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HomeMy WebLinkAbout0087 HOMEPORT DRIVE - Health 87 Homeport Drive Hyannis F/R A = 268 136 k F a G o i TOWN OF BARNSTABLE LQCATION �? ['h'J/ OUYQ'- vr,,� SEWAGE # PO a`0 Of VILLAGE S. -- ASSESSOR'S MAP & LOT 13 6 INSTALLER'S NAME&PHONE NO. " c�'✓( SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) NO. OF BEDROOMS BUILDER OR OWNER ��� PERMITDATE: —I I } COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and 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 } O o - .o { �T. 269� COMMONWEA1,TN of MA,SSACIIUSErps Enc uriv, OEM u oi�*EN°G'IRONMENTAI,ArrA Rs DEPARTMENT OF ENVIRONMENTAL PROTECTION r. MAP _ PARCEL, LOB �..! .� TITLE S OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address• e frxr- . Owner's Name: t- ' Jt' 2e'ALi Owner's Address: 87 Date of Inspection: Nacre of Inspector:(please print) Company Name. .a Mailing Address: +.5-4 1 Ste„ ?t//'yta-,. s ry Telephone Number. --2-2 > CERTIFICATION STATEMENT t certify that I have personally inspected the sewage disposal system at this address and.that the infon.n.a ion repor'ed co below is true,accurate and complete as of the time of the inspection.The inspection was perfortned based on.my� training and experience in the proper function and maintenance of on site sewage disposal systems.I s a DEP rn approved system inspector pursuant to Section 15.340 of.Title 5(310 CMR 15.000). The system: —L-.'asse5 Conditionally Passes Needs further Evaluation by the Local Approving Authority Fails Inspector's Signature: cDate: The system inspector shall submit a copy of this inspection report to the Approving Authority(hoard of Health or DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and.Comments ""This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6f 15/2000 page I Page 2 of I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM. PART A CERTIFICATION(continued) Property Address:—Lk1-7- L , ,Ysl ift - -l . Owner: Date of inspection: S7"t 9 _a Inspection Summary: Check A B,C,D or E/ALWAYS complete all of Section D A. System Passes: U I have not found any information which indicates that any of the failure criteria described in 3.10 CMP 15.303 or in 310 CMR 1.5.304 exist.Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional:Pass"section need to be replaced or repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,net 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 Gild is available. ND explain: Observation of sewage back-up or break.out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled.or uneven distribution box.System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box.is leveled or replaced ND explain. The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction:is removed ND explain: Title 5 Inspection form.6f 15t2000 Page 3 of l l OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM.INSPECTION FORM: PART A CERTIFICATION (continued) Property Address: T tl Pow» Pn 9 . Owner: LIit&A," l 4 5.h Date of inspection:'5 —l9r --a c� C. Further Evaluation is Required by the Board of Health: Conditions exist which.require further evaluation by the Board of 11calth in order to detemune 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 31.0 CM12 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 wager — 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 l 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 tarok 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,perfonned at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is frec from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen.is equal to or less than 5 ppnit,Provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: Title 5 Inspection norm 6/15/2000 3 Page 4 of 11 OFFICIAL INSPECTION FORM.-NOT:FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM:INSPECTION FORM PART A CERTIFICATION (continued) Property Address: g`7 � + Owner: Date of Inspection: S--=� D. System Failure Criteria applicable to all.systems: You must.indicate"yes"or"no"to each of the following for all inspections: Yes No �.- 4`-Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool -je ischarge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or ged SAS or cesspool L-' Static Liquid level in the distribution box above outlet invert due to an overloaded or.clogged SAS or Paswol _ i-r"�LL' depth in cesspool is less than 6"below invert car available volume is less than'dz day flow -1-- equired Pumping more than 4 times in the last year NQ due to clogged or obstructed pipe(s).Number J' yroes pumped 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 cr supply. :y portion of a cesspool or privy is within a Zone 1 of a public well. _,y/Ann rtion of a cesspool or privy is within 50 feet of a private water supply well. L,-Kny portion of a cesspool or privy is less than 100.feet but greater than 50 feet from a private water supply well with no acceptable water quality,analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] W-0—(Yes/No)The system fails,l have determined that one or more of the above failure criteria exist as described.in 310 CMR 1.5.303,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 most serve a facility with a design flow of 10,000 gpd to 15,000 gpd- You must indicate