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HomeMy WebLinkAbout0111 IRVING AVENUE - Health (2) 111 (Main) Irving Avenue Hyannis P A 287 065 a i I 0 f COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS . DEPARTMENT OF ENVIRONMENTAL PROTECTION NIAP Z�� �✓ PARCEL , �- L07 TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION RECEIVED Property Address: 1 1 1 Irving AvPnire (.main) 1 5 2004 Hyanni -sport, MA MAR Owner's Name: rarnl i ne Kennedy__ RNSTpgLE Owner's Address: � ; —` TOWN OF BA HEALTH DEPT: � ` Date of Inspection: Name of Inspector.(please print) Wi 1 1 i am _ •Robinson Sr. CompanyName: William E. Robinson Septic Service Mailin&Address: .P O Box 1089 Centerville MA Telephone Number:— (508) 775-8776 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 Se ion 15340 of Title 5(310 ChIR 15.000). The system: Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority 'Fails Inspector's Signature: rir, IV( (�°��'— Date: ate— ncl The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Heankor. ,- 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 Beater,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 Iconditions of use. Title 5 Inspection Form 6/152000 page 1 Page 2 of 11 a OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 1 1 1 Irving Avenue (main) HYanni c; c)ri- , MA Owner. C'arnl i na Kannarly Date of Inspection: 2=1=(�/' , Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. Sys Passes: ` -fir. 1 have not found any information which indicates that any of the failure criteria described in 310 CMK 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. j Comments: ;t rtxr- B. stem Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaire .The system,upon completion of the replacement or repair,as approved by the Board of Health,'will pass.' Answer es,no or not determined(Y,N,ND)in the for the following statements.If"not determined"please explain. Th septic tank is metal and over 20 years old*.or the septic tank(whether metal or not)is structurally unsound, xhibits substantial infiltration or exfiltration or tank failure is imminent System will pass inspection if the existing U nk 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 expl bservation of sewage backup or break out or high static water level in the distribution box due to-broken or obstruct pipe(s)or due to a broken,settled or uneven distribution box._System will pass inspection if(with approv of Board of Health): broken pipes)are replaced obstruction is removed distribution box is leveled or replaced ND ex lain: e system required pumping more than 4 times a year due to broken or obstrtxted pipe(s).The system will pass insp ction if(with approval of the Board of Health): broken pipe(s),are replaced Obstruction,is n=vod ND expl n: Page 3 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY.ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 1 1 1 T ry i n k Av n u a (main) Ayann i gport , MA Owner: Kenn Date of Inspection: . C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is fail g to protect public health,safety or the environment. 1. ystem will pass unless Board of Health determines in accordance with.310 CMR.15.303(1)(b)that the. ystem 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. Sy tem will fail unless the Board of Health(and Public Water Supplier,if any)determines that(he- 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 su face water supply or tributary to a surface water supply. The system has a septic.tank and SAS and the SAS is within a Zone 1 of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more fronl 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 acteria and volatile organic compounds indicates that the well is free from pollution from that facility and e presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other ill criteria are triggered.A copy of the analysis must be attached to this form. 3. ther: I 3 Page 4ofII y OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY.ASSESSMENTS SUBSURFACE`SEWAGE DISPOSAL SYSTEM INSPECTION FORM. . PART A CERTIFICATION(continued) Property Address: 1 1 1 Irvine Avenue (main) - Hs ann i spart , MA Owner: Cara Date of Inspection:. ,©L D. •stem Failure Criteria applicable to all systems: You ust indicate des" ".