HomeMy WebLinkAbout0085 HAMPSHIRE AVENUE - Health 85 HAMPSHIRE AVENUE, HYANNIS
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Commonwealth of Massachusetts (b
Executive Office of Environmental Affairs
RfC j�fp
Department of NOV 2
Environmental Protection s �990 _f
Wiliam Weld 4 49Gove !�
S..,yry%EA
David B.Struhs r
Commissioner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
gf�r✓1�0�!j,/'e/ �li-e- PART A /t/N
y�fi / CERTIFICATION /
Property Address: Address of Owner:
Date of Inspection: J/ — ,, (If different)
Name of Inspector: W.E. Robinson .Sr.
Company Name, Address and Telephone Number: W.E. Robinson Septic Service
P.O. Box 1089
Centerville MA.
CERTIFICATION STATEMENT ��77 77��77
I certify that I have personally inspected the sewage disposl s�sCerh�t this address and that the information reported below is true,accurate
and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems. The system:
1/Passes
_ Conditionally Passes
_ Needs Further Evaluation By the Local Approving Authority
_ Fails
Inspector's Signature: s i Date:
I
The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (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 Department of Environmental Protection.
The original should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority.
INSPECTION SUMMARY:
Check A, B, C, or D:
A] SYSTEM ASSES:
I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303.
Any failure criteria not evaluated are indicated below.
B] SYSTEM CONDI LLY PASSES:
One or more systeI
nts need to be replaced or repaired. The system, upon completion of the replacement or repair,
passes inspection.
Indicate yes,+no, or not deteN, or ND). Describe basis of determination in all instances. If"not determined", explain why not)
The septietal, cracked, structurally.unsound, shows substantial infiltration or exfiltration, or tank failure is
imminentm will pass. inspection if the existing se
ptic'tank is replaced with a conforming septic tank as
approvedrd of Health.
(rev aed'8/15/95)
One Winter Street Boston,Massachusetts 02108 a FAX(61n 5WI049 • Telephone(611)M-5500
Printed on Recycled Paper ,
1 i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:
Owner:
Date of Inspection:
B]SY EM CONDITIONALLY PASSES (continued)
Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed
pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the
Board of Health):
broken pipe(s) are replaced
obstruction is removed
distribution box is levelled or replaced
_ The System required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass
insp ction if(with approval of the Board of Health):
broken pipe(s) are replaced
obstruction is removed
C] FURTHER EVALUATI N IS REQUIRED BY THE BOARD OF HEALTH:
Conditions exi which require further evaluation by the Board of Health in order to determine if the system is failing to protect the
public health, afety and the environment.
1) SYSTEM WILL PAS D LESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER
WHICH WILL PROTECT HE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
Cesspool or privy i 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 T E BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT
THE SYSTEM IS FUNCTIONIN IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
_ The system has a septa tank and soil absorption system and is within 100 feet to a surface water supp:y or tributary to a
surface water supply.
_ The svgem has a sep is tank and soil absorption system and is within a Zone I of a public water supply well.
_ The system has a sep'c tank and soil absorption system and is within 50 feet of a private water supply well.
_ The systen has a septi,- tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water
supply well, unless a we I water analysis for coliform bacteria and volatile organic compounds indicates that the well is
free from pollution from at facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5
ppm.
D] SYSTEM FAILS:
I have determined that the syste violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis
for this determination is identifi below. The Board of Health should be contacted to determine what will be necessary to correct
the failure.
Backup of sewage into facili or system component due to an 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.
(revised 8/15/95) 2
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:
g 3� �/,yrn/oShr�'CJ 9v� oL>%9n�2i�S
Owner: Al
Date of Inspection: �.
"U5�
D)SYSTEM ILS(continued):
Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
L uid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow.
R uired pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Nu ber of times pumped
Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation.
Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
An portion.of a cesspool or privy is within a Zone I of.a public well.
y portion of a cesspool or privy is within 50 feet of a private water supply well.
_ Any rtion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no
accepts le water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for
coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen.'