either"yes''or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no the system is within 4 f of a surface drinking water supply the system is withi 00 t of a tributary to a surface drinking water supply the system is located in a 'nitrogen.sensitive area(Interim Wellhead.Protection Area--IWPA)ora mapped Zone II of public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes"in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 31.0 CMR 15.304.The system owner should contact the appropriate regional office of the Department. Title 5 Inspection form 6//15/2000 4 Page 5 of 11 OFFICIAL INSPECTION.FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: {honer: L$/A/A t kl&f1_5 h Date of Wspection: 65"-119 - Check if the following have been done.You must indicate"yes"or"no"as to each of following. Yes �N,�" Pumping information was provided by the owner,occupant,or Board of Health C. Cre any of the system components pumped out in the previous two weeks ' ✓_Has the system received normal flows in the previous two week period 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) c--- �Was the facility or dwelling;inspected for sips of sewage back up -j�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 time tank inspected for the condition of thc 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 sue and.location of the Soil Absorption System(SAS)on the site has been determined based on: Ys L% _ Existing information,For example,a plan at the Board of Health. Determined in the field(if any of the failure criteria related to Part Cis at issue approximation of distance is unacceptable)[310 CMR I5.302(3)(b)f Title 5 Inspection Form 6/1.5/2000 5 Page 6 of l i OFFICIAL INSPECTION FORM:-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM:INFORMATION Property Address: ?7 ,j�r#n 4.Pb e_7`_A? Owner: V/ W:4:6 b„ Date of Inspection.- FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design.):,3__ Number of bedrooms(actual): & DF,SIGN flow based on 310 C:MR 15.203(for example: 110 gpd x#of bedrooms): Number of current residents: 2Z — Does residence:have a garbage grinder(yes or no):,fit Is laundry on a separate sewage system(yes or no)V.rLV [if yes separate inspection required] Laundry system inspected(yes or no):1 Seasonal use:(yes or no):fit? Water meter readings,if available(last 2 years usage(gpd)): N 0 Sump pump(yes or no): Last date of occupancy: tslato" COMMERC AIJINDUSTRIAL Type of establishment: Design.slow(based n 310 CMR ): gpd Basis of design flXd � t! nstsgft,etc.): Grease trap pre : .Industrial wastresent(yes or no): Non-sanitary w to the Title 5 system(yes or no):_ Water meter reble: Last date of occupancy/use: OTHER.(describe): GENERAL INFORMATION Pumping Records Source of information: C> u!� 7` •wt «2 ` '.5 a L o Was system pumped as part of the inspection(yes or no): If yes,volume putnpcd:gallons--How was quantity pumped determined.? Reason for pumping: T P*A*SYSTEM: i Scptic 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 or no): ? Title 5 Inspection Form 6/1.5/2000 6 Page 7 of 1.l OFFICIAL INSPECTION:FORM:—NOT FOR.VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM:INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: , ' (honer: C-V A I)V k W*Cls A Date of Inspection: BUILDING SEWER(locate on site plan) Depth.below grade: w,ZY f/ Materials of construction:_cast iron VC otber(explain): Distance from private water supply well or suction line: Continents(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK.:_(locate on site plan) r( Depth below grade:. /� Material of construction: oncrete_:metal.fiberglass_polyethylene —other(explain) if tank is metal.list age: Is age confirmed by a Certificate of Compliance(yes or.no): (attach a copy of certificate) Dimensions:to )6 e± I-6 Sludge depth: 'VV Distance from top of sludge to bottom of outlet.tee or baffle: Scum thickness: w^-- Distance from top of scum to top of outlet tee or baffle: Distance from.bottom of scum to bottom of outlet tee or baffle: Now were dimensions determined: �5 UAL Comments(on pumping recommetxlations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): GREASE TRAP:_(locate on site plan) Depth below grade: Material of construction: c .._: metal:metal!fiberglass_polyethylene_..._other. (explain): Dimensions: Scum thickness: Distance from top of scum t p of outlet tee or baffle: Distance from bottom of um o bottom of outlet tee or.baffle: Date of last pumpin.- Comments(on put ing recommendations,inlet and.outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): Title 5 Inspection Form 6/15/2000 7 Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C '! SYSTEM INFORMATION(continued) Property Address: rZ 9...e_ 1'"pp. Owner t tJ dot S h Date of Inspection: c= t r '-o y TIGHT or HOLDING TAN!{:—(tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material.of construction: oncrete metal fiberglass—___polyethylene other{explain): Dimensions: P> tt t3 Capacity: �— gallons Design Flow: 3-?v --gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX:_____{t/ if prescnt_must,be opened)(locate on site Plan) Depth of liquid level above outlet invert: .4 7 4o 04F t... 