HomeMy WebLinkAbout0078 HOMEPORT DRIVE - Health 78 Homeport Drive
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Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
78 Homeport Drive
G M t m oa.
Property Address t -
Claudio Da Silva
Owner Owner's Name
information is Hyannis Ma. 02601 6/1/2007
required for H y ,w....r .
every page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted'on this form. Inspection forms may not be altered in any
way. .{.:.,
Important:WilliA. General Information
When filling out c_.-
forms on the
computer,use 1. Inspector:
only the tab key s N
to move your Robert Paolini `
cursor-do not Name of Inspector
use the return . .
key. Ca ewide Enterprises LLC. ry
Company Name Uj
P.O.Box 763 N
Company Address
Centerville Ma. 02632
CitylTown State Zip Code -
(508)428-4028 '
Telephone Number. License Number _.
B. Certification
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:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Need?-Further Eval tion by the Local Approving Authority
6/1/2007
Inspect nature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(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 DER The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of-ia
at that time.This inspection does not address how the system will perform in the future under-
the same or different conditions of use.
78 Homeport dr.•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
,M 78 Homeport Drive M
Property Address
Claudio Da Silva
Owner Owner's Name
information is required for Hyannis Ma. 02601 6/1/2007
every page. City/Town State Zip Code Date of Inspection T. w
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) 'System Passes: " .
® 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:
The septic system is in proper working order at the present time. �-
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
A pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced m -
❑ obstruction is removed "
78 Homeport dr.•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15
Commonwealth of Massachusetts
u v Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
,M 78 Homeport Drive
Property Address -
Claudio Da Silva
Owner Owner's Name
information is Hyannis Ma. 02601 6/1/2007
required for y
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.) -: ---
B) System Conditionally Passes (cont.):
❑ distribution box is leveled or replaced _.
ND Explain:
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The _y r
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced
❑ obstruction is removed '..•, -.
ND Explain:
C) Further Evaluation is Required by the Board of Health: n-= ;
❑ Conditions exist which require further 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. a
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public waters ..
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water---
supply well.
78 Homeport dr.•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of
s=ac:
Commonwealth of Massachusetts .. .
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments -
78 Homeport Drive
Property Address
Claudio Da Silva
Owner Owner's Name
information is required for Hyannis Ma. 02601 6/1/2007
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
C) Further Evaluation is Required by the Board of Health (cont.): `.
❑ 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 colifor: "
bacteria indicates absent 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:
D) System Failure Criteria Applicable to All Systems: a
You must indicate "Yes".or"No"to each of the following for all inspections:
Yes No .
El ® 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 wate.
due to an overloaded or clogged SAS or cesspool W-
El ® Static liquid level in the distribution box above outlet invert due to an overloads; =" =
or clogged SAS or cesspool
El ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than Y2 day flow fi=`
❑ ® 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.
78 Homeport dr.•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15 .
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 'µ T
,M 78 Homeport Drive
Property Address k
Claudio Da Silva
Owner Owner's Name
information is Hyannis Ma. 02601 6/1/2007 `
required for Y
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.) ,
D) System Failure Criteria Applicable to All Systems (cont.):
Yes No .
❑ ® 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.
,❑ ® An portion of a cesspool or privy is less than 100 feet but greater than 50 feet
YP P P Y
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 fecal coliform bacteria indicates absent 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
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failureua'
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 flow of 10,000 gpd to 15,000 gpd. 4
For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Section D.
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 w...
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 theT
system in"accordance with 310 CMR 15.304. The system owner should.contact the appropriate
regional office of the Department.
78 Homeport dr.-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of i5 >
I
Commonwealth of Massachusetts r
w Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments -�
�M 78 Homeport Drive
..:AP-
Property Address .,
Claudio Da Silva "
Owner Owner's Name
information is Hyannis Ma. 02601 6/1/2007 �n
required for H y
every page.a City/Town State Zip Code Date of Inspection "
.-.
C. Checklist f
Check if the following have been done. You must indicate "yes"or"no" as to each of the following:
Yes No a.
® ❑ 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?
J -
® Have large volumes of water been introduced to the system recently or as part;"
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?
® ❑ Was the site inspected for signs of break out? emu'
® ❑ 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 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 hasbeen determined based on:
❑ ® 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 distance is unacceptable)[310 CMR 15.302(5)] - =
78 Homeport dr.-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 6 of 15
f
Commonwealth of Massachusetts
w v Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�M 78 Homeport Drive
Property Address - —^-p
Claudio Da Silva
Owner Owner's Name
information is required for Hyannis Ma. 02601 6/1/2007 _m
every page. City/Town State Zip Code Date of Inspection
D. System Information g
.a Residential
x--
Residential Flow Conditions: -- :
Number of bedrooms (design): 3 Number of bedrooms (actual): 3 -�
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 -:
Number of current residents: unknown
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No
Laundry system inspected? ® Yes ❑ No
Seasonal use? ❑ Yes ® No��'
Water meter readings, if available last 2 ears usage (gpd)): 2005:62,000
g ( y g 2006:19,000
Sump pump? ❑ Yes ® No" 'M
Last date of occupancy: 6/1/2007 -�
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.): µKS
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
Last date of occupancy/use: Date
Other(describe):
78 Homeport dr.•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15 �<
Commonwealth of Massachusetts
Title 5 Official Inspection Form -=
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
GSM 78 Homeport Drive �--
---mmsjN.m.
Property Address
Claudio Da Silva
Owner Owner's Name
information is .�i..
required for Hyannis Ma. 02601 6/1/2007 ;
every page. City/Town State Zip Code Date of Inspection '.
.w#Vx
D. System Information.(cont.) "=
General Information
Pumping Records:
Source of information:
Was system pumped as part of the inspection? ❑ Yes ❑ No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for.pumping:
Type 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/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: _
Were sewage odors detected when arriving at the site? ❑ Yes ® No ---•
78 Homeport dr.-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15
•�aw�.r 0.4•;•
aim
Commonwealth of Massachusetts 4
w Title 5 Official Inspection Form
_ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�M 78 Homeport Drive
Property Address
Claudio Da Silva
Owner Owner's Name
information is Hyannis Ma. 02601 6/1/2007
required for y
every page. City/Town State Zip Code Date of Inspection
D. System Information cont. '
Building Sewer(locate on site plan):
Depth below grade: feet
Material of construction: '
❑ cast iron ®40 PVC ❑ other(explain): ..
Distance from private water supply well or suction line: feet fr. .
Comments (on condition of joints, venting, evidence of leakage, etc.):
Joints appear tight.No evidence of Ieakage.System vented through the house vents.
Septic Tank(locate on site plan):
'
Depth below grade: eetM_.
Material of construction:
❑ concrete ❑ metal ❑fiberglass ® polyethylene ❑ other(explain)
If tank is metal, list age:
years ----�-
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑. Na
10'6„x5,7„x5181'
Dimensions:
4„ :..:.,
Sludge depth: `-
Distance from top of sludge to bottom of outlet tee or baffle
28"
Scum thickness.
