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Home My WebLink About0016 ISALENE STREET - Health 16 Isalene Street Hyannis A 267 - 080 1 o. Commonwealth of Massachusetts Executive of Environmental Affairs DEP Department ofl , Environmental Protection �� SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM �� ' - -- - -- - .. .PART A -- -- --- -- - - --- - ---- -- - C. ��„ -- CERTIFICATION ya Property Address: a0 �S�aLe►�e s1 �*i�� N�s�„�-� Mrs . —a R' Address of Owner: (if different) Date of Inspection: ; Name of Inspector: Michael. DeDecko Company Name, Address and Telephone number: Atlantic Environmental P.o B ox 2384 - M ashpee M a 02649. Tel: (508)4771420 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 Passes --- Conditionally Passes - Needs further evaluation by the local Approving Authority -- Fails Inspector 's S ignatur : ua Date: The system Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (30) days of completing this inspection. If the system. is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office or the Department of Environmental Protection. The original should be sent to the system owner and copy sent to the buyer, if applicable and the approving authority. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: a0 Owners : IZA 6� Date of Inspection : b INSPECTION SUMMARY: Check A, B, C, or D A)SYSTEM PASSES: I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CM 15.303. Any failure criteria not evaluated are indicated below B) SYSTEM CONDITIONALLY PASSES: ••-- One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair,passes inspection. Indicate yes, no, or not determinate (Y,N, or ND). Describe basis of determination in all instances. If"not determinated",explain why not. -•-- The septic tank is metal, 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 conforming 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 pipe(s). The system will pass inspection if(with approval of the Board of Health): ---- broken pipe(s)are.replaced •--•• obstruction is removed f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 0'1O Owner : Date of Inspection : Ir\%VS e C) FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: --- Conditions exist which_require further evaluation by the Board of Health in order to de- termine if the system is-failing to protect the public health , safety and the environ- ment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETYAND THE ENVIRONMENT: ---- Cesspool or privy is within 50 feet of a surface of water -••- Cesspool or privy is;within 50 feet of a bordering vegetated wetland or a small marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNC- TIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT. -•-• The system has a septic tank and soil absorption system and is within 100 feet to a surface water supply or tributary to a surface water supply. ---- The system has a septic tank and soil absorption system and is within a Zone I of a public water supply well. •-•- The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. --• The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water supply wen,unless a well water analy- sis 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 notrogen is equal to or less than 5 ppm. D)SYSTEM FAILS: -- I have determined that the system violates one or more of the following falure criteria as defined 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 cor- rect the failure. --- Backup of sewage into faciity or system component due to an overloaded or or clogged SAS or cesspool. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: oX �s� Owner: tk-Nrt%oN3 Date of Inspection: D)SYS T E M FAI LS (continued) •• 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 over- loaded or clogged SAS or cesspool. •-• Liquid depth in cesspool is less than 6"q p p 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 cesspool or privy is within 100 feet of a surface water supply ortributary 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 ana- lysis. 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. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Owner: M4yeozo,,j Date of Inspection : i`S .----E) -LARGE SYSTEM FAILS:- The following criteria apply to large systems in addition to the criteria above : The design flow of system is 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 : --• 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 bring the system and facility into full compli- ance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please, consult the local regional office of the Department for further information. 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: Owner: Date of Inspection: Check if the following have been done : -x Pumping information was requested of the owner ,occupant and 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 rate s duringthe period.p od. Large 9 volumes of water have not been introduced into the system recently y 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 'sep- tic tank was inspected for conditions of baffles or tees,material of construc- tion, dimensions, depth of liquid, depth of sludge, depth of scum. --x The size and location of the Sal Absorption System on the site has been deter- mined based on existing information or approximated by non-intrusive methods ---x The facRity owners and occupants 9 different from owner were provided with information on the proper maintenance of Subsurface Disposal System. 