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.): PUMP CHAMBER:_(locate on site plan) Fusnps in workin order or no): Alarms in wor_kin r(yes or no): Comments(no dition of pump chamber,condition of pumps and appurtenances,etc.): Title 5 Inspection form 6/15/2000 8 Page 9 of l i OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: T.? ' Owner C `�nld1"C fy 4L 5 h Rate of Inspection. SOIL ABSORPTION SYSTEM:(SAS): (locate on site plan,excavation not required) If SAS not located explain why: f1'e�'e Type leaching pits,number:_ leaching;chambers,number: leaching galleries,number:— leaching trenches,number,length: �✓ltraching fields,number,dirncnsions: Si'Y K _overflow cesspool,number: _innovativelalte:rnative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): CESSPOOLS:_(cesspool must be pumped as part of inspection)(locate can site plan) Number and configuration: Depth top of lay id to inlet' w : Depth of solids la r: Depth of scum layc - Di.mcnsions of ol. Materials of ,nstru ion: Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure,.level ofponding,condition of vegetation,etc.): PRIVY: (locakdiof plan) Materials of constru Dimensions: :Depth of solids: Comments(note soil,signs of hydraulic failure,level,of pondirtg; condition of vegetation,etc.): Title 5 Inspection Form 6/15/2000 9 Page 10 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address ` Owner: �}lAr j 'r Date of Inspection: S"—I qy if 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. .xi E f � t s } (i Page 1.1 of I OFMCIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM. PART C SYSTEM INFORMATION(continued) Property Address: 9'-7r—par-7 Owner: C.'V11" e UL* _s /1 Date of Inspection.: SITE EXAM Slope Surface water Check cellar. Shallow wells Estimated depth to ground water 2� fc ct Please indicate(check.)all methods used to determine the high ground water elevation: _Obtained.from system design plans on record-I f checked,date of design plan reviewed: Observed site(abutting;property/observation hole within 150 feet of SAS) ecked with local Board of Health-explain: Checked with local excavators,installers-(attach documentation) cesscd USGS database-explain: You must describe how you established the high ground water elevation: Old G- uru/ Z7-4 -a Title 5 Inspection Form 6/15/2000 11 r 1!io. ����� � Fee / THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE. MASSACHUSETTS { 0[ppricatton for Migogar *pgtem Congtruction Permit' ' Application for a Permit to Construct( )Repair(V)Upgrade( )Abandon( ) ❑Complete System El Individual Components Location Address or Lot No.'T7 Owner's Name,Address Tel.No. Assessor's Map/Parcel / j(o g'�Q��S (L�p�i , Inst is Name,Add and Tel.No. Designer's Name,Address and Tel.No. in e�rrh9 c,`/ �� �5f-, m9 aZ ia� . esrUoe © Type of Building: 2 Dwelling No.of Bedrooms 1 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building 4 No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow -33 gallons. Plan Date 'lA Number of sheets Revision Date Title _ Size of Septic Tank ✓VI(J iSUy 9 Type of S.A.S. r C 5 DESIGNING ENGINEER MUST SUP RVISE Description of Soil 0,t4 CA f), -INSTALLATION ..ID G THE SYSTEM WAS !NSTA t D IN STRXT ar.CARDANCE M PLAN Nature of Rep irs or Alterations(Answer when applicable) A n P nl&) Date last inspected: h Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provision of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been iss d b th'' Boardo ea Signed Date,3 11 eQZ Application Approved s -Datefl--� i Application Disapproved for the following reasons Permit Date Issued '"� Nor " Fee—Ul ' . THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: / Yes ✓i PUBLIC HEALTH DIVISION =TOWN OF BARNSTABLE., MASSACHUSETTS ZfppYication for M000l *patent Construction Permit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No.87 6 Net Owner's Name,Address and Tel.No. Flores fa Assessor's Map/Parcel Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. ( S—0 3 ) r Nrlene oher6 Dv� ,,nf_ e in�ec�lh� y`t� l b(P We S r 0 ro c.5-h__CZ` / i/+/• L bfYl/?UrY1. /� 646,73 >�� C rlI l�10 rla/ni ©'Z✓ Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures ` Design Flow .>3 a gallons per day. Calculated daily flow 3 gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank MU) i/.SQ U 9at Type of S.A.S. Description of Soil 12,e I'n Q 1 Oil/I.— y J - Nature of Repairs or Alterations(Answer when applicable) t. rr� (-eifit 1/- �n #, rI A Date last inspected: _�_- v Agreement: The undersigned agrees to ensure the construction and maintenance of the afore.described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by,this Board of-Health. Signed IJ' t/i4 a Date Application Approved b r Date --cam ' r Application Disapproved for the following reasons 4 .Permit No. 'O�—4' Date Issued C —j `'�� �-- —=—_------ —___—=--_-- {'`` THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certif irate of Compliance THIS IS TO CERTIFY, t��}}a,',t'the Ong-site.Sewage Disposal System Construct('4 )Repaired( )Upgraded(¢/) Abandoned( )by /) I i f.�/LL. p0���� — ��he/, S_t Z�J at ,N q 14r)jr1e06l4. ll Y//2 . ,Lkla n /S has been constructed in/accordance IT- with the provisions of/Title 5 and for Disposal System Construction Permit f1 dated Installer /�.1,<✓11!�/� �. L� I,Z�� Designer The issuance of this permit shall not be construed as a guarantee that the systein will fun t/ln as d si'gne Date )_ 01 Inspector rW«•.,.==tom.—.._.