3"
Distance from top of scum to top of outlet tee or baffle
8„ ..
d,:a
Distance from bottom of scum to bottom of outlet tee or baffle 12" r
How were dimensions determined? Measured
78 Homeport dr.r 08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System r Page 9 of 15 ,-„., ,
Commonwealth of Massachusetts
Title 5 Official Inspection Form -
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 78 Homeport Drive
Property Address
Claudio Da Silva
Owner Owner's Name
information is required for y H annis Ma. 02601 6/1/2007 �'
- -��
every page. City/Town State. Zip Code Date of Inspection
D. System Information (cont.) Y
Comments (on pumping recommendations, inlet and outlet tee or baffle condition. structural integrity,..
liquid levels as related to outlet invert, evidence of leakage, etc.): ,
Pump septic tank every 2-3years.lnlet and outlet tees are in place.Tank appears structurally
sound.No evidence of leakage.
Grease Trap (locate on site plan):
Depth below grade: feet -
Material of construction: �m=.
❑ 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: Date
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.): -�
Tight or Holding Tank (tank must be pumped at time of inspection)(locate on site plan): _
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(expla
78 Homeport dr.•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15 cw-
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage.Disposal System Form -Not for Voluntary Assessments
.ro .
,M 78 Homeport Drive
Property Address
Claudio Da Silva '
Owner Owner's Name ~
information is required for Hyannis Ma. 02601 6/1/2007
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Tight or Holding Tank(cont.)
Dimensions:
Capacity: gallons A
Design Flow: gallons per day - Y `•i
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ NoP
Date of last pumping: Date '
Comments (condition of alarm and float switches, etc.):
*Attach copy of current pumping contract(required). Is copy attached? ElYes ❑ No
Distribution Box(if present must be opened)(locate on site plan): .°. }
Depth of liquid level above outlet invert No. #.
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, ahy--
evidence of leakage into or out of box, etc.): m
Box is level.Box has two laterals with equal flow.No signs of solids carryover.No evidence of leakage
into or out of box. --
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No ,;; .
Alarms in working order: ❑ Yes ❑ No
78 Homeport dr.•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 78 Homeport Drive �.
Property Address
Claudio Da Silva
Owner Owner's Name
information is Hyannis Ma. 02601 6/1/2007 w'
required for y _.«
every page.a e. City/Town State Zip Code Date of Inspection
F
D. System Information (cont.) - ;
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): -
... vim,.
Soil Absorption System (SAS)(locate on site plan, excavation not required):
If SAS not located, explain why:
Type:
❑ leaching pits _ number:
® leaching chambers number: 5-1-12O Inflitrators., ry
❑ leaching galleries number:
❑ leaching trenches number, length: -
❑ leaching fields number, dimensions:
❑ overflow cesspool number: —n
❑ 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.):
Sandy soil.No signs of hydraulic failure.No ponding or damp soil.
78 Homeport dr.•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 1S
-ter ,.
Commonwealth of Massachusetts maw
Title 5 Official Inspection Form -=.
m Subsurface Sewage Disposal System Form -Not for Voluntary Assessments .. .. .•
M 78 Homeport Drive
Property Address „-
Claudio Da Silva
Owner Owner's Name
information is
required for Hyannis Ma. 02601 6/1/2007
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
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 ❑ No
Comments (note condition 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 of soil, signs of hydraulic failure level of ponding, condition of vegetation;
etc.): -
..: ,..;roe..
78 Homeport dr.•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments i
78 Homeport Drive y
Property Address l
Claudio Da Silva
Owner Owner's Name I .
information is required for, Hyannis Ma. 02601 6/1/2007
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
. i.
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. __;J.
Locate where public water supply enters the building.
i
a
...:..nark..
78 Homeport dr.•08/06 Tifle 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 15 _
' Commonwealth of Massachusetts ,
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °"
�M 78 Homeport Drive
Property Address ~---
Claudio Da Silva - •
Owner Owner's Name
information is Hyannis Ma. 02601 6/1/2007 ���
required for y
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
1
® Check Slope.
® Surface water '
® Check cellar
❑ Shallow wells
24' bottom of leaching
Estimated depth to ground water: feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record -
If checked, date of design plan reviewed: Date
❑ Observed site(abutting property/observation hole within 150 feet of SAS)
® Checked with local Board of Health-explain: -
as-built card
❑ Checked with local excavators, installers- (attach documentation)
❑ Accessed USGS database-explain: .._
You must describe how you established the high ground water elevation:
Used:Gaherty& Miller Model 12/16/94 ground water elevations.Used.-USGS observation well data ---
June 1992.Used:Technical Bulletin 92-000-01 plate#2 annual ranges of ground water elevations.
,
78 Homeport dr.•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15
_ TOWN OF BARNSTABLE
LOCATION SEWAGE #
VILLAGE ASSESSOR'S MAP LOT
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) d1 (size)
NO.OF BEDROOMS
BUILDER OR OWNER
PERMITDATE: CkPl IANCE DATE:
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
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No. FEE J lJ
C®MMONWFALT14 OF MASSAC14US ETTS r r
Board of Health, MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair Upgrade( ) Abandon( ) -XComplete System ❑Individual Components
Location btB 14 ty, �" '��� Owner's Name
Map/Parcel# �(Q Address
Lot# ` Telephone#
Installer's Name 1i7-t k-%Qr Designer's Name �r S•►cs'
Address Address 0
Telephone# a �_ 4 Telephone#
Type of Building �,-0►\ Lot Size sq.ft.
Dwelling-No.of Bedrooms Garbage grinder (4l
Other-Type of Building oCXI@ No.of persons�c _Showers (te'Cafeteria (+�9
Other Fixtures L-CC60-a-3Cit" .
Design Flow(min.re uired) gpd Calculated design flow Design flow provided 3 3 I, g gpd
Plan: Date Number of sheets I Revision Date
Title CL 4'C SA U
Description of Soil(s)
Soil Evaluator Form No. �� Name of Soil Evaluator ate of Evaluation o d
DESCRIPTION OF REPAIRS OR ALTERATIONS
The undersigned afire s install th o described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to not ace the in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed Date / /�
Inspections
����f�• '(A'�'rl^"h"rT( t� 1 4R 7VJ�Y`SJY-fL'.'i�-f+. i �.y.i• �
No. �I- , 4� , 'FEE
N' �
,;Boa,d of He
. . alth, MA. #
; 7 'APPLICATION FOP DISPOSAL SYSTEM CONSTRUCTION NSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair Upgrade( Abandon(-,XComplete System ❑Individual Components
J1
Location (�, oce,�� 'y����.Q„ � � Owner's Name
Map/Parcel# (g Address
Lot# , ® Telephone#
.I•nstaller'sName Designer's Name
Address U ` Address ^;�
Telephone# U (��L Telephone# _
Type of Building l�n N,C.1 Lot Size sq.ft. i.
