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Home My WebLink About0006 HOLIDAY LANE - Health 6Flo liday.Lane`°% ' Hyannis , A= 267-085 _I TOWN OF BARNSTABLE z. LOCATION10 SEWAGE #J 9-d(617 VILLAGE i&5f I ASSESSOR'S MAP & LOTQ / INSTALLER'S NAME&PHONE NO. lu 7775 7 7/. SEPTIC TANK CAPACITY I5640 LEACHING FACILITY: (type) f� I S (size) A14 l O f NO.OF BEDROOMS BUILDER OR OWNER `� y PERMTTDATE: ` - COMPLIANCE DATE: S L 199 Separation Distance Between the: Maximum 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 Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by I r ' ' �y ' • .� Q - 1 ° s A � ` � �s '� � ' o � t � _ � � r 1 1 ®. { I — r� I • COMMONWEALTH OF MAS5ACHUSETTS TjEXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS - DEPARTMENT OF ENVIRONMENTAL PROTECTION et �O =E5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM / PART A CERTIFICATIONlj Property Address: t �Ca l Owner's Name- Owner's Address: TC-� 160 X tC,'7 Date of Inspection: Name of Inspector.(please print) Company Name: William E. Robinson Septic Service Cr t50 Mailing Address: P O Box 1089 .► u. Centerville, MA Telephone Number. (5(181 775-877.6. W CYN CERTIFICATION STATEMENT 1 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 S on 15340 of Title 5(310 CMR 15.000). The system: Passes Conditionally Passes Needs Furthe -valuation by the Local Approving Authority Fails Inspector's Signature: Date: cum .-Me system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Heatthvr t . 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 eopies'sent to the buyer,if applicable,'and the appco.xing authority. Notes and Comments ****This report only describes conditions at the time of inspection and tinder 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 or use. ! na Title 5 Inspection Form 6/152000 page 1 1 Page2 of ' . `: ': r OFFICIAL INSPECTION FORM-NQT FOR VO'I,UN-PgRY ASSESSMENTS r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address- Owner. Date o!laspeetion: Inspection Summary: Cheek A,B,C,D or IF ALWAYS complete sl!`ofSectioa D A. Sy e n Passes: - , I have not found any information which indicates that any of the failure criteria described 310 CNIIL ' 1 S_303 or in 3 t 0 CUR 15.304 exist_Any failure criteria not evaluated are indicated below. Comments: B- System Conditionally Passes: { One or more system components as desmbed in the"Conditional Pass"section need to be replaced or , repaired.The system,upon completion of the replacement or r epair,as approved by die Board of Health,will pass. Answer yes,no or not determined(Y,A MDN in the for the following Statements`If'�iot determined"p}eaze„ explain. t ` The septic tank is nietal and+over 20 years old! or the septic tank ' unsound;exhibits substantial infiltration or exfiltration or tank failure is imminent-S m��P is ass existing tank is replaced with a complying septic tank as approved by the Board of Health. P inspection if the "A meta(septic tank will pass inspection if it is structurally sound,not leaking and ifa 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'hgb static wafer Level in the distribution box Jere to'b-oken or obstructed pipe(s)or due to a broken,scttla:d or tmevert d'-}mhon box.System will Pass inspection if(with approval of Board of Health): r +broken`PiPe(s)are replaced # , obstiuction is removed f .•distn'bution box is levelod or replaced ND explain: The system required pumping more than 4 times a year due to brokrn or obsutxtcd Pass inspection if(with approval of the Board of Health). pipt�s).The system will brok�s :. , PlF�s)arereplaced x ' ol Stifissmot+cd ND explain:t n: Page 3 of I I OFFICIAL INSPECTION FORM-'NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM' PART_A_ As CERTIFICATION(continued) Property Address: : Date of Inspection: O T J � C. Further Evaluation is Required by the Board of Health: N j A / *r i Conditions-exist which require further evaluation by the Board of Health in order to determine if the system ' is failing to protea public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR15303(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 S0 feet or more frottl`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 welt is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than S ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form' 3. bther: 3 Pagc 4 of I l OFFICIAL INSPECTION FORM—NOT•FOR VOLUNTARY ASSESSMENTS = SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM . . . PART A CERTIFICATION(continued) Properly Address: Owner: e "e ,i i a Date of Inspection: tl D. Sy stem Failure Criteria applicable to-alt systems: You must indicate')-res"or"no"to each of the following for all inspections: Yes No/ ' ✓ ackup of sewage into facility or system component.due to overloaded or clogged SAS or cesspool _ �Dischargc or ponding of effluent to the surface of the ground or surface waters due to an"overloaded or /clogged SAS or cesspool .J Static liquid.level in the distribution box above.outtet invert due to an overloaded or clogged SAS or . j cesspool Liquid depth in cesspool is less than 6"below invert or available volume is less than'h day flow ✓.Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped _ �/r 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., r Any portion of a cesspool or privy is within a Zone I 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 SQ Let front a private water. supply well with no'accepiable water quality analysis.IThis system passes if the well water anatysisi performed at a DEP certified laboratory,for coliferm bacteria and.votatiie 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 S ppm,provided that no other failure criteria n are triggered.A copy of the analysis must be attached to this form.) Yes/No The s•stem fails.I have determined that one or more o the above ailure criteria exist as ( ) } f f is described in 31.0 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 facifily with a design flow-of 10,000 gpd to 15,000 hpd- You must indicate either'-yes"or"no"to each of the following: (71te following criteria apply to large systems in addition to die 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 I l 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.