E]LARGE SYSTEM FAILS:
The following riteria apply to large systems in addition to the criteria above:
The design f o of system is 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety
and the environ nt because one or more of the following conditions exist:
the system is within 400 feet of a surface drinking water,supply
the syste is within 200 feet of a tributary to a surface drinking water supply
the syst is located in a nitrogen sensitive area(Interim Wellhead Protection Area (IWPA) or a mapped Zone 11 of a
public ater supply well)
The owner or operator of any uch system shall bring the system and facility into full compliance with the groundwater treatment prograrn
requirements of 314 CMR 5.0 and 6.00. Please consult the local regional office.of the Department for further information.
(revised'8/15/95) 3
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
/
Property Address: 4,1
Owner: _
Date of Inspection: -
Check if the following have been done:
1_<Umping information was.requested of the owner, occupant, and Board of Health.
✓done 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.
As built plans have been obtained and examined. Note if they are not available with N/A.
yie facility or dwelling was inspected for signs of sewage back-up.
L,1 he system does not receive non-sanitary`or industrial waste flow
tXe site was inspected for signs of breakout.
L.,6..system components, excluding the Soil Absorption System, have been located on the site.
1, e septic tank manholes were uncovered, opened baffles, and the interior of the septic tank was inspected for condition of baes or
tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum.
V(he size and location of the-Soil Absorption System on the site has been determined based on existing information or
approximated by non-intrusive methods:
h/fhe facility ov ner (and occupants;-if`different from owner) were provided with information on'the proper maintenance of Sub
Surface Disposal System:
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(revised 8/15/95)
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address:
Owner: �/1 . f=. F Q / e./
Date of Inspection:
FLOW CONDITIONS
RESIDENTIAL:
Design flow: 33 0 Qallons
Number of bedrooms:y7
Number of current residents:0
Garbage grinder(yes or no):-Lt/
Laundry connected to system (yes or no):
Seasonal use (yes or no): A-1®
Water meter readings, if available: 9 9
Last date of occupancy: 9
COMMERCIAUI N DUSTRIAL:
Type o stablishment
Design fl w:_gallons/day
Grease tra present: (yes or no)_
Industrial ste Holding Tank present: (yes or no)_
Non-sanitary waste discharged to the Title 5 system: (yes or no)_
Water meter adings, if available:
Last date of oc upancy:
OTHER: (Desc be)
Last date of oc upancy:
GENERAL INFORMATION
PUMPING RECORDS and source of innforrm`ion-
System pumped as part of inspection: (yes or no)�i/
If yes, volume pumped. gallons
Reason for pumping.
TYPE OF SYSTEM
Septic tank/distribution box/soil absorption system
---je'Single cesspool
Overflow cesspool
Privy
Shared system (yes or no) (if yes, attach previous inspection records, if any)
/Other(explain) v �
APPROXIMATE AGE of all components, date installed (if known) and source of information:/ i,dZ S /' ►/� s/U y'�e S
Sewage,odors detected when arriving at the site: (yes or no) !l�
5
'(revised 8A5/95)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: N�n�p
Owner: M
Date of Inspection:
SEPTIC TA
(locate on site an)
Depth beAs:
Material _concrete _metal _FRP—other(explain)
Dimensio
Sludge de
Distance e to bottom of outlet tee or baffle:
Scum thic
Distance from top of scuVn to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Comments:
(recommendation for pu ping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
integrity, evidence of le kage, etc.)
GREASE TRAP:_
(locate on site plan)
Depth below grade:
Material of construction: _con ete _metal _FRP—other(explain)
Dimensions:
Scum thickness:
Distance from top of scum to top outlet tee or baffle:
Distance from bottom of rum to h ttorn of outlet tee or bade:
Comments:
(recommendation for pumping, con ition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
integrity, evidence of leakage, etc.,
(revised 8/15/95) 6
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
Owner: ✓4. F• F v /e
Date of Inspection:��.����. c�
TIGHT OR OLDING TANK:_
(locate on site Ian)
Depth below grad
Material of construct on. _concrete _metal _FRP_other(explain)
Dimensions:
Capacity: RaIons
Design flow: g Ilons/day
Alarm level: I
Comments:
(condition of inlet tee, cj1dition of alarm and float switches, etc.)