Dwelling-No.of Bedrooms c Garbage grinder ( ll
s1 �
Other-Type of Building IyCXI@ No.of persons Showers ( 0;tafeteria
Other Fixtures
J '
Design Flow (min.,re uired) 4 gpdt Calculated design flow �? 0 If Design flow provided . g gpd
Plan: Date ®� Number Qf sheets Revision Date -�
Title C" '� st � UDr frig
Description of Soil(s)
Soil Evaluator Form No. —. Name of Soil Evaluator �1' & -Date of Evaluation (�
r
DESCRIPTION OF REPAIRS OR ALTERATIONSc2
`s .. ( ,(', ,v +^..rt'^',�!lid�•t�� �f
The undersigned gees o install th�e:abo/ escnbed Individual Sewage Disposal System in accordance with'the provisions of TITLE 5 and
further agree�no lace thesystem m operationuntil a Certificate of Compliance has been issued bythe Board of Health.Sig ed r Date , L7 f . ,
14y/ o
Inspections
No. g6oqFEE
COMMONWEALTH OF MASSACHUSETTS
V'V'
Board of Health, �?�r,I%-o ke MA.
CERTIFICATE OF COMPLIANCE
Description of Work: ❑Individual Component(s) ❑Complete System
The undersigned hereby certify that the Sewage Disp al System; Constructed (Repaired ( ),Upgraded ( ),Abandoned ( )
I-Plt
has been installed in�ayc�cordance with the r visilonsyof 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. f ��Pr, dated g010�I . Approved Design Flow .4&h.J (gpd)
Installer
Designer: r Inspector C Date: 3Q%"T�
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
No. U FEE G ��
Board of Health, e-17KA �/ MA.
DISPOSAL. SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repairy,\
(< Upgrade( ) Abandon( ) an individual sewage disposal system
at �_( 0 I�P'� Nek? / as described in the application for
Disposal System Construction Permit No. �g16 dated / o )
Provided:- Construction shall be completed within three years of the date-of i -p 9t. 1 local conditions must be met.
Form 1255 Rev.5/96 A.M.Sulkin Co.Boston,MA Date G Board of Healt +.
Town of Barnstable
F fit1E Tp�
o Regulatory Services
Y Thomas F. Geiler,Director
+ BARNSTABLE, +
9 MASS- Public Health Division
Al fog A Thomas McKean,Director
200 Main Street,Hyannis,MA 02601
Office: 508-862-4644 Fax: 508-790-6304
Installer & Designer Certification Form
Date:
Designer: �J'�l �Z? ,� Installer: c�„ r
Address: T 0 Address: 4—+4 HAir,�
On was issued a permit to install a
date staller)
septic system at t�C t� ��eased on a design drawn by
(address}
GdZMT� dated
(designer)
I certify that the septic system referenced above was installed substantially according to
the design, which may include minor approved changes such as lateral relocation of the
distribution box and/or septic tank.
I certify that the septic system referenced above was installed with major changes (i.e.
greater than 10' lateral relocation of the SAS or any vertical relocation of any component
of the septic system) but in accordance with State & Local Regulations. Plan revision or
certified as-built by de ' er t llow.
�-\N OF MASS
o� CARPJIEN GN`
sta ler' Signature) E.�� A
SHAY
►O. 1181
_ o
GIsTE�<
S \Pt%
(Designer'sSignature) (Affix Desi eT Here)
PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE
OF COMPLIANCE WILL NOT BE :ISSUED UNTIL BOTH THIS FORM AND AS-
BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION.
THANK YOU.
Q:Health/Septic/Desiper Certification Form
TOWN OF BARNSTABLE
LOCATION ow, f SEWAGE #'
VILLAGE ASSESSOR'S MAP ,T
INSTALLER'S NAME&PhONE NO.
SEPTIC TANK CAPACITY -Z�
LEACHING FACILITY: (type) V1 (size)
NO.OF BEDROOMS
BUILDER OR OWNER.
PERMTTDATE: C PLIANCE, DATE:
Separation Distance Be n the:
Maximum Adjusted Groundwat r 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
�Er�
*q.I T
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS' "
DEPARTMENT OF ENVIRONMENTAL PROTECTION ,:
TITLE 5 '
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS '
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A a
CERTIFICATION
Property Address: 78 HOMEPORT DR HYANNIS,MA 02601
Owner's Name: PETER OLESKEY
Owner's Address: 78 HOMEPORT DR HYANNIS,MA 02601 "
Date of Inspection: 11/19/01r' 1
' Name of Inspector: (please print) JOHN GRACI RECEIVED .� �
Company Name: SEPTIC INSPECTIONS
$
Mailing Address: P.O.BOX 2119 TEATICKET,MA.02536 ���
DEC 2 0 2001
Telephone Number: 508-564-6813 FAX 508-564-7270
TOWN OF BARNSTABLE
HEALTH DEPT.
CERTIFICATION STATEMENT s` r
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
P P P g P Y Pp Y
inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: tr
`}t P
X Passes
_ Conditionally Passes s `
Needs Furth r aluation by the Local Approving Authority ,
Fails
F
Inspector's Signature: Date: 11/19/01
The system inspector shall submit copy of this inspection report to the Approving Authority(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 ¢ t.
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 tojhe buyer, if applicable,and the approving authority.
'
Notes and Comments ' - 1
SYSTEM PASSES TITLE V INSPECTION. RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG SYSTEM's
USEFUL LIFE. t1r7"
This report only describes conditions at the time of inspection and under the conditions of use at that time.This r�•ti��
inspection does not address how the system will perform in the future under the same or different conditions of use.
t
Title S Incnrrtinn form L!I Sil"no1l)
Page 2 of 11
'43 lx ti
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTSr,�
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM _ ,
PART A
i; CERTIFICATION(continued)
t. k
Property Address: 78 HOMEPORT,DR HYANNIS,MA 02601
Owner: PETER OLESKEY
Date of Inspection: 11/19/01
k v
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 k R
i CMR 15.304 exist.Any failure criteria not evaluated are indicated below. "
w� of
Comments:
SYSTEM PASSES TITLE V INSPECTION.RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG f '
SYSTEM'S USEFUL LIFE.
B. System Conditionally Passes: r t
_ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system,
s.r
upon completion of the replacement or repair,as approved by the Board of Health,will pass. '
'Y?..�
Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined"please explain. %
n/a The septic tank is metal and overkyears old* or the septic tank(whether metal or not) is structurally unsound,exhibits
substantial infiltration or exfiltration or tank failure is imminent. System will ass inspection if the existing tank is replaced
�{
Y P P g P
` 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. r{
ND explain: n/a
"®4
# n/a Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed
or due to a broken,settled or uneven distribution box. System will ass inspection if with approval of Board of
pipe(s) Y P P ( Pp
Health): '
_ broken.pipe(s)are replaced `
_ obstruction is removed ' ;'
_ distribution box is leveled or replaced
p
ND explain: n/a w
n/a 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
a fysi:
_obstruction is removed hj
' ND explain: n/aa3hC�
"
ow
"t�y
Page 3 of 1 1
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS `;
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
s PARTA =
CERTIFICATION(continued)
Property Address: 78 HOMEPORT DR HYANNIS,MA 02601 `4
Owner: PETER OLESKEY r
Date of Inspection: 11/19/01 ,�
C. Further Evaluation is Required by the Board of Health: 4
x
Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to �
protect public health,safety or the environment. '
-sue
1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is
t
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 Mi
_ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh r
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. :y
_ The system has a septic tank and SAS and the SAS is within a Zone I of a public water supply. " f
_ 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 1
supply well". Method used to determine distance n/a
"This y
This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria andft
,, .
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 m provided that no other failure criteria are triggered.A co t ,
g g 9 pP ,P gg copy
i k �a
of the analysis must be attached to this form.