='°"'"" -•- �� =="=—— - _--� ———— �-(—`�..a��—`^'—— Fee THE COMMONWEALTH OF MASSACH0=SNING ENGINEER MUST SUPERVISE PUBLIC HEALTH DIVISION - BARNSTABLE., MfS I WRITING V" TAL EDN STRICT liqu al *pgtem Congtrurtioq. tl ff TO PLAN. Permission is hereby granted to Construct( )Repair; V)Upgrade( )Abandon( ) System located at 3 r and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided: Construction must be completed within three years of the date of this p rmit. j Date: /� Approved f ` I 1 TOWN OF BARNSTABLE LOCATION �� ����� SEWAGE # VILLAGE— ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. �✓ SEPTIC TANK CAPACITY' LEACHING FACILITY: (type) d�.,Cl� fP�'I S (size) L�`G NO. OF BEDROOMS BUILDER OR OWNER PERMIT DATE: I I—U COMPLIANCE DATE: �- Separation Distance Between the: Maximum Adjusted Groundwater Table and 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 0 0 a /t t OUTBACK( 106 west Grove Street Mi , MA ENGINEERING, INC. Tell.: 508r946-9231346 Fax: 508 947-8873 March 13,2002 Town of Barnstable Health Department 367 Main Street Hyannis, MA 02601 Subject: 87 Homeport Drive,Septic Repair Inspection To whom it may concern: An inspection of the newly installed Title V septic system for the subject property was conducted. I hereby certify that the new septic system has been installed in compliance with the approved plan, dated 3/6/02. Very truly yours, J es A. Pavlik, P.E. r SL ►56 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS r DEPARTMENT OF ENVIRONMENTAL PROTECTION Sy0 D INSPE.CTION TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 9 /700, orT Ql' Owner's Name: &/0 DC / /0✓ps o,/ RECEIVED Owner's Address: . No$I e o '02�,,,1, 01) 60 0 1 � 1 Date of Inspection: P (P ) % "/ �� /- �� Cyr A.uTH lRITY Name of Inspector: lease lint Grp O r i . .t-y Pf��9F irtY Company Name: 2FA, lO — EC/ Mailing Address: D file7.,4 /d Telephone Number: OW- 77-S--97S�f CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: Passes Conditionally Passes Further Evaluation by the Local Approving Authority Fails Inspector's Signature: o� Date: /"-? v 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 DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. Notes and Comments G �44 // c ��►�/N ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. a Page 2 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: e 17ge-jL Owner. /0r,-S A ( Date of Inspection: // ''j p Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: /V/ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements.If"not determined"please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced - obstruction is removed ND explain: , Page 3 of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A u CERTIFICATION(continued) Property Address: lIOtMe o✓ �i� l t7o2 6 O Owner: FILWS 161 Date of Inspection: C. Further Evaluation is Required by the Board of Health: A/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. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well".Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered A copy of the analysis must be attached to this form. 3. Other: Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) , Property Address: Owner: �—/��Pt a Date of Inspection: gJ 0 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool yDischarge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool _ Liquid depth in cesspool is less than 6"below invert or available volume is less than'/Z day now ✓Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped V Any portion of the SAS,cesspool or privy is below high ground water elevation. 1�Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. _ �Any Any portion of a cesspool or privy is within a Zone 1 of a public well. _ portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as (T 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• You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no _ the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered "yes"in Section D above the large system has failed The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. ` I Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B p / vie Property Address: O 7o � 0 / a A.11"441-C, � / Owner: ��O�e Date of Inspection: J Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes No Pumping information was provided by the owner,occupant,or Board of Health V 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 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) V/_ Was the facility or dwelling inspected for signs of sewage back up t/ Was the site inspected for signs of break out Were all system components,excluding the SAS,located on site /ZIes Were the septic tank manholes uncovered opened,and the interior of the.tank inspected for the condition offfl or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes/moo ✓/_ Existing information.For example,a plan at the Board of Health. v 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)] Page 6 of 1 I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: V 4, rt�!r 0.1601 Owner: Flom / Date of Inspection: 12LOI FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): -Z�'d Number of current residents:_/ Does residence have a garbage grinder(yes or no): NO Is laundry on a separate sewage system(yes or no):LVU[if yes separate inspection required] Laundry system inspected(yes or no):NJ Seasonal use: (yes or no): A10 Water meter readings,if available(last 2 years usage Sump pump(yes or no): IV° / Last date of occupancy: Zurm--!