1 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: .2-0 Owner: �lcP�rso►� Date of Inspection: ., RESIDENTIAL: Design flow : Z-6b gallons Number of bedrooms : o'3 Number of current residents: # c Garbage grinder (yes or no) :- t-v Laundry connected to system(yes or no): `�p S Seasonal use (yes or no) : 1,� Water meter readings, if available: Last date of occupancy : COMMERCIALANDUSTRIAL : Type of establishment: Design flow : gallons/day 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 sourceA information � alZRO ► P Sy tem pumped as part 6f inspection (yes or no) O if yes,volume pomped: .................... gallons Reason for pumping : K L SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner:Vk�Q�� Date of inspection: TYPE OF SYSTEM 4 S eptic tank/distribution box/soil absorption system -- Single cesspool --- Overflow cesspool -- Privy --- Shared system (yes or no)(if yes, attach previous inspection records, if any) -- Other (explain). ......................................................................................... APPROXIMATE AGE of all components, date installed (if known) and source of information .Q. ,z...,P �...:,.... .. �,�....................................................................................... ................................................................................................................................................ ................................ Sewage odors detected when arriving at the site : (yes or no)...tits.. SEPTIC TANK : (locate on site plan) Depth below grade: .A4T...GV b .-- Material of construction: ..(:.. concrete ......... metal........ FRP ........ other (explain) ................................................................................................................................................ Dimensions: �K.!�.x..�. Sludge depth:...0'. ...... Distance from top of sludge to bottom of outlet tee or baffle:......... ................ Scum thickness :...d.`.'........... Distance from top of scum to top of outlet tee or baffle: ..........(.G......................... Distance from bottom of scum to bottom of outlet tee or baffle:.......1.6.............. Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in rel ti to outlet invert,struchu I integrity evidenFe of leakage,etc.) ....... . �..?s�?�.. .il!fl'l�!. .... 9Y?.P . �.5.... .1�..... b...�`v :::::::::::................................................... Q SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: �iTSr�kN.� Owner: Date of inspection: GREASE -TRAP: ...-.�O.... (locate on site plan) Depth below grade: ............... Material of construction: ........concrete.........metal........FRP........other(explain).... ...i ............................................................................................................................... Dmens........ions:............................... Scum thickness:........................ Distance from top of scum to top of outlet tee or baffle:....................................... Distance from bottom scum to bottom of outlet tee or baffle:............................... 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.)........................ ................................................................................................................................................ ................................................................................................................................................ TIGHT OR HOLDING TANKS:... ?Z�.... (locate on site plan) Depth below grade:............... Material of construction:........concrete........metal.........FRP..........other (explain).......... ................................................................................................................................................ Dimensions:............................ Capacity:....................gallons Design flow:...............gallons/day Alarm level:............................. Comments: (condition of inlet tee,condition of alarm and float switches, etc.) ................................................................................................................................................ ................................................................................................................................................ SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property address: a�0g lrc►.��" c Owner: ►� thaw-so-J Date of inspection: - CESSPOOLS:....!?.(P.. - (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: ..................... Indicator of ground water: .:....:............. inflow (cesspool must be pumped as part of inspection) ................................................................................................. ..................................................................................`.............. Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) ..................:............................................................................................................................. ................................................................................................................................................ PRIVY: ....N-10... (locate on the site) Material of construction: ................................... Dimensions: ....................... Depth of solids: ................ Comments: (note condition of soil,signs of hydraulic failure,level of ponding, condition of vegetation, etc.). ................................................................................................................................................ ................................................................................................................................................ ;s r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address : Tsai L� Owner, (lc-P�. of Date of inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate at wells within 100' - I� f f • R3 _ 4 3 A,S - �� -'-►Z' ,t DEPTH TO GROUND WATER: Depth to groundwater: fi.dQ,feet k Method of deterin on or approximative: ............................................................................ .......................................... ......:....:.:....:........:.. ........................................................ a17 TOWN OF BARNSTABLE LOCATION? �� SEWAGE # VILLAGE �� i�ca�i1c��c��i ASSESSOR'S MAP & LOT 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: r 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 ?' V) M M Y � e