3. Other: :, t
A
n/a
w
� S.
r
Page 4 of 11r#;
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued) #y {
g k C
s V.
Property Address: 78 HOMEPORT DR HYANNIS,MA 02601
Owner: PETER OLESKEY
fr
Date of Inspection: 11/19/01 ;�t�
D. System Failure Criteria applicable to all systems:
You most indicate"yes"or"no"to each of the following for all-inspections: i4
Yes No rz`
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�
X Liquid depth in cesspool is less than 6"below invert or available volume is less than''/z 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 nLa. tL=
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 I 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 $ ':t
certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free
,xr
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 forma
(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. : n
F s
E. Large Systems:
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. i
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) ;w
yes no
X the system is within 400 feet of a surface drinking water supply ;
X the system is within 200 feet of a tributary to a surface drinking water supply
X 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
V
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 oily 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 f
should contact the appropriate regional office of the Department. ;7, 0�,t'
1Yi.
h•, �1
i� 4•
Page 5 of I 1
•n ky,�i
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS r, -
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM yw"
PART B
CHECKLIST
Property Address: 78 HOMEPORT DR,HYANNIS,MA 02601
Owner: PETER OLESKEY _' �
5 1.
Date of Inspection: 11/19/01
Check if the following have been done. You must indicate "yes"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? f.
X _ Has the system received normal flows in the previous two week period? .,
r
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 N/A)
t
X _ Was the facility or dwelling inspected for signs of sewage back up?
X _ Was the site inspected for signs of break out'? h
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?
wt
F
The size and location of the Soil Absorption System(SAS)on the site has been determined based on: e
Yes no f a
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)], '
� $ b
t i
v
e
S
Page 6 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 78 HOMEPORT DR HYANNIS,MA 02601
Owner: PETER OLESKEY '
Date of Inspection: 11/19/01 s
t1 iFLOW CONDITIONS ,. .
RESIDENTIAL
Number of bedrooms(design): 3 ��Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms):3301.
Number of current residents: 1
Does residence have a garbage grinder(yes or no): NO
Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required]
Laundry system inspected(yes or no)`: NO,
Seasonal use: (yes or no): NO .
Water meter readings, if available(last 2 years usage(gpd)): n/a
Sump pumpes or no): NO
Last date of occupancy: n/a _ P
COMMERCIAL/INDUSTRIAL
Type of establishment: n/a 1 t
Design flow(based on 310 CMR 15.203):�n/agpd
Basis of design flow(seats/persons/sgft,etc.): n/af
Grease trap present(yes or no): NO
Industrial waste holding tank present(Yes or no): NO r
Non-sanitary waste discharged to the Title 5 system(yes or no): NO
Water meter readings, if available: n/a
Last date of occupancy/use: n/a
-
OTHER(describe): n/a s :1
••i:t: .
GENERAL INFORMATION #,
Pumping Records !
Source of information: n/a
Was system pumped as part of the inspection(yes or no): NO
If yes,volume pumped: n/agallons--`How was quantity pumped determined?n/a
Reason for pumping: n/a
TYPE OF SYSTEM
�.
X Septic tank,distribution box,soil absorption system -`a *
_Single cesspool ;
_Overflow cesspool
_Privy
_Shared system(yes or no)(if yes,attach.previous inspection records, if any) .5 <
_Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract to be obtained from jqft'
system owner)
_Tight tank Attach a copy of the DEP approval $ Y
Other(describe): n/a _ *'
' Approximate age of all components,date installed(if known)and source of information:
1966
Were sewage odors detected when arriving at the site(yes or no): NO f �
i
1
Page 7 of 11
OFFICIAL INSPECTION FORM—NOT FOR-VOLUNTARY ASSESSMENTS
SUBSURFACE-SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 78 HOMEPORT DR HYANNIS,MA 02601
Owner: PETER OLESKEY
Date of Inspection: 11/19/01
BUILDING SEWER(locate on site plan) ` to
Depth below grade: 18" t
Materials of construction:_cast iron —40 PVC Xother(explain): ORANGEBURG
Distance from private water supply well or,suction line: n/a 'w
Comments(on condition of joints,venting,evidence of leakage,etc.):
TOWN WATER
SEPTIC TANK: X(locate on site plan) -_
Depth below grade: 12"
Material of construction: Xconcrete metal—fiberglass_polyethylene other(explain)n/a
If tank is metal list age: n/a I5,age confirmed by a Certificate of Compliance(yes or no): NO(attach a copy of certificate) x r
Dimensions: 6' X 6' BLOCK CESSPOOL" >
Sludge depth:3"
Distance from top of sludge to bottom of outlet tee or baffle: n/a
E Scum thickness: 1"
Distance from top of scum to top of outlet tee or baffle: 1"
( Distance from bottom of scum to bottom of outlet tee or baffle: n/a
How were dimensions determined: MEASURED ';
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related.,
to outlet invert,evidence of leakage,etc.): s
CESSPOOL AND ALL COMPONENTS ARE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY. #�
RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE. "r*�
GREASE TRAP:_(locate on site plan)
Depth below grade: n/a a '
Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a x °
Dimensions: n/a
Scum thickness: n/a H£ `
Distance from top of scum to top of outlet tee or baffle: n/a
j Distance from bottom of scum to bottom of outlet tee or baffle: n/a
Date of last pumping: n/a `
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related T1
to outlet invert,evidence of leakage,etc.): '
5`
�( }4. i.
ti
Page 8 of 1 I
y Ias
OFFICIAL INSPECTION FORM—NOT FOR.VOLUNTARY ASSESSMENTS "tr
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
,r f
F�
9�1 (.
PART C ti _.,r
SYSTEM INFORMATION(continued) * f
Property Address: 78 HOMEPORT DR HYANNIS,MA 02601 rx
Owner: PETER OLESKEY lr „rs
Date of Inspection: 11/19/01
i a}�
TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) AP
'
Depth below grade: n/a
Material of construction:_concrete_metal_fiberglass polyethylene_other(explain): n/a i.
Dimensions: n/a a F
Capacity: n/a gallons ,° `_z t
Design Flow: n/a gallons/day
Alarm present(yes or no): N/A >
Alarm level:N/A Alarm in working order(yes or no): NO
Date of last pumping: n/a A :
Comments(condition of alarm and float switches,etc.):
DISTRIBUTION BOX: _(if present must,be•opened)(locate on site plan) , '
41
Depth of liquid level above outlet invert: n/a
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.):
n/a
Y
PUMP CHAMBER:_(locate on site plan) `
Pumps in working order(yes or no):No �x.
Alarms in working order(yes or no):NO
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): ` `
n/a z.
a
Ar
t r^
s�
k: r
ppk�,
i
Page 9 of 11
.a
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C i
SYSTEM INFORMATION(continued)
;.y
Property Address: 78 HOMEPORT DR HYANNIS,MA 02601
Owner: PETER OLESKEY
Date of Inspection: 11/19/01 `!