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, Discharge or pondingof a fluent to the surface'of the ground or surface waters due to an overloaded or clogged'"SAS or cesspool _ Static liquid level in the distribution box above.outlet invert due to an overloaded or clogged SAS or. cesspool Liquid depth in cesspool is less than`6"below invert or available volume is less'than%day flow _ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipc(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 I00,feet of a surface water supply or tributary to a surface water supply. Any portion of.a cesspool orprivy 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 uatLr supply well with no acceptable water quality analysis.(This system passes if the well water analysis, performed at a DEP certified laboratory.,for conform bacteria and volatile organic compounds indicates that the well is free.from pollution from that facility and the-presence of ammonla 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.) (YeslNo)The system fails.I have determined that one or more ofthe 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. i E. arge Systems: To a considered a large system the iystem must serve a facility with a'design floc+•of 10,000 gpd to 15,000 gpd• You ust indicate either"yes"or"no"to each of the following: (71te ollowing criteria apply to large systems in addition to the criteria above) yes o 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—I WPA)or a mapped Zone 11 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 faikd.The awns or operator of imy large system considered a signiGc nt threat under Section E or failed tinder Section D shall upgrade the system in accordance with 310 CMR 15.304,The system owner should contact the appropriate.regional office of the Department. 4 i� Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 1 1 1 Irving Avenue (main) Hyanni .sport-' MA Owner. r;;rnl i ne Kennedy Date of Inspection: 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. 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 T. ✓ 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? 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 baM or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? _ _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no ✓ Existing information.For example,a plan at the Board of Health. Determined in the field(if any of the failure criteria related`to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)] 5 Page 6 of 11 OFFICIAL INSPECTION FORM-,NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL"SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 111 Trvinq AvPnne (main) . Hyann i S1LLt r . M.A Owner. Date of Inspection: FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):. Number of bedrooms(actual): DESIGN flow based on 310 CMk 15.203(for example: 110 gpd x#of bedrooms): Number of current residents: Does residence have a garbage grinder(yes or no):/-0: Is laundry on a separate sewage system(yes or no):,L—) (if yes separate inspection required] Laundry system inspected(yes or no). �/'` Seasonal use:(yes or no): v� Water meter readings,if vailable(last 2 years usage(gpd)):`°2 0 0 3':'= 3 4`8,0'0`0 Sump pump(yes or no):. A-D 2002 — 273,750 Last date of occupancy: CO ERCIAL/INDUSTRIAL Type f establishment: Desig flow(based on 310 CMR I5.203): Qpd Basis design flow(seats/persons/sgft,etc.): Grease p present(yes or no):_ Industr al waste holding tank present(yes or no):_ Non-s" titary waste discharged to the Title 5 system(yes or no): Water i ieter readings,.if available: Last d e of occupancy/use: OTHE (describe): GENERAL INFORMATION Pumping Records Source of information: ti Was system pumped as paKof the inspection(yes or no): If yes,volume pumped: `_gallons-=How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM _Sep is tank,distribution box,soil absorption system S' gle cesspool verflow cesspool —_Privy _Shared system(yes or no)(if yes,attach previous inspection records,if any) _Innovative/Alterna0ve 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 com onents,date install d Qf known)and source of information: Were sewage odors detected when arriving at the site(yes or no):-L6 6 I'age 7 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: ill Irving Avenue .