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HomeMy WebLinkAbout0685 IYANNOUGH ROAD/RTE 28 - Health 685 Iyannough/Rte 132 Hyannis A = 311 - 009 - 's E w `I o i i I i 1 I i Q (� W 1 Commonwealth of Massachusetts f Executive Office of Environmental Affairs Department of Environmental Protection William F.Weld Governor Trudy Coxe S.a Izy,ECEA ' David B. Struhs Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM MAP# 3�' PART A PAR# a0 ,� — CERTIFICATION Cape Bank Property Address: Lamplighter Motel Rte 132 Hyannis Address of Owner: SO• ,,'T Date of Inspection: e?`;z?- y3— (if different) Name of Inspector: James Sears Company Name, Address and Telephone Number: A & R Canco 350 Main Street West Yarmouth, MA 02673 (508) 775-2800 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 Signature: �� P—, � Date: n/ 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 of the Department of Environmental Protection. The original should be sent to the system owner and cople� wni to the buyer, ii applicable and the approving authority. INSPECTION`! SUMMARY: Check A, B, C, or D: A] SYSTEM PASSES: e R�cE� iV p '3 OCT 6 1995 I have not found any information which indicates that the system violates any of the failure c e.Tia as defined in 310 CMR 15.30 Any failure criteria not evaluated are indicated below. YMWOF8NGt BIF y WAR DEPE B] SYSTEM CONDITIONALLY PASSES: One or more system components need to be replaced or repaired. The system, upon completion oft lac meet or.repair, passes inspection. 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, 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. (rev,sed 8/15/95) 1 line Winter Street a Boston, Massachusetts 02108 a FAX(617)556-1049 a Telephone(617)292-5500 A %Jf Printed on Recycled Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Owner: Cdp Date of Inspection: B] SYSTEM CONDITIONALLY PASSES (continued) 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 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 the public health, safety and the environment. 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 SAFETY AND THE ENVIRONMENT: I� Cesspool or privy is within 50 feet of a surface water Al 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 APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: JV The system nas a septic tank and suii ausorptiun sysiem and is within 100 fCei to a surface water supply or trbutary 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. _H The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. N The systen, has a septic tank and soil absorption system and 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. D] ,SY/STEM FAILS: /V I have determined that the system violates one or more of the following failure 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 correct the failure. 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. (revised 8/15/95) 2 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A / CERTIFICATION (continued) Property Address: Owner: Date of Inspection: D] SYSTEM FAILS (continued): 1✓ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. P d- 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. I✓ 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. 1✓ 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: 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 compliance 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. (revised 8/15/95) 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: �`s IP/ 1 3)- Owner: Date of Inspection: Check if the following have been done: Pumping information was requested of the owner, occupant, and Board of Health. None of the system components have been pumped for at least two weeks and the system has'4en 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. ✓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. All system components, excluding the Soil Absorption System, have been located on the site. 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. V The size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods. PVThe facility idnd occupants, if different fron-, o,,ner; •,•.•ere prodded wi;h information on the proper maintenance of Sub- Surface Disposal System. (revised 8/15/95) 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: �S T�j(�� Owner: C/po j- Date of Inspection: a `%s FLOW CONDITIONS RE)f1o L: De : all s Nue oms: Nucurve sidents:_ Gander a or no):— Laundry cted to stem (yes or no):_ Sea (yes or no):� Wr readings, if available: Last date of occupancy: V N/�/IiJ 6v COMMERCIAUINDUSTRIAL: Type of establishment: ` Design flow:__gallons/day Grease trap present: (yes or no) A✓ A Industrial Waste Holding Tank present: (yes or no)_ / Non-sanitary waste discharged to the Title 5 system: (yes or no)�" /V Water meter readings, if available: Last date of occupancy: OTHER: (Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: 't`a S /LL CLcs�� /vv P✓,,��,,�� i•� dos Y R' ma System pumped as part of inspection: (yes or no)_ �Vc ✓ �iZ If yes, volume pumnPd 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) Other (explain) APPROXIMATE AGE of all components, date installed (if known) and source of information: PrAwr Sewage odors detected when arriving at the site: (yes or no) -�D£Pr (revised 8/15/95) 5 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C y SYSTEM INFORMATION (continued) Property Address: G Owner: Date of Inspection: � SEPTIC TANK:_VfS (locate on site plan) Depth below grade: 7 0 Material of construction: 1,/concrete _metal _FRP —other(explain) Dimensions: 0-" ti Ar Sludge depth: 2 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:_ Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, struct ral integrity, evidence of leakage, etc.) C v✓r/L S o'' QE k w Gif'/1D F s�' j i✓ P�//c L -7,g.�� 47— •il"f�i•�.c Lt"✓t L GREASE TRAP:_ SV N (locate on site plan) Depth below grade: Material of construction: _concrete _metal _FRP _other(explain) Dimensions: Scum thickness: Distance from top of scum to too of outlet tee or baffle: Distance from bottom ­i­ - hnttnm of outlet tee o, haffle 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 8/15/95) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C n SYSTEM INFORMATION (continued) Property Address: �s �`T 3`� Y Y Owner: N p L Date of Inspection: TIGHT OR HOLDING TANK:_ o (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.) DISTRIBUTI OX: (locate.on site plan) