HomeMy WebLinkAbout0093 FOURTH AVENUE (HYANNIS) - Health (2) 94 FOURTVENIJE
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COMMONWEALTH OF MASSACHUSETTS RECEIVED
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIR 30
d DEPARTMENT OF ENVIRONMENTAL PROTECTION MAY 3 12005
TOWN OF BARNSTABLE
HEALTH DEPT.
David B.Mason,R.S,Certified Title V Inspector,508-833-2177
p pp 7-
01,
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address:93 Fourth Ave,Hyannis,MA
Owner's:Ann Franklin
Owner's Address: 188 Old Schoolhouse Lane,Hanover,MA
Date of Inspection:May 27,2005
Name of Inspector: (please print)David B.Mason
Company Name:_N.A.
Mailing Address:4 Glacier Path
East Sandwich,MA 02537
Telephone Number:$08-833-2177
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 Sign tune: -Date: � 27 0 5r
The system inspector shall submit a copy of this inspection report to the Approving Auth /1ty(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.
Notes and Comments: System as inspected appears to have operated based on occupancy level. Increase in
occupancy may cause hydraulic failure. There appears to be excessive water use based on water records. The
system requires pumping for maintenance purposes. The,information as identified represents only the condition of
the system on May 27,2005 at 10:00 AM.
****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.
Page 2 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address:93 Fourth Ave
Owner: Franklin
Date of Inspection: May 27,2005
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:
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:
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 (THIS IS REQUIRED TO BE
COMPLETED)
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:
Page 3 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address:93 Fourth Ave
Owner: Franklin
Date of Inspection: May 27,2005
C. Further Evaluation is Required by the Board of Health:
Conditions exist which require fiurther 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
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 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: The primary cesspool is not a typical configuration for a cesspool. It appears to be a pipe
cylinder with an inlet pipe and outlet pipe with tee connected to a pre-cast 4'deepx6'diameter leach
pit with stone. Permit on file with the BOH for the pre-cast leach pit.
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
Page 4 of 11
PART A
CERTIFICATION(continued)
Property Address: 93 Fourth Ave
Owner: Franklin
Date of Inspection: May 27,2005
D. System Failure Criteria applicable to all systems:
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 cesspool is less than 6"below invert or available volume is less than '/2 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.
X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
X Any portion of a cesspool or privy is within a Zone 1 of a public well.
_X Any portion of a cesspool or privy is within 50 feet of a private water supply well.
—X 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 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.]
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:
To be considered a large system the system must serve a facility with a design now 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
"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.
Page 5 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address:93 Fourth Ave
Owner: Franklin
Date of Inspection:May 27,2005
Check if the following have been done.You must indicate`des"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 NIA)
X T 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)on the site 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(3)(b)]
OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS
Page 6 of 11
PART C
SYSTEM INFORMATION
Property Address:93 Fourth Ave
Owner: Franklin
Date of Inspection:May 27,2005
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design):4(per assessors records)Number of bedrooms(actual):4 septic design
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): (440 gpd capacity)
Number of current residents:_Unkown_
Does residence have a garbage grinder(yes or no):NO(Not Allowed)
Is laundry on a separate sewage system(yes or no):NO [if yes separate inspection required]Per owner
Laundry system inspected(yes or no):NA
Seasonal use: (yes or no): YES
Water meter readings,if available(last 2 years usage(gpd)): ,2004:230,250 gal. 2003;183,000ga1.
Sump pump(yes or no):No
Last date of occupancy:Unknown
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): gpd
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:Pumping conducted after inspection as a maintenance pumping.
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: Tank was pumped due to lack of pumping and as part of maintenance. Pumped after
inspected.
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 a copy of the DEP approval
_Other(describe):
Approximate age of all components,date installed(if known)and source of information:Approx.Nov. 1982
Were sewage odors detected when arriving at the site(yes or no):NO
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
Page 7 of 11
PART C
SYSTEM INFORMATION(continued)
Property Address:93 Fourth Ave
Owner:Franklin
Date of Inspection:May 27,2005
BUILDING SEWER(locate on site plan)
Depth below grade:Approximate;24 Inches
Materials of construction:_cast iron _X_40 PVC_other(explain):
Distance from private water supply well or suction line: NA
Comments(on condition of joints,venting,evidence of leakage,etc.): Appears in good condition. No evident
leakage.
SEPTIC TANK:N.A.(locate on site plan)
Depth below grade: 11 inches
Material of construction:X_concrete_metal_fiberglass polyethylene Tother(explain)_
If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of
certificate)
Dimensions: Typical 1500 gallon tank
Sludge depth: 10"
Distance from top of sludge to bottom of outlet tee or baffle:20"
Scum thickness:6 inches
Distance from top of scum to top of outlet tee or baffle:2"
Distance from bottom of scum to bottom of outlet tee or baffle: 12.5"
How were dimensions determined: Actual measurements with tape and scour stick.
Condition of tank(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid
levels as related to outlet invert,evidence of leakage,etc.) Inlet tee in good condition,Outlet tee in good condition,
Effluent level with outlet pipe. In need of Maintenance Pumping. No evident structural issues.
GREASE TRAP: 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.):
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
CTTRCITRF A PF CFW A V-V "11QV Q A T. CVCTTi M TN4ZPFPT1rnX IMUM
Page 8 of 11
PART C
SYSTEM INFORMATION(continued)
Property Address:93 Fourth Ave
Owner:Franklin
Date of Inspection: May 27,2005
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 even with outlet invert: liquid level even with outlet pipe
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.): No Indication of solids carryover. D-box 14 inches below grade.Invert is 24"
below grade.•Outlet pipe at slight negative pitch,but not enough to inhibit operation.
PUMP CHAMBER:_(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.):
Page 9 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 93 Fourth Ave
Owner: Franklin
Date of Inspection: May 27,2005
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:
—X_leaching trenches,number,length: 1 Trench;73'x4'x2'444gpd
_leaching fields,number,dimensions:
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) no saturated soil,nor signs of hydraulic failure,no indication of staining,No excessive vegetation growth.
Vent was required due to length of trench. Currently,the vent is buried and it must be exposed for air flow.
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 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.):
Page 10 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 93 Fourth Ave
Owner: Franklin
Date of Inspection: May 27,2005
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. ,
5 0
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Page 11 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:93 Fourth Ave
Owner:Franklin
Date of Inspection:May 27,2005
SITE EXAM
Slope
Surface water
Check cellar (crawl space)
Shallow wells
Estimated depth to ground water_feet
Please indicate(check)all methods used to determine the high ground water elevation:
X Obtained from system design plans on record-If checked,date of design plan reviewed:
X Observed site(abutting property/observation hole within 150 feet of SAS)
X Checked with local Board of Health-explain:Recent Test Holes, Existing engineer records with BOH
X_Checked with local excavators,installers-(attach documentation)
Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Utilized an engineered plan prepared by David B.Mason,RS,which was prepared on March 16,2002. No ground
water was noted to a depth of 126"for soil analysis conducted at property on March 15,2002. The system as
proposed was 5'above the bottom of the test hole.
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No. VD 2 r I Fee �Q
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: +�
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
Zpprication for Migoml i6p5tem Com5truction 3permit
Application for a Permit to Construct( )Repair( )Upgrade Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. Owner's Name,Address and Tel.No.
may.-�.c.�it ��Cl�.���h F��.6•v��i�-
Assessor's Map/Parcel
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
d7l.4 Adis•
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow ��,5�� gallons per day. Calculated daily flow® gallons.
Plan Date Number of sheets / Revision Date
Title
Size of Septic Tank S"®® 9.d j Type of S.A.S. 15��.dG�i�
Description of Soil 7.? X`/
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 Certifi-
cate of Compliance has been issued by this Boald of Health.
Signed �^ Date � ����`
Application Approved by A k Date ';2/' 0
Application Disapproved for the ollowing reasons
Permit No. U d a / Date Issued —
7.7
`, ^1 „� � .. V(Itww'+.w.y�+QarR'_"M91v�•`�Ernar'K!'�.,y - � � V.L
t No. VQ 1 _ "` y -.. Fee
i T-HE?C.OMMONWEALTH,4 OF MASSACHUSETTS Enteied'incomputer:
_ � PUBLIC HEALTH DIVISION'-TOWN OF BA&4STABLEi\a MASSACHUSETTS� Yes
ZippIication for Mizpaar *p!5tem Construction Permit
Application for a Permit to Construct t )Repair( )Upgrade Abandon( ) O Complete System ❑Individual Components
Location Address or Lot No./ ? eraC X:fw Owner's Name,Address and Tel.No. r
Aelp
Assessor's Map/Parcel �6. �.�• -.
i
Installer's Name,Address,and Tel.No. 3 Designer's Name,Address and Tel.No.
'Type of Building:
• _ Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder
Other Type of Building- -OPZJ' No. of Persons Showers( ) Cafeteria
Other Fixtures J'
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date 3 -- e0;<-- o Ar. Number of sheets / Revision Date
Title
Size of Septic Tank 9.8-e Type of S.A.S. _Lt',OCiYi.�4 T/?'Fi►'��°
Description of Soil i i v 7� X Y
i
Nature of Repairs or Alterations(Answer when applicable) t
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 by this Boald of Health.
Signed bA Date
Application Approved by '. Date
Application Disapproved for the oi%wing reasons + J 1
I Permit No. Date Issued 3 l-U
---------------------------------------
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
• I
Certificate of Compliance
THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired( )Upgraded)
Abandoned( )by
at has been constructed in accordance
i
F with the provisions of Title 5 and the for Disposal System Construction Permit No.a ode dated 3 'c2/—U ;1
Installer O-/ Designer O-A G/d A& _,iV
The issuance of this ermit shall not be construed as a guarantee that the syst ilLf nction as esig ned.
Date r� � 1 u} Inspecto 4-/.
----------------------------------------
No. U U 7 Fee QU
i
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS
Mig pogar bpgtem .Construction Permit
Permission is hereby granted to Construct( )Repair( )Upgrad><)Abandon( )
System located at 9 3 4/t;p2y . 4liE''
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.
Provided:Construction must be completed within three years of the date of ermit.
Date: 3 ' J- U Approved by �nr
TOWN OF BARNSTABLE
LOCATION 9.�
SEWAGE #
VILLAGE ASSESSOR'S MAP & LOT'z�`�
INSTALLF.R'S NAME:&PHONE NO.O'�"'
SEPTIC TANK CAPACITY i�`o A ��i�• �! i®
LEACHING FACILITY: (type) (size)
NO. OF BEDROOMS
BUILDER OR OWNER
PERMITDATE: "Z���'£ COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
I� 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
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