•she u%m,-r or operator of awry 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. • 4 Page S of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM .PART B CHECKLIST Property Address: C Owner: 5 :`t - +AC'�L100 X . Date of Inspection: �fTsT p Check if the following have been done.You must indicate`yes"or"no"as to each of the following: ~ Yes Not - _ ✓ Pumping information was provided by the owner,occupant,or Board of Health Were any of the system components pumped out in the previous two weeks? ✓ _ Has the system received normal flows in'the previous two week period? r /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? • r Was the site inspected for signs of break out? ✓ _ Were all system components,excluding the SAS,located on site? _ _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of thh 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: no Existing information.For example,a plan at the Board of Health. _✓ _ Determined in the fold(if any-of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CUR 15.302(3)(b)) 5 Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C ` SYSTEM INFORMATION Property Address: _- i Owner: Date of Inspection: 'FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):. Number of bedrooms(actual): DESIGN flow based on 310 CMR 15103(for example: 110 gpd x#f of bedrooms): 33J Number of current residents: Does residence have a garbage grinder(yes or tw): A Is laundry on a separate sewage system(yes or no):tvv tiryes separate inspection required] Laundry system inspected(yes or no): Seasonal use:(yes or no): i F •r Water meter readings,if available(last 2 years usage(gpd)): `�'/Cr Z - ( J ? v' Sump pump(yes or no):. NJ Last date of occupancy: COMMERCIAIANDUSTRIAL 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 r— Source of information: Was system pumped as part of the inspection(yes or no): AO If yes,volume pumped:=gallons--How was quantity pumped determined? Reason for pumping: TY ,E OF SYSTEM ` _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/Alterna6ve 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: Were sewage odors detected when arriving at the site(yes or no): 6 I'agc 7 of I I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C, SYSTEM.INFOHAIATION(continued) + i Property Address: (a Owner: Date of Inspection: BUILDING SEWER(locate on site plan) Depth below grade: 3*/ Materials of construction:_cast iron �0 PVC_other(explaut): Distance Gem private Hater supply well or suction iinc: Comments(on condition of juutIs.venting,cvidcncc of leakage ctc-}: -J o:-,f-x tie- - ^--r, - SEPTIC TANK: +!(locate on site plan) Depth below grade: Material of construction:—Concrete metal Fiberglass_polyctlrylene + ' _otltcr(explain) If tank is metal list age:_ 1s age con finned-by a Certificate of Compliance(ycs or no):_(attach a copy of certificate) Dimensions:Sludge depth: Distance Gom top of sludge to bottom of outlet Ice or baffle: 3 -5 r Scum thickness: Distance from top of scum to top of outlet tee or baffle: 7 ' Distance Gom bottom of scum to bottom ore u►1 t tee or banlc: 1 low were dimensions determined: V't�,t� Cry-j- C.nf rAe-j.hvr+o� Comments(on pumping recommendations.inlet and outlet tee or baRle eonditicn, structwal integrity,liquid levels r + as related to outleteinvert,cvidcncc of leakage,vc.): ei nc4 &ts c->-f /L��je:- /tom:) �E•'k ��/lit_�alf•f �r�� u�G� �' j•?a�.cas L.�rCT' (•r�„er Q� �J� GREASE TRAP:_'(locate on site plan) r t Dcpth below grade:— Matetial of construction-_concrete_natal_fiberglass____polyethylene—tithe, # (explain): Dimensions: Scum thickness: iistance Gom lop of scull,to 101)of outlet Ice or baMc: Distance Eton,bottom of scum to bottom of outlet tee or baffle: Dale of last pumping: Conunents(on pumping reconuucndatiuns,u,lel and outlet Ice or battle condititta,structural integrity,liquid lcvcls as related to outlet invert,cvidcncc of leakage,etc): 7 8or11 - - L r i • 9 ' OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOR I PART C SYSTEM INFORMATION(continued) rerty Address: 'e: C:� 60,q WU-4—_ of Inspection: U 11T or IIOLDING TANK;, A(tartk tnusi be pumped at time of inspection)(locate on site plan) th below grade: , erial of construction: concrete metal fiberglass Polycthylene • other(explaut). tensions: achy: gallons ign Flow: gallons/day nu present(yes or no): -. • " ' . rm level: Alarm in working order(yes or no): c of last pumping: nmcnts(condition of alanu and float switches,etc.): STIUOUTION BOX: (if present must be opencd)(locate on site plan) pth of liquid level above outlet invert: E• nunents(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of kale into or out of box,etc.): t � �� fi,acf�i� „>c��f e.•c ff a,.�- �&mod•- �,C �..�{�,-� )NIP CHAMBER:A01ocate on site plan) imps in working order(yes or no): arms in working order(yes or no): _ )nunents(note condition of pump chamber,condition of pumps and appurtenances,ese.): _ . - f Page 9 of-1 l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM { PART C SYSTEM INFORMATION(continued) Property Address: (C I C�Get-{ S j 1 Cx'1 . Owner: �� ' ��{h cy Date of Inspection: / SOIL-ABSORPTION SYSTEM(SAS): f/ (locate on site plan,excavation not required) If SAS not located explain why: Type ___Jeaching pits,number._ v"leaching chambers,number_ a 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. : I 1 ca M a,.j ,� t va in y��sus fit:,.► S 4d e l Pst- �Vclr��f rc ,r..te. a 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:/V ocate 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.): 9 s Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION"FORM PART C SYSTEM INFORMATION(continued) Property Address: PI A'O'ec t. Owner: ,";;a-v-e- ,VT r rid 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. t 6 t4w 5c a 3 . �a i3 7 10 I Page l 1 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C tt-- SYSTEM INFORMATION(continued) Property Address: Owner. Date of Inspection: SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water J 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 groundwater elevation: 11