_r
SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required) x :p;
r
If SAS not located explain why:
n/a ;
Type f y;
n/a. leaching pits, number: n/a
n/a leaching chambers, number: n/a
n/a leaching galleries, number: n/a
n/a leaching trenches, number, length: n/a s"
n/a leaching fields, number: n/a
6' X 6' BLOCK CESSPOOL overflow cesspool, number: '
n/a innovative/alternative system R
J., �:.G
,Type/name of technology: n/a 4
Comments(note condition of soil;signs of hydraulic failure, level of ponding,damp soil,condition of vegetation,etc.):
CESSPOOL IS STRUCTURALLY SOUND AND FUNCTIONING PROPERLY.WAS NEVER MORE THAN HALF °g
FULL.
CESSPOOLS: .(cesspool must be pumped as part of inspection)(locate on site plan) ,
Number and configuration: n/a
Depth—top of liquid to inlet invert: n/a
Depth of solids layer: n/a '
Depth of scum layer: n/a
Dimensions of cesspool: n/a t '
v Materials of construction: n/a :..
Indication of groundwater inflow(yes or no): NO
' Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
n/a
PRIVY: locate on siteplan) r
Materials of construction: n/a s '�
Dimensions: n/a •:`
Depth of solids: n/a € '
Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): 4'
n/a F
I
4.
4 k; ,
Page 10 of 11
OFFICIAL'INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART Ct
SYSTEM INFORMATION(continued) a"
rye.
X
Property Address: 78 HOMEPORT DR HYANNIS,MA 02601
Owner: PETER OLESKEY y
Date of Inspection: 11/19/01
R6
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. ;z
Locate all wells within 100 feet. Locate where public water supply enters the building. 3'
'I
- N
Cte d(l
Yi
DA
G &i�
�A 37
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in
Page 11 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued) .
Property Address: 78 HOMEPORT DR HYANNIS,MA 02601
Owner: PETER OLESKEY
Date of Inspection: 11/19/01 '
SITE EXAM
_Slope
_Surface water
_Check cellar
Shallow wells r:
Estimated depth to ground water 10+feet
Please indicate(check)all methods used to determine the high ground water elevation:
i
NO Obtained from system design plans on record-If checked,date of design plan reviewed: n/a
YES Observed site(abutting property/observation hole within 150 feet of SAS)
NO Checked with local Board of Health-explain: n/a
NO Checked with local excavators, installers-(attach documentation) t
YES Accessed USGS database-explain: n/a I
You must describe how you established the high ground water elevation:
GROUNDWATER DETERMINED BY AUGER-NO WATER AT 10' BOTTOM OF CESSPOOL AT 7'
II '�
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4 .
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1
1 i
'' 1 f
. j
k
11
TOWN OF BARNSTABLE
LOCATION SEWAGE #
VILLAGE ASSESSOR S a
i
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) ��-�� (size) C f
NO.OF BEDROOMS
BUILDER OR OWNER
PERMITDATE: COMPLIANCE DATE: 7
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) ��� t Feet
Furnished by
s
s, @
I
r
A
EL_
' TOWN OF BARN STABLE
LOCATION SEWAGE #
VILLAGE ASSESSOR'S MAP &;L' 1 3Q
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) (size)
NO. OF BEDROOMS
BUILDER OR OWNER
PERMITDATE: COMPLIANCE DATE:
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
Q
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Om
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-j-r COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAI AFFAIRS John Grad
DEPARTMENT OF ENVIRONMENTAL PROTECTION DEP Title V Septic Inspector
ONE WINTER STREET BOSTON MA 02108(617)292-3500 P.O.Box 2119
TeaTicket,Ma.
(508)564-6813
TRUDY COXE
Secretary
ARGEO PAUL CELLUCCI DAVI D B U S 8
Governor Com idne
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM 1b
PART A
CERTIFICATION
-0 r � � v ►r
Property Address: 78 HOMEPORT DR. HYANNIS MAP 268 PAR 130 L 10 ,o� 51 1119
�
Name of Owner MR&MRS WOLF 4q A.-
Address of Owner: C/O BK REAL ESTATE 1645 FALMOUTH RD.CENTERVILLE ATT.BERNIE
A7~
Date of Inspection: 3112/99
Name of Inspector:(Please Print)JOHN GRACI
1 am a DEP approved system inspector pursuant to Secdon 15.340 of Tide 5(310 CMR 15.000), 7i
Company Name: John Graci Title V Septic Inspection '
Mailing Address: P.O.Box 2119 TeaTicket,Ma.02636
Telephone Number: (608)664-6813
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 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:
X Passes The Inpection Is based on criteria defined in Title V
_ Conditionally Passes code 310 CMR 15.303.My findings are of how the system Is
_ Needs Further Evalyetion By the Local Approving Authority performing at the time of the inspection.My Inspection does
_ Fails not Imply any warranty or guarantee of the longgevity of the
septic system and any of its components useful life.
Inspector's Signature: iub
Date:3/13/99
The System Inspector shallt a copy of this inspection report to the Approving Authority(Board of Health or DEP)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.
NOTES AND COMMENTS
THE SYSTEM PASSES TITLE V INSPECTION.SYSTEM MUST GET PUMPED NOW AND THEN MAINTAINED EVERY YEAR.THE OVERFLOW HAS 3'
OF WATER IN IT AT TIME OF INSPECTION.
revised 9/2/98 Page 1 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 78 HOMEPORT DR.HYANNIS MAP 268 PAR 130 L 10
Owner: MR&MRS WOLF
Date of Inspection:3/12199
INSPECTION SUMMARY: Check A, B, C, Or D:
A. SYSTEM PASSES:
_ I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist.Any failure criteria not evaluated
are indicated below.
COMMENTS:
System passes Title V inspection
B. SYSTEM CONDITIONALLY PASSES:
n(a 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.
Indicate yes,no,or not determined(Y,N,or ND).Describe basis of determination in all instances.If"not determined",explain why not.
I
NO The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate of
Compliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection;or
the septic tank,whether or not metal,is cracked,structurally unsound,shows substantial infiltration or exfiltration,or tank
failure is imminent.The system will pass inspection if the existing septic tank is replaced with a complying septic tank as
approved by the Board of Health.
IO 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
inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
revised 9/2/98 Page 2 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 78 HOMEPORT DR.HYANNIS MAP 268 PAR 130 L 10
Owner: MR&MRS WOLF
Date of Inspection:3112/99
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 failing to protect the public health,safety
and 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 ThE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
Cesspool or privy is within 50.feet of 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 AND SAFETY AND THE 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 soil absorption system and the SAS is within a Zone I of a public water supply well.
The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well,
The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a
private water supply well,unless a well water analysis 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,Method used to determine distance nla_(approximation not valid).
3) OTHER '
n1a
revised 9/2198 Page 3 of 11
I
I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 78 HOMEPORT DR.HYANNIS MAP 268 PAR 130 L 10
Owner: MR&MRS WOLF
Date of Inspection:3/12199
D. SYSTEM FAILS:
You must indicate either"Yes"or"No"to each of the following:
I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303.The basis for this determination is
identified below.The Board of Health should be contacted to determine what will be necessary to correct the failure.
Yes No
X Backup of sewage into facility or system component due to an 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 1/2 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 nLa.
X Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation.
X Any portion of a 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 I 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.If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic ompounds,
ammonia nitrogen and nitrate nitrogen.
