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HomeMy WebLinkAbout0079 ISLAND AVENUE - Health 79 ISLAND AVENUE Hyannis — 025 a o 0 i � e i 'y /5 TOWN OF BARNSTABLE LOCATION SEWAGE# VILLAGE l� l�hN�S f�l�— ASSESSOR'S MAP&PARCEL INSTALLER'S NAME&PHONE NO. �) C� 'G ✓ 5 Cc �i��, v SEPTIC TANK CAPACITY U y— G LEACHING FACILITY:(type) '� (size) NO.OF BEDROOMS OWNER PERMIT DATE: J—ly /3 COMPLIANCE DATE:3 -?—z Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY T i v � fig v Y No. 2-p l-z_�' 0 y ` 4 0 �Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 01pplitation for Mispo8AY *pstrm Construttiun 3permit. Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑Complete System Individual Components Location Address or Lot No. -M 'S,Ctdlfi KV IP- Owner's Name,Address,and Tel.No. Assessor's Map/Parcel �Cp 015- J)�. 1..41(. NC( s, Gc%6, � Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. 1 'T0N Ind Q U- Type of ilding: I ` ` Dwelling No.of Bedrooms / Lot Size L . 1� �_1465sq.ft. Garbage Grinder(NO) Other Type of Building 96 ar\}-1 No.of Persons Showers( ) Cafeteria(N®) Other Fixtures Design Flow(min.required) -77 0 gpd Design flow provided -71 o gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank 1 ,000 2.0 Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) 1 e C. ($'1'°c 6 0 1, 000 1 Vc, -\/cL/ (A/ L/ -(` 2.0 Date last inspected: 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 Certificate of Compliance has been issued by this Board Signed Date �- Application Approved by Date r r y Application Disapproved b Date for the following reasons Permit No. Z063— Date Issued all /"e 3 No. �1 OSN Fee / W� THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes ' Zipplitatlon for !Disposal 6pstem Construction Permit Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑Complete System Individual Components Location Address or Lot No. -711 LS 1tan4�, K V E: Owner's Name,Address,and Tel.No. I Assessor'sMap/Parcel �Cp d2� / � �UD�i(\ 1tG�.� , CA 16 Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. Type of uilding: Dwelling No.of Bedrooms -7 Lot Size ' .' �CF essq.ft. Garbage Grinder(WO) Other Type of Building ��C(�� (G�� No.of Persons.,'- Showers( ) Cafeteria(140) Other Fixtures Design Flow(min.required) -(7 7 o gpd Design flow provided 7 1 o gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank orv, 1 2n Type of S.A.S. Description of Soil ; Nature of Repairs or Alterations(Answer when applicable) q,(.0 E ( 0 0 0 0 V w W w 2 ; G 4 Date 1 t inspected: 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 Certificate of Compliance has been issued by this Board dt Signed Date �— `7 Application Approved by i/ Date Application Disapproved Date for the following reasons Permit No. Zola` ORS Date Issued g 9 17'Or-, . ----------------------- �t e THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS , Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(� Upgraded( ✓� Abandoned( )by _i �� tM A-(6J 1 S at L C Q(V has been constructed in accordance with the provisions of Title 5 and-the for Disposal System Construction Permit No.7e%3,-0%y dated Installer 7&o�.; t e t 11 D - Designer #bedrooms Approved design flow gpd The issuance of this permit shall not§e construed as a guarantee that the system-;ill nctdon' `lssde 'gned. Date `->, c�/i Inspector I. ._------. ... -. __ - ---,-/--. -_____..___.----._----_-_.- - -- _ --. __.---.-_ •_•- -_ .. __ _- ---------.------- No.Zb r ,27 — 09�"1 Fee;6/ W THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -BARNSTABLE,MASSACHUSETTS Misposal 6pstem Construction Permit Permission is hereby ranted to Construct Repair Upgrade Abandon � Y-7g ( ) P lV l Pg ( ) ( ) , System located at TC( 15LAA)b 606 "" Q i S and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Co truction must be completed within three years of the date of this pe it. _ Date /Zp/ ?� Approved b y COMMONWEALTH OF MA SSAGHUSETTS q. EXECUTJV;E OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION i TITLE.5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS' SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION - Back System#lrof 2 Property Address: 79 Island Avenue Mannisport.m 02647 Owner's Name: Richard Lublin` Owner's Address: Y Date of Inspection: March 21 203 Name of Inspector: (Please Print)James Ford Company Name: _ James Ford Mailing Address: P.O.Box 49 Ost Mille MA 02655-0049 Telephone Number: (508)862-9400 S CERTIFICATION STATEMENT . I certify that I have personally inspected thetsewage disposal system at this address and that the info ation reported below is true,accurate and complete as of the time of the inspection. The inspection Was performed,b sed on m4, M. training and experience in the proper function and maintenance of on site sewage disposal systems:ry-I am.a DEP . � approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15:000). The system. * ✓ Passes `s? C 'tionally Passes 00 N eds Further Evaluation by the Local Approving Authority s F' ils Inspector's Signature: Date: March 18. 2013 The system inspector shall sub i a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of complet g 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. *note The systein appears to be partly in the neighbors yard. The board of health was notified and Notes and Comments Inspected andpii ssed it. The owners and buyers should be aware of.this. 5 ****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 Fonn 6/15/2000 I Page i � I Page 2 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 79 Island Avenue H annis ort MA Owner: Richard Lublin Date of Inspection: March 18 2013 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: ✓ I have not found any information which indicates that any of the failure criteria described in 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. 310 CMR Comments: B. System Conditionally Passes: 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. 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 p (whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is'structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old'is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will 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 obstructi©n is removed f ND explain: A y 2 l i Page 3 of 11 OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM g' PART A CERTIFICATION (continued) Property Address: 79 Island Avenue H annis ort,414 Owner: Richard Lublin' Date of Inspection: March 18 2013 C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect 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: F 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: F 3 . • Page 4 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 79Island Avenue Hvannisnort MA Owner: Richard Lublin Date of Inspection: March 18 2013 1{ D. System Failure Criteria applicable to all systems: You must indicate either"yes"or"rid'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 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 gistribution 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 pipe(s). Number of times pumped ✓ Any portion of the SAS,cesspool or privy is below high ground water elevation. ✓ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ✓ Any portion of a cesspool or privy is within a Zone 1 of a public well. ✓ Any portion of a cesspool;or privy is within 50 feet of a private water supply well. ✓ 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 conform 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.] No (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15:303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large System: i 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 nitiogen 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 tho 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: 79Island Avenue Hvannisnort MA Owner: Richard L Win Date of Inspection: March 18 2013 Check if the following have been done: Ytiumust indicate"yes"or"no"as to each of the following: i. 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? Y ; ✓ Have large volumes of water been introduced to the system recently or as part of this inspection? My 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? 5� 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 baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of fhe 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)]. qi } 5 Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C a SYSTEM INFORMATION Property Address: 79 Island Avenue Hy mnisnort°MA Owner: Richard Lublin Date of Inspection: March 18 2013' FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 7-2 systems total Number of bedrooms(actual): 7 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 770 Number of current residents: 0 `. !, Does residence have a garbage grinder(yes or no): n/a Is laundry on a separate sewage system(yes or no): N/a [if yes separate inspection required] Laundry system inspected(yes or no): No Seasonal use(yes or no): No Water meter readings,if available(last 2 yeats usage(gpd)): Unavailable Sump Pump(yes or no): No Last date of occupancy: Weekend/summer COMMERCIAL/INDUSTRIAL , Type of establishment: t 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 oi•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): j Pumping Records GENERAL INFORMATION Source of informatiom pumped after the inspection Was system pumped as part of the inspection;(yes or no): Yes If yes,volume pumped: _gallons--How was quantity pumped determined? Reason for pumping: Maintenance TYPE OF SYSTEM s ✓ Septic tank,distribution box,soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no) (if yes,attach previous inspection records,if any) Innovative/Alternative technology.''iAttach 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: Installed on.unknown ' Were sewage odors detected when arriving at the site(yes or no): No 6 ' z Page 7 of 11 ' OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 79 Island Avenue _Hvannisnort',MA Owner: Richard Luhlin Date of Inspection: March 18, 413 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction: _cast iron _40 PVC _other(explain): 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: 20" Material of construction: ✓ concrete_other(explain) _metal _fiberglass _polyethylene If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): certificate) (attach a copy of Dimensions: _ 1000 gal. Sludge depth: S" Distance from top of sludge to bottom of outlet tee or baffle: 30" Scum thickness: 12 Distance from top of scum to top of outlet tee or baffle: 6" Distance from bottom of scum to bottom of outlet tee or baffle: 10" How were dimensions determined: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage„etc:): Tees were resent. There were no signs of 1eeikqcrp. The tank was um ed. GREASE TRAP: None (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.): 7 i Page 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 79 Lsland Avenue H annis Port MA Owner: Richard Lublin 1 Date of Inspection: March 18 2014 r ; TIGHT or HOLDING TANK: None (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: _concrete 5' metal _fiberglass _polyethylene _other(explain): Dimensions: Capacity: allons Design Flow: allons/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: None (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: None (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.): 1� 8 t Page 9 of 11 i� OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 791sland Avenue Hyannisnort.MA Owner: Richard Lublin Date of Inspection: March 18 2013 