DISTRIBUTION BOX:_
(locate on site plan)
Depth of liquid level above outle invert:
Comments:
(note if level and distribution is equal, evil ce of solids carr)o•,er, evidence of leakage into or out of box, etc.)
PUMP CHAMBER:_
(locate on site plan)
Pumps in working order:(yes or no)
Comments:
(note condition of pump chamber, condition of pi imps and appurtenances, etc.)
(revised 8/15/95) 7
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
Owner:
Date of Inspection: /
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:
Type. i
leaching pits, number:
leaching chambers, number:_
leaching galleries, number:
leaching trenches, number,length:
leaching fields, number, dimensions:
overflow cesspool, number:
Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation etc.)
16 I✓ 7 -t i I I 0 E re d Z:
CESSPOOLS:
(locate on site plan) i
Number and configuration:
Depth-top of liquid to inlet invert: '
Depth of solids layer: 3°' •
Depth of scum layer: ('2__�j
Dimensions of cesspool:
Materials of construction:
Indication of groundwater: Q
inflow (cesspool must be pumped as part of inspection)
Comments: (note conditio 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 o soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
Irevised 8/15/95) 8
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
Owner: /� • /=a ��
Date of Inspection: ,
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100'
I
6e
G (�
3,6 G�
DEPTH TO GROUNDWATER
Depth to groundwater: 1 `t feet �,p
method of determination or approximation: � 1J O �
(revised 8/15/95) 9
6
TOWN OF BARNSTABLE
r"LOCATTIIO�N_g Pnno&�,_ (2 SEWAGE #�_J �
VILLAGE ASSESSOR'S MAP & LOT �yf1
INSTALLER'S NAME-& PHONE NO.�P
SEPTIC TANK"CAPACITY
LEACHING'TACILITY:(type) ➢ �" (size) /6UO '.
NO O,FjBEDROOMS. PRIVATE WELL OR PUBLIC WATER
BUILDER OR OWNER (f V
DATE PERMIT ISSUED:
DATE COLIPLIANCE ISSUED:
VARIANCE GRANTED,,,: Syes No %�
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MOORS PIAP P40:
PARCEL N0.• �d
THE COMMONWEALTH OF MASSACHUSETTS
BOARD F HE L
- ...............OF. ... ..._....----------------
Appliration for Uispoiial Works Cnnnitrnrtiun Famit
Application is hereby made for a Permit to Construct ( ) or Repair (/-Y'0;an Individual Sewage Disposal
System at:
Location-Address or Lot No.
^. ...............••..
O Address
......•......................
Installer Address
d e of uilding Size Lot.............................Sq. feet
V Dwelling o. of Bedrooms................................ .....Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building ............................ No. of ersons...._............_...._.__.. Showers 1 — Cafeteria
P ( ( )
Q' Other fixtures ------------------------------•• -
W Design Flow............................................gallons per person per day. Total daily flow-----.......................................gallons.
1:4 Septic 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........................................
a Test Pit No. 1................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.................._-____
94 --- ------
0 Description of Soil........... ..
x
W -------•-------•-----------------------------•-----------------•------------------•------•---.--_----.•-.---------•-----------•----•----•--------- ------------•-------------•--------------------
x ••••---------------------------------------•••-•-••-•---------------•-----------••••••--------...-••---•---•--•••---••--.....---•-••---•-•...
V Nature of Repairs or Alterations—Answer when applicable---------- � �7_ ..._! ._.._..._................................
-------------------------------------------------•-----------------------------------------------•--•-------•••--•--••------••---•--•••----•-••-•------•------.........................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of'THE p 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been 'sued by e b rd of iealth.
Signed .:.. •• ---••-•--• 1 �
Date
ApplicationApproved By.................................................................... .... ............. ........................................