X The liquid level in the SAS is over the invert pipe,is In Hydraulic Failure.
E. LARGE SYSTEM FAILS:
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:
The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and
safety and the environment because one or more of the following conditions exist:
Yes No
X the system is within 400 feet of a surface drinking water supply
X the system is within 200 feet of a tributary to a surface drinking water supply
}
X 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)
The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.30412).Please consult the local regional office of the
Department for further information.
revised 9/2198 Page 4 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INS
PECTION FORM
PART B
CHECKLIST
Property Address: 78 HOMEPORT DR.HYANNIS MAP 268 PAR 130 L 10
Owner: MR&MRS WOLF
Date of Inspection:3/12199
Check if the following have been done:You must Indicate either"Yes"or"No"as to each of the following:
Yes No
X Pumping information was provided by the owner,occupant,or Board of Health.
X None 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.
X As built plans have been obtained and examined.Note if they are not available with N/A,
X The facility or dwelling was inspected for signs of sewage back-up.
X The system does not receive non-sanitary or industrial waste flow.
X The site was inspected for signs of breakout,
X All system components,excluding the Soil Absorption System,have been located on the site.
X 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:
X Existing information,For example,Plan at B4O,H,
X Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable)
[1 5.302(3)(b))
X The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of
SubSurface Disposal Systems.
f
revised 9/2198 Page 5 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 78 HOMEPORT DR.HYANNIS MAP 268 PAR 130 L 10
Owner: MR&MRS WOLF
Date of Inspection:3112199
FLOW CONDITIONS
RERIDENTIAI;
Design flow.-=g.p.d./bedroom
Number of bedrooms(design): 3_ Number of bedrooms(actual):nIa
Total DESIGN flow: nia
Number of current residents:7
Garbage grinder(yes or no):NO
Laundry(separate system)(yes or no): NO If yes,separate Inspection required
Laundry system inspected(yes or no).JMQ
Seasonal use(yes or no):M
Water meter readings,if available(last two year's usage(gpd): nta
Sump Pump(yes or no): NQ
Last date of occupancy: nla
COM M ERC IAUIN13USTRIAL
Type of establishment: nfa
Design flow: n&gpd(Based on 15.203)
Basis of design flow: n&
Grease trap present:(yes or no): NQ
Industrial Waste Holding Tank present:(yes or no): NQ
Non-sanitary waste discharged to the Title 5 system:(yes or no):NQ
Water meter readings.if available:WA I
Last date of occupancy: n(a
OTHER: (Describe)
n&
Last date of occupancy: n(a
GENERAL INFORMATION
PUMPING RECORDS and source of information:
NONE
System pumped as part of inspection:(yes or no):YE;a.
If yes,volume pumped 1b00 gallons
Reason for pumping: MAINTENANCE
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)
I/A Technology etc.Attach copy of up to date operation and maintenance contract
Tight Tank Copy of DEP Approval
Other: nla
APPROXIMATE AGE of all components,date installed(if known)and source of information:
1966 �
Sewage odors detected when arriving at the site:(yes or no): NQ
/
F
4
revised 9098 Page 6 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 78 HOMEPORT DR.HYANNIS MAP 268 PAR 130 L 10
Owner: MR&MRS WOLF
Date of Inspection:3/12199
BUILDING SEWER:
(Locate on site plan)
Depth below grade: 2'
Material of construction:_ cast iron _40 PVC X other(explain)
Distance from private water supply well or suction line: TOWN
Diameter: n&
Comments: (condition of joints,venting,evidence of leakage,etc.)
n1a
SEPTIC TANK: X
(locate on site plan)
Depth below grade: V
Material of construction:X concrete_ metal_ Fiberglass _ Polyethylene _ other(explain)
n1a
If tank is metal,list age Is age confirmed by Certificate of Compliance(Yes/No): No
n1a
Dimensions: 6'X7'BLCCK CESSPOOL
Sludge depth: JI
Distance from top of sludge to bottom of outlet tee or baffle: W
Scum thickness: V
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle: n&
How dimensions were determined: MEASURED
Comments:
(recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage,
etc.)
SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND RECOMMEND PLUMPING SYSTEM NOW AND THEM MAINTAINED EVERY
YEAR,
GREASE TRAP:
(locate on site plan)
Depth below grade:
Material of construction:_concrete_ metal_ Fiberglass _ Polyethylene_other(explain)
n&
Dimensions: n1a
Scum thickness: n&
Distance from top of scum to top of outlet tee or baffle:-1a
Distance from bottom of scum to bottom of outlet tee or baffle n1a
Gate of last pumping: n&
' Comments:
(recommendation for pumping,condition of Inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage,4.
nla
revised 9/2/98 Page 7 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 78 HOMEPORT DR.HYANNIS MAP 268 PAR 130 L 10
Owner: MR&MRS WOLF
Date of Inspection:3/12/99
TIGHT OR HOLDING TANK: NO (Tank must be pumped prior to,or at time of,inspection)
(locate on site plan)
Depth below grade: nla
Material of construction:_ concrete_ metal_ Fiberglass _Polyethylene_ other(explain)
nla
Dimensions: nla
Capacity: n& gallons
Design flow: Wa gallons/day
Alarm present: NQ
Alarm level:,n(a_ Alarm in working order:Yes_No_ NO
Date of previous pumping: n&
Comments:
(condition of inlet tee,condition of alarm and float switches,etc.)
nla
DISTRIBUTION BOX: _
(locate on site plan)
Depth of liquid level above outlet invert:n&
Comments: E
(note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.)
Ili'S
PUMP CHAMBER: NO
(locate on site plan)
Pumps in working order:(Yes or No): NQ '
Alarms in working order(Yes or No): NO
Comments:
(note condition of pump chamber,condition of pumps and appurtenances.etc.) _
Wa
{
revised 9/2198 Page 8 of 111
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 78 HOMEPORT DR.HYANNIS MAP 268 PAR 130 L 10
Owner: MR&MRS WOLF
Date of Inspection:3112/99
BUILDING SEWER:
(Locate on site plan)
Depth below grade: 2
Material of construction:_ cast iron _40 PVC X other(explain)
Distance from private water supply well or suction line: TOWN
Diameter: n&
Comments: (condition of joints,venting,evidence of leakage,etc.)
SEPTIC TANK: X
(locate on site plan)
Depth below grade: V
Material of construction:X concrete_ metal_ Fiberglass _ Polyethylene _ other(explain)
n1a
If tank is metal,list age Is age confirmed by Certificate of Compliance(Yes/No): MQ
n/a
Dimensions: 677'BLCCK CESSPOOL
Sludge depth: K
Distance from top of sludge to bottom of outlet tee or baffle: 2G"
Scum thickness: V
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle: n(a
How dimensions were determined: MEASURED
Comments:
(recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage,
etc.)
SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND RECOMMEND PLUMPING SYSTEM NOW AND THEM MAINTAINED EVERY
YEAR,
GREASE TRAP:
(locate on site plan)
Depth below grade:
Material of construction:_concrete_ metal_ Fiberglass _ Polyethylene_other(explain)
n/a
Dimensions: Wa -
Scum thickness: n1a
Distance from top of scum to top of outlet tee or baffle:_nLa
Distance from bottom of scum to bottom of outlet tee or baffle n1a
Date of last pumping: nLa
Comments:
_(recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage,
etc.)
n/A
revised 9/2198 Page 7 of 11
1
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 78 HOMEPORT DR.HYANNIS MAP 268 PAR 130 L 10
Owner: MR&MRS WOLF
Date of Inspection:3112/99
TIGHT OR HOLDING TANK: NQ (Tank must be pumped prior to,or at time of,inspection) j
(locate on site plan) '
Depth below grade: Wa
Material of construction:_ concrete_ metal_ Fiberglass _Polyethylene_ other(explain)
WA
Dimensions: nLa
Capacity: nLa gallons
Design flow: nLa gallonstday
Alarm present: NO
Alarm level:.ila_ Alarm in working order:Yes—No_ NQ
Date of previous pumping: n&
Comments:
(condition of inlet tee,condition of alarm and float switches,etc.)
Wa
DISTRIBUTION BOX: _ I
(locate on site plan)
Depth of liquid level above outlet invert:nla
Comments:
(note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.)
PUMP CHAMBER: NQ
(locate on site plan)
Pumps in working order:(Yes or No): MQ
Alarms in working order(Yes or No): NQ
Comments:
(note condition of pump chamber,condition of pumps and appurtenances.etc.)
nla
revised 912198 Page 8 of 111
C _
I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 78 HOMEPORT DR.HYANNIS MAP 268 PAR 130 L 10
Owner: MR&MRS WOLF
Date of Inspection:3112199
SOIL ABSORPTION SYSTEM(SAS): X
(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: n1a
leaching chambers,number: _WA
leaching galleries,number: _/a
leaching trenches,number,length: n(a
leaching fields,number,dimensions: nla
overflow cesspool,number: 6'X7'BLOCK
Alternative system: n/a
Name of Technology: _n1a
Comments:
(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.)
THE OVERFLOW"'CESSPOOL IS STRUCTURALLY SOUND AND FUNCTIONING PROPERLY THERE WAS X OF WATER IN IT AT THE TIME OF THE
INSPECTION_
CESSPOOLS: _
(locate on site plan)
Number and configuration: n1a
Depth-top of liquid to inlet invert: nla
Depth of solids layer: Wa
Depth of scum layer. nIA
Dimensions of cesspool: n&
Materials of construction:. n1a
Indication of groundwater: n& inflow(cesspool must be pumped as part of inspection)Dla
Comments:
(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.)
n1a
PRIVY: _
(locate on site plan)
Materials of construction:Wa Dimensions:Dla 1
Depth of solids: n1a
Comments: ;
(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.)
Dla �
I
revised 9/2198 Page 9 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 78 HOMEPORT DR.HYANNIS MAP 268 PAR 130 L 10
Owner: MR&MRS WOLF
Date of Inspection:3112199
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent reference landmarks or benchmarks
locate all wells within 100'(Locate where public water supply comes into house)
n/a
�c�eQw
QA��C
�a 5a
revised 9/2198 Page 10 of 11
v
I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C '
SYSTEM INFORMATION(continued)
Property Address: 78 HOMEPORT DR.HYANNIS MAP 268 PAR 130 L 10
Owner: MR&MRS WOLF
Date of Inspection:3112199
NRCS Report name: nla '
Soil Type: nla
Typical depth to groundwater: a&
USGS Date websIte visited: nla
Observation Wells checked: NQ
Groundwater depth:Shallow _ Moderate _ Deep _
SITE EXAM _ Slope
_ Surface water
_ Check Cellar
Shallow wells
Estimated Depth to Groundwater 10 Feet
Please Indicate all the methods used to determine High Groundwater Elevation:
_ Obtained from Design Plans on record
_ Observed Site(Abutting property,observation hole,basement sump etc.)
l
Determined from local conditions
_ Checked with local Board of health
_ Checked FEMA Maps
_ Checked pumping records
Checked local excavators,installers
X Used USGS Data
Describe how you established the High Groundwater Elevation.(Must be completed)
USGS MAPS AND CHARTS-10+FEET
a
i
i
revised 912/98 Page 11 of 11
SECTION A -A •wuelwtr ��
10' min. from "NOTE: ALL PIPES ARE TO BE 4" SCHEDULE 40 P.V.0 VENT PIPE O Least 24 inches tdl)-'--- ALL OUTLET P1PE5 FROM THE
I f schedule 4r� PVC ■/Chorcod Odor Filter PROFILE VIEW OF ADDITION TO LEACHING SYSTEM Ixsmte��Twn soot SHALL ENE -- 12• oot�ctE COVER
E)dstkV Fovdotkon house to septic tons( - SET LEVEL FOR AT IEAST 2 FT.
TT39 OF FIAMDATION = ELEV. LOOM (Asswed) Septic took covers rtwet De 3" of 1,`4" - 1/2" Washed Psostone - _ '' q l '•�
r41f1ir1 6 in. of MOM grade r
orode over Septic Tank - 99.00 Grade over D-Box - 99.00 over SAS - %.00 3/4" to 1 1/2 Washed Crushed Stone I 3 - s' OUTLETWT !,
KNOCKOUTS'4' PVC(CAPPE!')M/SPECTNIN PORT TO SS'INSTALLED AND TO BE 97NN 6"OF GRADEOUTLETS - 0.02 3 HOLE H-10 Tap Load - Eiev. =95.50 ' 1DIST. BOX 3' kbximum Cow ;NEW s=o.m a Oreoter Top of SAS - Ehv. -95.0010'r_1ttcT. PIPE- rn V7 1,500 GAL. 10. 5- 0.01" Der foot ar proofs. 0" EffectM oaptn4" - SCH. ; �` 1 •` • i�
FROM EXIST. FauNDATIDR W SEPTIC TAHK 8 ,,, s Units a b.zs' s 3D' PAN SECTION CROSS-SECTIONin
H 10 a I L SE ,
caNCREtE FULL FouN11ATTo►F o p in
Y 0.83' (10 inches) 3- L 31.25' 3 Iw "fix.: ;! S• y f
' - 3 HOLE H-10 DISTRIBUTION BOX 5�.".R -- � .�,v.
SYSTEM PROFILE 6 n.of 3/4"-1 1/2' a 37.25' + , y
'c compacted stone > u u o rn Effective Length NOT TO SCALE
c o
Not to Stole - - 4' 4' o SOIL ABSORPTION SYSTEM (SAS) o'J07t1ed rwls.,
j 6 n.of 3/4"-1c1/2" $ 0 INFILTATROR HIGH CAPACITY (H-10 LOADING)/ GEORGE O'BRIEN GENERAL NOTES
compocted stone 10 Effective Vidti+ EQUIVALENT) Not to Scale
NOTE. ALL COMPONENTS MUST HAVE RISERS TO WITHIN 6" BELOW GRADE m (OR EOU ) 1. Contractor i3 responsible for Digsafe notification
Bottom of Test Hole 1 Dev.-88.00 NOTE: OVERALL HEIGHT OF INFILTRATOR IS 18" /EFFECTIVE HEIGHT IS 10" and protection of all underground utilities and pipes.
♦Obs. Groundwater - Test Hole 1 Elev.= NONE OBSERVED 2. The septic tank and distri ution box shall be set
level on 6" of 3/4"-1 1/2" stone.