- 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 Source of information: A6C9 pP� ��s 7�U•d e��y d w�„p Was system pumped as part of the inspection(yes or no):1r10 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 erflow 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): 1 Approximate age of all components,date installed(if known)and source of information: QVrCr �l� � 191�0S r Were sewage odors detected when arriving at the site(yes or no): IVO Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: �o�'►e- oi7� Q,,-. Owner: Date of Inspection: // 9 0/ BUILDING SEWER(locate on site plan) Depth below grade: 9 � Materials of construction:jZcast iron _40 PVC (i6ther(explain): ©1—C4 Distance from private water supply well or suction line: —� Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: (locate on site plan) Depth below grade: Material of construction:_concrete_metal __ _polyethylene polyethylene _other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions: Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: Distance from top of scum to top of outlet tee or bale: Distance from bottom of scum to bottom of outlet tee or baffle: How were dimensions determined: Comments(on pumping recommendations,inlet and outlet tee or bale condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): GREASE TRAP:/ (locate on site plan) Depth below grade: Material of construction:_concrete_metal_fiberglass polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): Page 8 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: JJ Y/" Owner: r�o�cs��� Date of Inspection: // 7 0 TIGHT or HOLDING TANK: lkl(tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass_polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX:A (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): PUMP CHAMBER:IV(locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): i Page 9 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 92 l/0y4e c/4 a- / / i 6o/ Owner: -/ / Date of Inspection: / 2 / SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number:_ leaching chambers,number: leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool, number: innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): CESSPOOLS: V(cesspool must bepumped as pqrt of inspection)(locate on site plan) Number and configuration: aZ / Depth-top of liquid to inlet invert. O✓e I 6-ye r, Depth of solids layer: G " Depth of scum layer: Dimensions of cesspool: !o x L rox Materials of construction: to,4- Indication of groundwater inflow(yes or no): C nts(note condition f soil signs of hydraulic failure,level of pon ' c nditi of vegetation,etc.): PS . 00/ O�n�/'" YPr /0/e OH c Co ve PRIVY: /y (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil, signs of hydraulic failure,level of ponding,condition of vegetation,etc.): Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: i0,1 f 1074 a6a Owner: �a�P 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. f i o7 �7'ouSG i # ✓fir- V-4 / oz cc CBSf:co Page 11 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 112 /&47 e,20Z Owner• Flon a Date of Inspection: 1/ O/ SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water oZ Y /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 feetVAS) JCChecked with local Board of Health-explain: To L,v7 g�f Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: /✓�/ �✓� 9 - zone � L You must scri how you establ'shed the.high ground water elevation: owl toC�2 p e r� CUSS oo / c✓ �, Ne 6 A Tom / Too o � Gr,, d C! 3 J 4 3.41 ti,�i, (Troµnd4.afYr a►� . _ - ' . - , I s " F . , , . .° ;.� � w ` i 1 J t t �- c , t-y l t yt .f .i i "s x t ''�.,,I,I.�I-i-,�-�,i.,,.-r I,�N 1-.�*,I-�,,,4�,---.I4,..:-,..I..�,­I,�-I',,I,.�I",,�',..-,,,,��-l..,'..1—L:%.I,�'",.''o II,',�,,%-,.�,,,,--.�,,-..L,,-,-,,I-�,L."L.,,,,.irI,�-."I,,,;,.-,,t.'II.",',�',-,�.',,,.,�.l,,�,.I-,*,�I.-,,I.,I��-.,'L:-+,,"',,,-.",,,-�,,,--I,.,�;,�-.:��.,",,",*��,".--,�.,%,:,"..,'-:-�,,",-.,"��,-_",1'.-.�.,,7-4.-3'.I'.,�,��I—'—,'.-,'"`---.+...,.I.I,.,1,�.,.1,,.�.I_',"--.-,k'.,',I-,�,.r,..1-.;�.,�.�,I'L,,�--�'.��,',-..,..:.'I-,,--1:I,I 1I,,,-.,:.,L-�,',;.�.­,�..",:,,,4��'",';�7,,-"I�,I,L�.�x,C;—,�".�.-;,i,-..'r��"rI,.-�f�-I LV-,�-I"�,,,'I 1.-,o:I,�I-,I,,I,�-'5"'I.,,-;,.�",.,,L'1,,,.,�I-I��;I'-.;1�'1 1 1_-,,,"--1 x,,1_-,"-',e7....,,,.-1,,,,�,-I,,1 I—'",-..-'��,�.,,I,..'L��,I�.�..;".�L'-4,,,--,i�,,�r�,,,1,�,1�...-'-,_I�L, t 1 - rt �,, S a , t b ' a r.'Z,r U '° ' ; "F t as ,(•, t}F`r i7 e ; Ir ..t 5 , ;� v Y w la ` tt ..}q {'t. t+ .,.. s n-V i 'Y ,.-� y a',�, n� i» 'F + 1 ii..t r fy 1}. r'" > ! f ;., t t r,r r� • 7h #. `�}S°`} ti n r 7 rc t " 't,. �. r. k ,.a ,.r . 4 C -1 `}' •• F`s '• b.; .+',.r� r 'r t '� I .,,...,� ;'� a A 5:.t t T i`'r II I-" F, eL k fi}s l{o- i 5 9 { YZ f) t r t 1 t S { F cfK I t i t { `r t tt r�k 'h Y ' �.. } 3 y I.MiI r5`� r,t , lot; , `5 tf r- 1 r r r S t S xs-. . „ . j '. ``` '�-», = SEPTIC SYSTEM INSPECTION REPORT µ`; { Mkt t�:. 4� � ,'` > r ., �R 3t.", ;ft, r : " .s:-: J r5 ` x 'a? l v a f� t ) h�J!}P �- 3 s Yi+ ' 4 'a r t Fe"r rr.: .VK` i s '� t f » £ A,, Y , a + 1 -., �f , 1 rY Lt.. h 9fi , { yM. �: -} - f , +' ,-z 4 14 x 4 r ,. 