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Home My WebLink About0016 GEORGE STREET - Health 1TGeorge Street Hyannis P A.=,291 ..084 t i c Y n ° u n 0 n U 0 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS . DEPARTMENT OF ENVIRONMENTAL PROTECTION MAP. PARCEL , i,.07 TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 16 George Street Hyannis, MA Owner's Name: Robert Daniels Owner's Address: 46 GPnrq4e St-rp Hyannis-, MA BAN 0 Date of Inspection: ; �-/ i Name of inspector:(please print) W i.1 1 i am E_ • Robinson Sr. Company Name: William E. Robinson Septic Service Mailing Address: P O Box 1 089 Centerville, MA Telephone Number: ( 5081 775-8776. CERTIFICATION STATEMENT 1 certify that 1 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: Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails01 nn Inspector's Sigtiature: (xi .1, t ,/l Date: P The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Heakhvr <. DEP)within 30 days of completing this inspection.if the system is a shared system or has a design now 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 approxing authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 Page 2 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 15 George Street Hyannis, MA Ownerr, Robert panieds Date of Inspection: —O Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. Sys m Passes: I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CUR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: Q B. S stem Conditionally Passes: ne 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 y s,no or not determined(Y,N,ND)in the for the following statements.If"aot determined"please explain. The eptic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,ekhibits substantial infiltration or exfiltration or tank failure is imminent.System will pass inspection if the existing tankiis 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 th t 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 p°pe(s)or due to a broken,settled or uneven distribution box.System will pass inspection if(with approval of oard of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: Thesystem required pumping more than 4 times a year due to broken or obsuwcd p' s).The system will pass inspection if(with approval of the Board of Health): broken pipes)are replaced obstruction is amotrod ND explain: r Page 3 of 11 OFFICIAL INSPECTION FORM=NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 16 George Street Hyannis, MA Owner: Rober • Dani 1 Date of Inspection: /— O i 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 fail' g to protect public health,safety or the environment. 1. yytem will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the s stem 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. S tem will fail unless the Board of Health(and Public Water Supplier;if any)determines that the syste2is 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 su face 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 aseptic tank and SAS and the SAS is less than 100 feet but 50 feet or more frond a prrvate water supply well" Method used to determine distance i'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. i 3. Other: . , 3 ( Page 4 of I I ` OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 16 George Street Hyannis, MA Owner: Robert Daniels Date of inspection: 4:�_B T/ D. System Failure Criteria applicable to all systems: You m st indicate'Yes"or"no"to each of the following for all inspections: Yes o 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 _ 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',day flow 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. _ 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. _ Any portion of a cesspool or privy is less than 100 feet but greater than 50 f^_et from a private xmater supply well with no acceptable water quality analysis. (This system passes if late 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.] (Yes/No)The system fails. 1 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. La ge Systems: To be onsidered a large system the system must serve a facility with a design now of 10,060 gpd to 15,000 gpd• You must dicate either"yes"or"no"to each of the following: (Tile follow' g criteria apply to large systems in addition to the criteria above) yes no _ _ the sy•em is within 400 feet of a surface drinking water supply the syste tu \is within 200 feet of a tributary to a sface drinking water supply _ the system5s located in a nitrogen sensitive area(Interim We Protection Area—IWPA)or a mapped Zone II of a ublic water supply well If you have answered"y "to any question in Section Ellie system is considered a significant threat,or answered "yes"in Section D above he large system has fatted.The owner or operator of any large system considered a significant threat under Se lion E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system o ner could contact the appropriate regional office of the Department. 4 Page S of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: - 1 6 George Street Hyannis, MA Owner: Robert Daniels Date of Inspection: ,/—3—0 =� Check if the following have been done.You must indicate`)res"or"no"as to each of the following: Yes No/ PP mping information was provided by the owner,occupant,or Board of Health ✓ Were any of the system components pumped out in th . /— Y p p p a previous two weeks? v _ Has the system received normal flows in'the previous two week period? V 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? t/_ Was the site inspected for signs of break out? Were all system components,excluding the SAS,located on site? J— 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: . Yes no _ _✓ 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 dis tance tstance is unacceptable)[310 CMR 15.302(3)(b)) 5 - 1 Page 6 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 16 George Street Hyannis-, MA Owner: Robert -nani P1 G Date of Inspection: 1-3—o'-/ FLOW CONDITIONS RESIDENTIAI. Number of bedrooms(design):. 