mass . 02632
Street Town or City state LIP
COMPANY TELEPHONE ( 508 775 - 3338 FAX ( 508) 790 - 1578
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at
this address and that the information reported is true , accurate , and
omplete 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 ;
System PASSED
The inspection which I have conducted has not found any information
which indicates that the system fails to adequately protect public
health or- the environment as defined in 310 CMR 15 , 303 , Any failure
criteria not evaluated are as stated in the FAILURE CRITERIA section of
this form.
System FAILED*
The inspection which I have con\\_'�oted has found that the system fails to
protect the public liealth and the environment in accordance with Title
5 , 310 CMR 15 . 303 , and as specifically noted on PART C - FAILURE
CRITERIA of this Inspectio orm .
Inspector Signature Date
ne copy of this c rtification must be provided to the OWNER, the BUYER
( where applicable ) and the DOARD OF HEAL1111.
If the inspection FAILED, the owner ors"operator shall upgrade ' the system
within o'ne year of the date of the inspection, unless allowed or required
otherwise as provided in 3,10 CMR 16 . 306 ,
partd .doc