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R'.r��'. ! 1 .. - D t, ... - .L ..,.y r ,.Y d7 ZIP. .r k ,, ' COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET, BOSTON MA 02108 (617) 292-5500 TRUDY CORE Secretary ARGEO PAUL CELLUCCI DAVID B.STRUHS Governor Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ' PART A CERTIFICATION Property Address: B� �+�E �2"lE Name of Owner (2-6co-T ' {}.(q.,.,r`r-5 , M4• AddressofOwner: `19"I GIokESJ-ice,-r Si4LetrT Date of Inspection: 5o p-rtm boc a- 1, 1,199 )-I tS w to l.t, "A,. 0 2 4(o 4- Name of Inspector:(Please Print) 1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000) Cornpany Name: Ga��,t SE�i ENy i k,�,J Mir i i—A( }LL(, MaifingAddress: P.o. 1988 i H44,jr i iS , 114. c2(.cl Telephone Number: (%c.8)49 e—f31 c-L ' 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:se Passes Conditionally Passes Needs Further Evaluation By the Local Approving Authority Fails Inspector's Signature:*nt �%�= Date: Z a i"SFd 3114�2,vo The System Inspectorop oft is inspection report to the Approving Authority(Board of Health or DEP)within thirty 130)days of completing this inspecem 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 A �t�u , ,- �,p��a.6a. bE i qva d c�r� L 0 l( -{ tvci t s�t c F i��r . ,r TIDE s; d 6 c n4 I t s e f' T h ' ctssPJ� 1 E,sI-eJ d �PePa-o ,I x A t- iy l �- r �.�wr},LAs `` 3 i� l"t9q � �•oc.JE�IGt�-� �E � �-•1L ��-F HV�5 Nut �Ouc" 1N 1cSt Si lGL� J�Iy CV`S101J rT 5�L..) d. L.�SQ.csO �OVt"02'�Ow( � tr.gg S(.o�til�YL$� of kA4N % `4� zo4d. ' k5 salt-- 1 it (Fss i?'�l ,` �pPr d- A-- bF I,' ' revised 9/2/98 Pagel of11 M1 _. rigf.Printed on.Recycled Paper I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continied) Property Address: 81 No roc Po a a , H—I N 15 Owner: f2.obeo�r EPnrt-is--(C- ' Date of Inspection: 9 )1 )`i`A 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: S c( lw.�—lFi vim, B. SYSTEM CONDITIONALLY PASSES: N I 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. 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. _ 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 pipels). 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 2of11 w . f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ' PART A CERTIFICATION (continued) Property Address: b 1 0 c-19or-If ba.4 ur Owner: 2a t wT E Mat G.y-- Date of Inspection: ej 9 q C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: 014 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 environmens. ' 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 15.303(1)(b)THAT THE SYSTEM IS NOT FUNCTIONING W 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. I 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: N Jq The system has a septic tank and Roil 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 (approximation not valid). 3) OTHER 1 revised 9/2/98 Page 3of11 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (contirwed) Property Address: 8I e rt Ao-i 4E r ply Owner: (2.a etA4-YcK- Date of Inspection: q I 9 q 1 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 Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). ' Number of times pumped— Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. 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 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 compounds, ammonia nitrogen and nitrate nitrogen. E. LARGE SYSTEM FAILS: rJ )A 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 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) The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional office of the Department for further information. revised 9/2/98 , Page aorll .. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B ' CHECKLIST Property Address: i7 7 I{�MFPONT (�2�.rF 1`�-1+}nrr l iS ' Owner: R•obrVT EMz�c1c Date of Impaction: c1 + t qq Check if the following have been done:You must indicate either "Yes" or "No" as to each of the following: Yes No / ' _ ✓ Pumping information was provided by the owner, occupant, or Board of Health. T.1a NE R--4;W q b\5 'M1-o 1`t tY 5 _ 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. ✓ As built plans have been obtained and examined. Note if they are not available with N/A. t-jc"'tF 4,4 `1� `Ole _ The facility or dwelling was inspected for signs of sewage back-up. ' ✓ _ The system does not receive non-sanitary or industrial waste flow. _ The site was inspected for signs of breakout. Y _ All system components, excluding,the Soil Absorption System,have been located on the site. v 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: _ V Existing information. For example, Plan at B.O.H. ' _V/ _ Determined in the field(if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) [15.302(3)(b)) The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of SubSurface Disposal Systems. revised 9/2+/98 Page 5of11 i ' 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ' PART C SYSTEM INFORMATION )'ropertyAddress: 4s Nyar+ti is Owner: lob.wT E a,vtti cic ' Date of kaspection: I try 9 FLOW CONDITIONS RESIDE]JT1AL: Design flow:'€$'i"X,'g.p.d./bedroom.;�` _ Number of bedrooms(design): 7 Number of bedrooms(actual): Z Total DESIGN flow (0-1 Number of current residents: v ' Garbage grinder(yes or no): uc Laundry(separate system) (yes or no):fk; If yes, separate inspection required Laundry system inspected (yes or no) N/q I ' Seasonal use(yes or no): *lo Water meter readings,if available(last two year's usage(gpd): lR 11 BLI9 l ,9 3 S 9 A-I s, 19 9 7 196 (r 7 Z S A,15. Sump Pump(yes or no): ,vo Last date of occupancy: 1 31 I99 COMMERCIAUINDUSTRIAL: rJ F� Type of establishment: Design flow: qpd ( Based on 15.203) Basis of design flow ' 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: ' OTHER:(Describe) Last date of occupancy: ' GENERAL INFORMATION PUMPING RECORDS and source of information: N-o a.Ec, rL,4S "a;(a bic ' System pumped as part of inspection: (yes or no) NO If yes, volume pumped: gallons 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) I/A Technology etc.Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other , APPROXIMATE AGE of all components, date installed(if known) and source of information: Lt-J krbw nl ' Sewage odors detected when arriving at the site: (yes or no) *J ' revised 9/2/98 Page 6of1l' 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ' PART C SYSTEM INFORMATION(continued) Property Address: °o 7 t 1 r Po vsJr D as V E 1�y a�.v i S Owner: 2.1oc-n--,t rz t c k Date of irupection: y i I I qci BUILDING SEWER: (Locate on site plan) Depth below grade: 6 Materiel of construction:_cast iron ✓40 PVC_other(explain) Distance from private water supply well or suction line ►.r JA Diameter A'� Comments:(condition of joints, venting, evidence of leakage, etc.) No le N 1��a� j �o� �tS A y r--ftt- In 1-�f-I .5o� SEPTIC TANK: N/') (locate on site plan) Depth below grade:_— — — — Material of construction: concrete metal Fiberglass Polyethylene_other(explain) If tank is metal,list age_ Is age confirmed by Certificate of Compliance_(Yes/No) ' Dimensions: Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: ' Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: How dimensions were determined: 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.) GREASE TRAP: NIA ' (locate on site plan) Depth below grade:_ Material of construction:_concrete_metal_Fiberglass _Polyethylene—other(explain) ' Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: ' Date of last pumping: Comments: (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.) ', revised 9/2%98 Page 7of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ' PART C SYSTEM INFORMATION(contirwed) Property Address: 81 Ilu(y�AJI/T 11�t�VC 1�-I!}NNIS O Wner: Date of kupection: 9 I 1 1 ay SOIL ABSORPTION SYSTEM(SAS): r'�✓} (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:_ leaching chambers,number:_ leaching galleries,number:_ ' leaching trenches,number,length: leaching fields, number, dimensions: overflow cesspool,number:_ Alternative system: ' Name of Technology: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.) CESSPOOLS:_ ' (locate on site plan) Number and configuration: 'L Depth-top of liquid to inlet invert: N- I S'-7'� �f>Qr, J vtn S(••aqE �W oP�E;,� Ov�s \ocJ) ' Depth of solids layer: S ". zqy�.J) J Depth of scum layer: NOrJE o.Iun-*tn-.4) Dimensions of cesspool: (,'-,c w I-r,. o,4wQ-+\4...i) Materials of construction: Cc- z-n----,- �o lbe_k Comer- boc(n7 Indication of groundwater: NO inflow(cesspool must be pumped as part of Inspection) Gc Ss on( w 1 rA f uM E� No ;,•�.,i c� q..� ,q,b t= 4a- nUF-i01NG - Soi k 6.'"d9 C'j-4"i:kE I A' �t--i CeL&g., ( Y�o'��o l-� 7.a It-' � . Flo •1 J ���{.ioJ 4g(Loc .l wt1 iE2 ' Comments: (note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.) Do 1,54 1 'Jt�iqF�-A-�;LN A 7 0-4ty'4 L PRIVY: J4 (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.) revised 9/2/98 Page 9oru ,.. I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ' PART C SYSTEM INFORMATION(continued) 7 roperty Adores: 8-7 14-utne poo T bo-�vc ON 4,4,4%s Owner: 2u6E t-t cr -^#Lick ' Date of ktspacdw: 9( t I qcl TIGHT OR HOLDING TANK:_t�A_(Tank must be pumped prior to, or at time of, inspection) ' (locate on site plan) Depth below grade:_ Material of construction:_concrete_metal_Fiberglass_Polyethylene_other(explain) Dimensions: Capacity: gallons ' Design flow: gallons/day Alarm present Alarm level: Alarm in working order:Yes_ No_ Date of previous pumping: ' Comments: (condition of inlet tee, condition of alarm and float switches,etc.) DISTRIBUTION BOX: 1� ' (locate on site plan) Depth of liquid level above outlet invert: ' .omments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) PUMP CHAMBER: fjjq ' (locate on site plan) Pumps in working order: (Yes or No) Alarms in working order(Yes or No) ' Comments: (note condition of pump chamber,condition of pumps and appurtenances, etc.) revised 9/2/98 Page 8of11 >., i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ' PART C SYSTEM INFORMATION (continued) 'ropertyAddress: 87 4owtEQwi--N bo:iVj ►�yrFN.viS ' owner: wC E I., R-t kc Date of inspection: 9q ' 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) 1 revised 9/2/98 Page 10of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ' PART C SYSTEM INFORMATION(continued) Property Address: $l Owner: Date of bupection: 9 I 1 9`1 NRCS Report name S.