3 Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x N of bedrooms): .3(. C� Number of current residents: off. Does residence have a garbage grinder(yes or no): ti Is laundry on a separate sewage system(yes or no):/,L) [if yes separate inspection required] Laundry system inspected(yes or no):_ Seasonal use:(yes or no):�i U Water meter readings, if available(last 2 years usage(gpd)): 2003 — 4 8,0 0 0 Sump pump(yes or no):,L!� 2 0 0'- _6 0,0 0 0 Last date of occupancy: / COMMER L/INDUSTRIAL - Type of establi hment: Design flow(b ed on 310 CMR I5.203): gpd Basis of design ow(seats/persons/sqft,etc.): Grease trap pres nt(yes or no):_ Industrial waste olding tank present(yes or no):_ Non-sanitary w�ste discharged to the Title S system(yes or no):_ Water meter re dings,if available: Last date of oc/ upancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: A, A Was system pumped as part o the inspection(yes or no): 1:,,0 If yes,volume pumped:_gallons--How was quantity pumped determined? Reason for pumping: TYP OF SYSTEM ,10F 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 contact(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: 44 ri 1-7 Were sewage odors detected when arriving at the site(yes or no): A, 6 J'agc 7 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:_1 6 George Street Hyannis., MA Owner: RnhPrf Dani Pls Date of Inspection: BUILD G SEWER(locate on site plan) Depth bel w grade: Materials f construction:_cast iron _40 PVC_other(explain): Distance om private water supply well or suction line: Comment (on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK:_(locate on site plan) Depth below grade: 1 Material of construction: ✓concrete_metal fiberglass_polyethylene _other(explain) —' If tan}:is metal list age:_ Is age confumed•by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions: Sludge depth: Distance Gom 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: How were dimensions determined: 0 ��w C. d a I. 3 Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc. A m� ` v V c `Jv [� IF GREASE T P:_(locate on site plan) Depth below grade:— Material of a nstruction:_concrete_metal fiberglass_pol),ethylene_other (explain): Dimensions: Scum thickness:— Distance Got top of scum to top of outlet tee or baffle: Distance fro bottom of scum to bottom of outlet tee or baffle: Date of last umping: Comments on pumping reconunendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels as related td outlet invert,evidence of leakage,etc.): 1 7 1 Page 8 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 16 George St eet Owner: Date or Inspects 1 s TIGHT o OLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth belo grade: Material of c nstruction: concrete metal fiberglass_polyethylene other(explain): Dimensions: Capacity: I allons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pi mping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: ZDrcsent 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.): / r� v rA e j PU(NP CI MBER: (locate on site plan) Pumps in w rking order(yes or no): j Alarms in w rking order(yes or no): Comments iole condition of pump chamber,condition of pumps and appurtenances,etc.): I i 8 age 9 of I l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS 'SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1 6 GPc)rge St-rPPt HUnnni g_ MA owner: s Date of Inspection: SOIL ABSORPTION SYSTEM(SAS): locate on site plan,excavation'not required) If SAS not located explain why: Type _. aching pits,number:_ leaching chambers,number: Leaching galleries,number: leaching trenches,number, length: 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.): CESSPOO1 : (cesspool must be pumped as part of inspection)(locate on site plan) i Number and c,nfiguration: Depth—top of iquid to inlet invert: Depth of solids layer. Depth of scum ayer: Dimensions of esspool: 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: (1 cate on site plan) Materials of co struction: Dimensions: Depth of solids. Comments(noie condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): 9 Page 10 of 11 . OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 16 George Street HYanniG� MA a Owner: Rnhrt thani el s Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building. 1L . �GI C ) 1 � 10 Page 11 ofl I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 16 George Street Hyannis, MA Owner. Robert Daniels Date of Iospection: SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: 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: 11 TOWN OF BARNSTABLE LOCATION 6�!7G' SEWAGE # 7 3T3 VILLAGE ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY S�oO G,�>> 01 LEACHING FACII.ITY: (type) ��rJ f lb"/ Cy� (size) /d cl--Yd Xot NO.OF BEDROOMS 3 BUILDER OR PERMTTDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility J _ -Feet Private Water Supply Well and Leaching Facility (If any wells exist ,,/ on site or within 200 feet of leaching facility) /� 19 Feet Edge of Wetland and Leaching Facility(If any wetlands exist ,. within 300 feet of leaching facility) Feet Furnished by e cP �� .J � �= . Y�� " O � ��000 ' �' O °� ' Z �,� f