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) 4 re Q ) If SAS not located explain why: Type ✓ leaching pits,number: 6'x6'1000 kaL 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.): The pit h2L&T and clean. There was no si n o ailure.Bottom to grade was 9.5. The cover was S"down. CESSPOOLS: None (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no):,; Comments (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: None (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.): 9 a i. Page 10 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 79 Island Avenue Hvannisnort'MA Owner: Richard Lublin Date of Inspection: March 18 2013 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 fq'e( Locate where public water supply enters the building. L sick, 6 rQ ,oi ' Q ► 33� ;1 3 �- 39 as 3 s3 ao 3 q 10 1, Page 11 of 11 g OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 791sland Avenue Hvannisnort,MA Owner: Richard Lublin, Date of Inspection: March 18 2M SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 2_0 _; `feet Please indicate.(check) all methods used to determine the high groundwater 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 Heali'h-explain: tonogranhic and water contours mans Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: s, You must describe how you established the;high ground water elevation: Usin Barnstable to o ra hic and water contours ma s the ma s were showin a roximatel 20'+/_to round water at this site. This report has been prepared only for�th�! septic system and components described herein. This septic system has been inspected and passed as of the date of inspection. This report is not a warranty or guarantee that the system will function properly in the future. There have been no warranties or guarantees,either expressed, written or implied, relating to the septic system,the inspection, this report and%r any components of the septic system which have not been located and inspected. a 11 y ` COMMONWEALTH OF MASSACHUSETTS ` EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF:ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS . SUBSURFACE.SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Front System#2 Property Address: 79 Island Avenue Hyannisnort.MA 02647 '24 /1 Owner's Name: Richard Lublin' Owner's Address: Date of Inspection: March 2.1, 2013 Name of Inspector: (Please Print)James Ford Company Name: James Ford , Mailing Address: P.O.Box 49 Osterville,MA( 02655-0049 Telephone Number: (508)862-940.I1 t, 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: ✓ asses Conditionally Passes eds.Further Evaluation by the Local Approving.Authority Is -4 Inspector's Signature: Date: Marcli 18, 2013:' Lv cO �y The systeminspecior shall s b t a copy of t tis inspection report to the Approving Authority(Boardof health or DEP)within 30 days of comp ng this inspection. If the system is a shared system or has a design flowof 10,000 t 11 gpd or greater,the inspector and the system O"er shall submit the report to the appropriate regional office of the y DEP. The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. t s �j W Notes and Comments r— � ""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 Fonn 6/15/2000 page 1 e S � i Page 2 of 11 ti OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 79 Island Avenue Hvannisport.AAA Owner: Richard Lublih Date of Inspection: March 18, 2013 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: ✓ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. i Comments: B. System Conditionally Passes: s; 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. a ; Answer yes,no or not determined(Y,N,ND)in'the for the following statements. If"not determined",please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years gold is available. fi 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: 2 1' Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 791sland Avenue Hvannisport.MA Owner: Richard Lublin Date of Inspection: March 18, 2013 C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect 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 withih 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 taFilc 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 I 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: s a 3 Page 4 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM 1' PART A CERTIFICATION (continued) Property Address: 79Island Avenue Hvannisport.MA Owner: Richard Lublin Date of Inspection: March 18, 2013 D. System Failure Criteria applicable to all systems: You must indicate either"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 ✓ 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%z 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 SAS,cesspool or privy is below high ground water elevation. ✓ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ✓ Any portion of a cesspool or privy is within a Zone 1 of a public well. ✓ Any portion of a cesspool or privy is within 50 feet of a private water supply well. ✓ 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.] No (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large System: To be considered a large system the syste&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. 4 o : Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B y CHECKLIST Property Address: 79 Island Aveh'ae Hvannisnort.MA. Owner: Richard Lublin Date of Inspection: March 18. 201.3 q� 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? N/a Were as built plans of the isystem obtained and examined?