\ A-f�S A,, ' Soil Type_ C OA,✓ VEVL Typical depth to groundwater g rt q � ry�g,j (o + USGS Date website visited Observation Wells checked M I w--L A Groundwater depth: Shallow _Moderate Deep SITE EXAM Slope --U)T ' Surface water Check Cellar r+.q.wl s P A-ci - -) Shallow wells -.,.4E ' Estimated Depth to Groundwater L 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.) ' _Determined from local conditions Checked with local Board of health Checked FEMA Maps Checked pumping records ' —Checked local excavators, installers Used USGS Data ' Describe how you established the High Groundwater Elevation. (Must be completed) q c L n(" �� -I o t+lt U S C4 S P«�M,p k t MAP --" `0, t N.� +>res a-A (}.I T tl"C' 5.(stz-r, o -s> ; s lolt � ar 4rfP��,�alFVlg �io,-I of 34 Lcv- M S L 00,jV4 aP ' gA"LwS W(}%K C,�,i i�..,x MqP 6I42 ;,.+ di<.R-J-E) 1L./}t �,La. 4d WatL,-, 6e,-,.,+ • T�c sib GgrJ L T 1EIE48 'I;�1,4 12, S MS(- Tlie wdic,}tU,t o-i t1 rt Tut S+ -i- wl ) . -e r 1-a de}t YL"•-tl: S c+�5 c JA 1 l l. 0 VL<,,.,.,.1 ,q tbx (1dS�`stcd JnA �Nd� � {t L c� b� ��a � �t 6 IFQ�- t'Q� 1�nE �w4'1�r� of Ilne cC<SSP��1 >5 11 �e �o�� "F Su.,'�t}ec p, E 1cvq 7�� rJu1 .., v' a CeSSP�aI ',S aQPrwKJI-��4+Ely 10.9 ljr�_,.E schsutj.1-1 ' F I7o1'4-0r-+ °� �F a.� r+ ��ov.! iS '7.ZS r 666,4 `I"�iz- ScrP 7 fi P►T F 1F�FF H® . 2b,'75 MSL. 4 lklcyt��y2 r 1I�F ho��°1.�a-� t�nF ov�Pe-�bu iS HPP4us-E{9. (.% 10. 1xS� r4 bovu S�H4cN�) revised 9/2/98 Page 11 of 11 ' 4 ,'" Gooseberry :y a .� �_ 3i� �• hN 1 'J a ;• _ a oisland n ..k `�. .• ' °� ♦ P' L� i' + ulcer r :�j; •.��?� � �� �� mow. Q � + tE --- oPt � ' � ` at) 4u9 pGQR � ' �.� •�. at P � �_ •© l.� lI sel _ ss •• � � ` off � r r^• �1� ,1; � � .I :I 4' �F ,Y,�`• II :fO,., � /I yaJS �� ����1� h!!�I{I • � YJ � 3 �.! •� , ''^.....G. � g a 3 4M t�iff✓.f C)a • =�, f ` .� v. f 4' � � �'��F --mac. �. re P61a . ° , 1, �•. ,•, o •' / 2 pj97 J cQ t) a EX t � r Cs f f O_ r- • EA • � �''``• N' �Z.. A K Beaoh � 0C14`a` A iD7 I_�l YA.NNIS Q 1. AR Hya t1k5 19 16 I I5 u�t <Defaulb-2 Markers,Length=2 miles,1377 feet Locus- 041°39'29.1"N, 070°16'14.8"W Locus- 041°38'34.5"N, 070°18'34.5"W ' Name: HYANNIS Location: 041°38'53.7" N 070°18'37.7" W Date:3/16/100 Caption:87 Homeport Drive Scale: 1 inch equals 2000 feet Hyannis, MA ' Copyright(C)1997,Maptech,Inc. Schematic Site Plan 1 Homeport Drive N #87 1 36.5' 37.8 46 0 34.8' Soil Boring _. Cesspool Overflow Location: 87 Homeport Drive Not To Scale Hyannis, Massachusetts Based on Visual Observations G� a d� Date: September 1, 19" t ��' Revised: March 14, 2000 BENCH MARK: TOP OF FND. c.-jS (SAS) SHALL BE ELE=31.0 �L v o,�6Q 34.25' LONG L MANHOLE COVERS TO EXTEND TO y. ' 1't.0' WIDE WITHIN 6" OF FINISH GRADE I v Qp 10' DEEP LePtt Act �J� S 2x BAFFLE REQ'D ac 28.50 iE 7.0% EL=27.70 Zr (.. 0 C ki S 28.3 NEW 8.05 D.B. —— — — _— —_ 2' PEASTONE TOPPING 1,500 GAL 27.2s 7 a ..: - _ GENERAL NOTES: �� CAP ENDS 9, lV +MHEn TONE 3, ,R'• _— _— _ _ "� — ELEVATIONS SHOWN BASED ON U.S.G.S. DATUM. 3/4" DOUBLE WASHED SYSTEM PIPE SHALL BE EITHER C.I. OR EL=26.36 STONE ALL AROUND SCHEDULE 40 P.V.C. 6' CWJSHED STONE — THE BOARD OF HEALTH SHALL BE NOTIFIED 10' PRIOR TO BACKFILLING OF SEPTIC SYSTEM. 1.5 31.25' .5' — SEPTIC SYSTEM STRUCTURAL COMPONENTS 20° MIN. SHALL BE CAPABLE OF WITHSV(NDING A USE FIVE (5) INFILTRATORS H-10 LOADING, UNLESS SPECIFIED OTHERWISE PROPOSED SEPTIC SYSTEM WITH 4.0' OF STONE ® SIDES — SEPTIC SYSTEM UNDER DRIVEWAYS SHALL do 1.5' OF STONE O END: COMPLY WITH A H-20 LOADING. NO SCALE NO STONE AT BOTTOM — THE DESIGN AND COMPONENTS OF THE SEPTIC SOIL TEST LOG 7.36' PERC RATE= < 2 MIN/INCH SYSTEM SHALL BE IN COMPLIANCE WITH THE STATE OF MASSACHUSETTS SANITARY CODE NOTE: NOTE: EL=19.0 TITLE V. AND SHALL BE IN COMPLIANCE WITH WELL MIW-29, ZONE BADJUSTMENT =:t.0' BOTTOM TEST HOLE THE LOCAL BOARD OF HEALTH RULES AND DEPTH ELEV.= 30.0 PRIOR TO INSTALLING THE NEW (SAS) THE NO WATER OBSERVED REGULATIONS. 0 A LOAMY SAND 10YR 3/1 CONTRACTOR SHALL PUMPOUT ALL CESSPOOLS 5.36' SEPARATION FROM BOTTOM (SAS) AT THIS DEPTH AND BACK FILL WITH CLEAN MEDIUM SAND • TO BOTTOM of ADJUSTED TEST HOLE THE CONTRACTOR SHALL BE RESPONSIBLE FOR 6 B LOAMY SAND tOYR 5/1 IF CESSPOOLS ARE ENCOUNTERED IN THE ELEVATION HAS BEEN PROVIDED FOR IN LOCATION OF ALL UNDERGROUND UTILITIES AND 24" _ (SAS) AREA THEY SHALL BE REMOVED IN THIS DESIGN SHALL NOTIFY DIG — SAFE PRIOR TO i CONSTRUCTION. --Cl MEDIUM SAND 10YR 8/2 \ I — NO GARBAGE GRINDER DESIGN CRITERIA: In 125" Z DESIGN FLOW SOIL TEST CONDUCTED ON MARCH 6. 2002 3 BEDROOMS AT 110 G.P.B. / DAY 330 G.P.D. BY JAMES PAVLIK, SOIL EVALUATOR 15 REQUIRED SEPTIC TANK: NEW 1.500 GALLON PERC BOTTOM ® 30" O Z7 r SEPTIC TANK PROVIDED 1,500 GAL r 14. o LLJ DESIGN PERC RATE <2 MIN/INCH o/JO WATE, !� �� O la O > SIZE OF REQ'D (SAS) AREA = 330/0.74 = 446 S.F. SIDEWALL 2 0.83)(34.25)+(2)(0.83)(11)= 75.12 S.F O 0M � � _ � BOTTOM t�11)(34.25) = 376.75 S.F. O ' �► SIZE OF LEACHING FACILITY PROVIDED: 376.75 S.F. + 75.12 S.F. = 451.87 S.F. O 334.4 GPDj u vj �— O EFFECTIVE DEPTH: 10" EFFECTIVE LENGTH: 34.25' IL EFFECTIVE WIDTH: 11.0' LJ ` OUTBACK ENGINEERING `SH OF 44, 106 WEST GROVE STREET LEGEND: 2 8 i R I\j E JAM EIS A.�q�y 508LL9406 o923A 02346 EXISTING CONTOUR ————————— _ ( ) MAP WATER' GATE �}— W.M. LoT 13b CIVIL PROJECT: SEPTIC SYSTEM REPAIR FOR WATER SERVICE 4 1N=-W— - - - - - \ - `"" ``- -- - a9� �� 87-HOMEPORT DRIVE, HYANNIS - TEST HOLE lg� �e.1C.t Q '* ! AS SHOWN 0R 1M B" JP GAS SERVICE G—G �� 3/6/02 MAP 268 / LOT 136 ■. BENCH MARK 0;BM l QO t" `\ v W OWNER: ENOCK FLORESTAL 168 BARNSTABLE ROAD HYANNIS, MA 02601 - 2-O I