3. Backfill should be clean sand or gravel with no
stones over 3" in size.
4. This system is subject to inspection during installation
by Carmen E. Shay - Environmental Services, Inc.
5. The contractor shall install this system in accordance
PERCOLATION TESTT with Title V of the Massachusetts state code, the approved plan
and Local Regulations.
Date of Percolation Test: MARCH 29, 2004 6. If, during installation the contractor encounters any
soil conditions or site conditions that are different
Test Performed By. CARMEN E. SHAY, R.S., C.S.E. from those shown on the soil log or in our design
Results Witnessed By. WAIVER (per BARNSTABLE B.O.H.) installation must halt & immediate notification be
Excavated By. SHAY ENVIRONMENTAL SERVICES, INC. made to Carmen E. Shay - Environmental Services, Inc.
Percolation Rate: Less Than <2 MPI
7. No vehicle or heavy machinery shall drive over the
septic system unless noted as H-20 septic components.
- - -- --- N 04d 33' 20" E .99 8. Install Tuf-rite gas baffles or equals on all outlet tee ends.
Test Hole -- ---- - ---- - --No. 1 W 1 75.00' 9. All Distribution Lines shall be 4" diameter Schedule 40 NSF PVC pipes.
DEPTH SOILS ELEV.v.1! 12 I 10. All solid piping, tees & fittings shall be 4" diameter
_ 5
O q•,�5' �,¢•25' Schedule 40 NSF PVC pipes with water tight joints.
0 99�
5.5 11. Municipal Water is Connected to ALL OF The Residence and Abutting
....:
Sandy >`�!�?=tit -;i • .z-`(�� �t 4" PVC Properties Within 150 Feet.
Loom e t• Vent Pipe
10 rR 3/2 nt
-• �,: THE PROPERTY LINES ARE APPROXIMATE AND
O"-6" Ae 98.50 �i4' 'S•i�T ' :�'"i'f .i<t; t ►;�
Loamy PROJECT BENCH MARK TEST HOLE #1 z COMPILED FROM THE SURVEY PLAN GENERATED BY
' �� ELEV.= 99.00 DAVCS D-Box 1 O EENTIITLED GREPLAN oOF YLAND S
ANNI . MA
^d TOP OF FOUNDATION N BARNSTABLE, MA
,o ,R 5/6 ELEV. = 100.00 (Assumed) DATED NOVEMBER 1965, PLAN BOOK 197 PAGE 123
6 32" 8■ 97.25 - ` AND IS NOT INTENDED TO BE A SURVEY PLOT PLAN
Med. 9g_ - z // 0 IT SHOULD BE USED FOR NO PURPOSE OTHER THAN
Sand
z.s r e/e Septic Tank J Failed NEW 15 gal. THE SEPTIC SYSTEM INSTALLATION.
32"- 132 .00 Cesspool f
W EXISTING LEACH PIT TO BE PUMPED OUT AND
FILLED IN PLACE OR REMOVED TO FACIUTATE INSTALLATION OF NEW SAS.
LOT #9 HOUSE #78 PORCH V. LOT #11 NOTE: ANY STRIPPED OUT SOIL CONTAINING LEACHATE
t, FROM THE EXISTING LEACH PIT TO BE DISPOSED
EXISTING F N OF AS PER BOARD OF HEALTH SPECIFICATIONS.
1 O 3 BEDROOM i I NO WETLANDS ARE PRESENT WITHIN 200' OF THE PROPERTY
ko
O HOUSE co ASSESSORS MAP 268, PARCEL 130
Perc #1
Depth to Perc: 48" to 66" LEGEND
C ( Q 3
Pert Rate= Less Than 2 MPI ( U
fr Observed ESHWT® - NONE OBS.- 132" Assumed LOT #10 �---a o--� -98 104X1
DENOTES PROPOSED
ADJUSTED H2O Elev. = NONE OBS. - 132" Assumed 98 _--_ _ ----------------- ---- - SPOT GRADE
7,500 Square Feet DENOTES EXISTING
x 104.46 SPOT GRADE
75.00'
I
- PL PROPERTY LINE
S 04d 33' 20" W 6 PROPOSED CONTOUR
_-_ - - - - - -97 EXISTING CONTOUR
H0ATEPOR 7T DRIVE'
3-24' DIA,M. ACCESS MANHOLES
DEEP TEST HOLE &
(40 FOOT RIGHT OF WAY) PERCOLATION TEST LOCATION
6 FOOT STOCKADE FENCE
INLET w / - 1
ee ` / ` / \ / ou T
k PTHE ACCESS COVERS FOR THE SEPTIC TANK, LOT P LAN
-t'T--'-•.- .F ��'^'--�..;., ".. DISTRIBUTION BOX AND TEACHING COMPONENT
STEEL REINFORCED PRECAST CONCRETE FINISHEDDEGRRADED TO W1T}HN 6" OF
E. OF PROPOSED SEPTIC SYSTEM UPGRADE
PLAN VIEW INSTALL TUF-T1TE GAS BAFFLES OR EQUALS
ON ALL OUTLET TEE ENDS PREPARED FOR
3-24' FEMOVABU COVERS
_ MS . JAQUELINE MIRANDA
INLET _ min f=nin m a.to out1N y : I 11r AT
12
OUTLET # 7 8 H O M E P O R T DRIVE
5 -r .: _� 15 ► _ 5 -r HYAN N I S , MA
E
a.ere• '- LiPiid depN
b� Design Calculations
Zt+ PREPARED BY:
T.
i Number of Bedrooms: 3 Equivalent to 330 Got./Day (3 . Gal-/Day Min. per T;tle V) 9C :
IT-O, r , 5' -� Garbage Grinder: No A G CARNEW E. SfA Y
Leaching Capacity Proposed: 330 Gal./Day Minimum (Min. Per Title VI
CROSS SECTION END-SECTION
Septic Tank - 3 x 330 Gal./Day = 660 USE NEW 1,500 GAL. Septic Tank. 0 20 40 50 H N ENVIRONMENTAL SERVICES, INC.
SOIL ABSORPTION AREA: Using percolation rate of <2 min./inch 0. 1
TYPICAL 1500 GALLON SEPTIC TANK Bottom Area: 0.74 gal/sq. ft. x 370 sq. ft. = 273.8 gallons p o P.O. BOX 627
Sidewall Area: 0.74 gal./sq. ft. x 78 sq. ft. = 58 gallons R /sTS4' EAST FALMOUTH, MA 02536
� NOT TO SCALE Providing: = 331.80 gallons Sq to
NITAR\a TEL/FAX : 508-548-0796
(H- 1 0 LOADING) Use: (5) INFILTRATOR HIGH CAPACITY H-10 UNITS, HAVING A 0.83' (10 INCHES) EFFECTIVE DEPTH, SCALE: 1 "=20
SCALE: 1 "=20' DRAWN BY: CES DATE: APRIL 7, 2004
TO BE USED WITH 4.0' OF WASHED STONE ON THE SIDES, AND 3.5' OF WASHED STONc
ON THE ENDS. No STONE UNDER. PROJECT#SD553 FILENAME: SD553PP.DWG SHEET 1 OF 1