(If they were not available note as N/A) ✓ Was the facility or dwelling inspected for signs of sewage back up? F. ✓ _ 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 baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? { ✓ _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes No ✓ _ Existing information. Forsexample,a plan at the Board of Health. ✓ Determined in the field(iftiany of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)]. r ill ,i 5 a I � ; Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTIO N FORM PART C SYSTEM INFORMATION Property Address: 79Island Avenue Hvannisport.MA Owner: Richard Lublin; Date of Inspection: March 18, 2013 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): _ 7-2 systems total Number of bedrooms(actual): 7 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 770 Number of current residents: 0 Does residence have a garbage grinder(yes or no): n/a Is laundry on a separate sewage system(yes;or no): N/a [if yes separate inspection required] Laundry system inspected(yes or no): Noy i. Seasonal use(yes or no): No Water meter readings,if available(last 2 years usage(gpd)): . Unavailable Sump Pump(yes or no): No Last date of occupancy: Weekend/summer COMMERCIALANDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): s 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: Was system pumped as part of the inspection(yes or no): If yes,volume pumped: gallons--How.was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM Septic tank,distribution box,soil absorption system Single cesspool Overflow cesspool a 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: Installed on unknown Were sewage odors detected when arriving at the site(yes or no): No 6 Y Li Page 7 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SE`VVAGE DISPOSAL SYSTEM INSPECTION FORM ' PART C SYSTEM INFORMATION (continued) Property Address: 79Island Avenue Hvannisnort,MA Owner: Richard Lublim Date of Inspection: March 18, 2013 h BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction: _cast iron _40 PVC _other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: ✓ (locate on site plant',. Depth below grade: 16" Material of construction: ✓ concrete _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: 1500 Qal.H-20 Sludge depth: 0" Distance from top of sludge to bottom of outlet tee or baffle: 0" Scum thickness: " Distance from top of scum to top of outlet tee or baffle: if 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 baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): A new H-20 tank was installed. The system"is in the drive way. Steel covers are to grade GREASE TRAP: None (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: 4: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): n, 7 + F Page 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 79 Island Avenue Hvannisport.MA Owner: Richard Lublin. Date of Inspection: March 18, 2013 TIGHT or HOLDING TANK: None (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 I"; 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 swii'Aes,etc.): DISTRIBUTION .BOX: None (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: None (locate on site plan) a� 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.): S 9 C. 8 r ti Page 9 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEW, AGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 79Island Am me Hvannisnort.MA Owner: Richard Lublin Date of Inspection: March 18, 2013 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type ✓ leaching pits,number: 4'x6'6001 gal.H-20 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.): The nit was dry and clean and in the drive wav There was no sign offailure Bottom to grade was 8.5.A steel cover to grade was installed. - CESSPOOLS: None (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: _ Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: None (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.): S 9 i Page 10 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 791sland Avenue Hvannisnort.MA Owner: Richard Lublin'' Date of Inspection: March 18 20i'3i1 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. U Fr-an�' 4 A , , Q o a - �JbriV t wAj (3 O 3 a as as 3 3s 3y I 10 3 - . :d Page 11 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 79 Island Avenue Hvannisport,MA Owner: Richard Lublin Date of Inspection: March 18, 2013 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 20' 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 Healih=explain: topographic and water contours mans Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain.; You must describe how you established the,high ground water elevation: Using Barnstable topographic and water contours mans, the maps were showing approximately 20'+/-to ground water at this site. 4 II This report has been prepared only for the septic system and components described herein. This septic system has been inspected and passed as of the date of inspection. This report is not a warranty or guarantee that the system will function properly in the future. There have been no warranties or guarantees,either expressed, written or implied, relating to the septic system, the inspc'cteon, this report and/or any components of the septic system which have not been located and inspected. 11 t h syST�,M, 6� a GA(lk Sys -t,-A TOWN OF BARNSTABLE LOCATION ^LSIAINJ Ave SEWAGE# ' < VILLAGE A)iAM1 S T ASSESSOR'S MAP&PARCEL Z S INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY.(type) ��� (f jrtj (size) NO.OF BEDROOMS OWNER (y I/\ PERMIT DATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet o< �3 FURNISHED BY � a ► A (3 3 39 as 3 s3 ao g sysraM a of a. FroAr syM/A TOWN OF BARNSTABLE LOCATION I AV SEWAGE# VILLAGE J�jAMIA QM_ASSESSOR'S MAP&PARCEL INSTALLER'S NAME&PHONE NO. J SEPTIC TANK CAPACITY nW LEACHING FACILITY:(type) `'rT G (size) a S 1�A. NO.OF BEDROOMS OWNER PERMIT DATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY �, d4 3 J d � G � d 1 O O ! W �1 Y I � p