(.main) Hyanni spnrt ,._MA Owner: edy Dale of Inspection: —0' v L-j BUILDIN SEWER(locate on site plan) Depth belo grade: Materials f construction:_cast iron 40 PVC other(explain): Distance om private water supply well or suction line: Commen s(on condition of joints,venting,evidence of leakage,etc.): SEPTIC T NK:—(locate on site plan) Depth below ade: Material of co struction: concrete metal fiberglass_polyethylene _other(expl in) If tank is metal list age:_ is age confi medby a Certificate of Compliance(yes or no): (attach a copy of certificate) Dimensions: Sludge depth: Distance from t p of sludge to bottom of outlet tee or baffle: Scum thicknes Distance from op of scum to top of outlet tee or baffle: Distance from ottom of scum to bottom of outlet tee or bafMe: How were di ensions determined: Comments(o pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to utlet invert,evidence of leakage,etc.): GREASE T _(locate on site plan) Depth below gr, de: Material rkn tion:_concrete metal fiberglass_polyethylene_other (explain): _ Dimensio Scum thic Distance f scum.to top of outlet lee or baffle: Distance of scum to bottom of outlet tee or baffle: Date of la :Commenting recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as relatedvert,evidence of leakage,etc.): 7 Page S of 11 OFFICIAL INSPECTION FORM:-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORA'[ PART:C . SYSTEM INFORMATION(continued) Property Address: 191 I=zJ aq Awenue (main) Owner: , A Date of Inspection: _ r nedy TIGHT or HOLD VGTANK: (tank must be pumped at tune of inspection)(locate on site plan) Depth'below gradeMaterial of constru concrete metal fiberglass. . polyethylene other(explain):: Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or o): Alarm'level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,.etc.): DISTRIBUTION BOX: (if present must be opened)(locate on site plan) Depth of liquid level abo a outlet invert: Comments(note if box i level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of b x,etc.): PUHiP CHAMBER: (locate on site plan) Pumps in working order es or no): Alarms.in working order yes or no): Comments(note con n of pump chamber,condition of pumps and appurtenances,etc.): 8 Page 9 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 111 Irving Avenue (main) Hvannisport, MA Owner: Ca r ed Date of inspection: _ 2 —/ �� ty SOIL ABSORPTION SYSTEM(SAS): /(locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number:_ leaching chambers,number: V hing galleries,number: hing trenches,number,length: hing fields,number,dimensions: f overflow,cesspool,number: innovative/altemative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): 2= C s s d A/-a Z0/1,)Z CESSPOOLS: " (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: `4 Depth—top of liquid to inlet invert: (� Depth of solids layer: 3 ' Depth of scum layer: Dimensions of cesspool: _fg Materials of construction: Indication of groundwater inflow.(yes or no): Comments note con ition�Pof soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): �j 6 o V . !✓ I -TA// 1 Y YYi- y Ci 0 L PRIVY: (locate on site plan) Materials of c,nstruction: Dimensions: Depth of soli s: Comments( to condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): 0 9 Page 10 of I I OFFICIAL INSPECTION FORM=NOT FOR VOLUNTARYASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 111 TrvinQ Avenue (main) HYanni sport. MA Owner: Carnl i ne xenned Date of Inspection:�--1G- 6 J. 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. rL . . Wd Sz l� 7� i 1 X— 10 Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 111 Irving Avenue (main) Hyannisport, MA Owner. Caroline xenriedy Date.of Inspection: if SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: 11 4 Make application to local Fire Department. bs �� Fire Department retains original application and issues duplicate as Permit. � o 0/ V kiss`g9 APPLICA TION and PERMIT Fee: �• for storage tank removal and transportation to approved tank disposal yard in accordance with the provisions of M.G.L. Chapter 148, Section 38A, 527 CMA 9 00, application is hereby made by: a Ent • Tank Owner Name(please print) 111111111t'Kennedy X i aP J'mD Germ Address tll_1 Irbing Street Hyann— rt;MA ynarure sneer ----- _ chy 1111171 MR • stare A, Company Name Enviro—Safe it Co.or Individual P.O.�BOX 810, E.Sandwich, MA P`�` Address Address Prirml ' . Prinf Si nature a lying for per r1L /Sr``���Yi- gnature(if applying for permit) ® IFCI,Certified Other O IFCI Certified 0 LSP'# Other. 111 Tank Location Irving Street Hyannispor.t, MA - - Sleet Address city �a Tank Capacity(gallons)_ _ 5 0 0 _ Substance Last Stored #2_ 0 i-1 Tank Dimensions(diameter x length) Remarks: �j Firm transporting waste Enviro=Safe State Uc.# 329 MA Hazardous waste manifest# dV1/a k-�S TY0 E.P.A.# MAD 9 8 5 2 6 9 3 2 3 -Approved tank disposal yard Turner Salvage Tank yard# 002 -------------- Type ofiner(gas Tankyardaddress 235 Commercial Street Lynn, MA City or Town A-1�&i.f FDID# Permit# 99 Date-of-issue :S�?—e�yll Date of expiration Dig safe approval number: 19991103613 Dig Safe Toll Fr , r-800-322-4844 Signature/Title of Officer granting permit 95 710W After removal(s)send Form FP-290R signed by Local FiWtSTgulatory Compliance Unit,,` Ash n;1 ce, Room 1310,Boston, MA 02108-1618. f - s '-292(revised 9/96)