Date
Application Disapproved for the following reasons:.......................... --••••---•••--••-•••••-•••••••--••••-••-•-•-••--.....-•-•••---••-••...........:.�
---------------------•-----•-----------------------•-------------•---......------•--...-'------......-•----•----•-----••-•-•-••--•--------••-----••-•••-••-----•-----•---------------- --------
Date
PermitNo......................................................._ Issued.......................................................
Date
No------------------------- Fes$.. ........_............._
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
...................0 F....�.!�.... ......... .......
, pplirFatiou for BiiposFal Workii Toustrurtiou Prrutit
Application is hereby made for a Permit to Construct ( ) or Repair fill)an Individual Sewage Disposal
System at: ,� f
Location-Address or Lot No.
.._..:-•--•--:......:............................................. ...............................
[ ownt. Address
W .I /� �.�Jj i/.�/ G.r'
---------------------=-----•-•---•-•----•-•---------------------..._..........................-- -------.......----....----.._..._....-----•-----------•-----------...-•------•-•--------••-._...._
j Installer Address
Type of Building,,/ Size Lot............................Sq. feet
Dwelling—No. of Bedrooms..................................._--------Expansion Attic ( ) Garbage Grinder ( )
'4 Other—T e of Building No. of persons____________________________ Showers — Cafeteria
al Other fixtures ----------------------------•--- -
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
1:4 Septic Tank—Liquid capacity............gallons Length................ Width................ Diameter---------------- Depth................
Disposal Trench—".\To_____________________ 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........................................
Test.Pit No. 1----------------minutes per inch Depth of Test Pit.................... Depth to ground water__-__-_-______________.-
GZ4 Test Pit No. 2................minutes per inch Depth of Test Pit............._...... Depth to ground water........................
0 ---------------- ----------------------------------------------------------------•-•---•----------•----•------••--------------------••---------•-•-----------
0 Description of Soil------------------ ------ -----•-----------------.........•---••-•-----•-------•••-----••-••-•-•------------••-•----••-----•-•-••--••-----------------------•--
x
--------------------------------------------.........................................
W
-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
U Nature of Repairs or Alterations—Answer when applicable----------------------------------
..........-
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of 1�Tt p `5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health.
Signed.......................
---...............n.........................................
........................._------
Date
ApplicationApproved BY....................-.................................--........... _,...... ............. •---------------- --------•----
Date
Application Disapproved for the following reasons----- .................... . ..................................................................................
.............•----------•-•••-•---...--------------------•---------------..__....•--•--•-------......_...._
Date
PermitNo.......................................................- Issued-.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF...-.........:.............. -. t
Trrtifiratr of Toutplitturr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( }
bY------------------------------------------'............................................ --•-- -•------...-----•---•-•------.._..---------------------•---------•-....-•------•.....--------••-
Installer
at..........................................n------------------------------•_..._---•----•- ---•---•-•..._._...------•-•--•---•----...-•••----------------------------....--•-•----•------
has been installed in accordance with the provisions of T i T IE j of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No--------- __����. dated-------�_��. _________________
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT YHE
.SYSTEM WILL F NCTION SATISFACTORY.
DATE.............. _2.•1 a _____________-----___-_-•------____-_--- Inspector -
`� �� j THE COMMONWEALTH OF MASSACHUSETTS
BOARD;OF HEA; T
(7 J
No FEE 0._C
�i��ro��1 : k boat #rttr�io � rruti�
._
to CPermission is herebons y granted
a an In idual Sewa posalSystem
s° s.*_•_•_
atNo.-- -- •----- _..---.•---- --------------- ..........
Street (
as shown on the application for Disposal Works Construction Permit No`s'�_:?_c?r}�" Dated______1f_j._(-f___�..__-
PP P !!!!!!
.....:..............n ==-•--�-•= .................. --------•......
joaed d�ealth
DATE....................I C1- -
f- -K=371------
FORD 1255 HOBBS & ARREN. INC.. PUBLISHERS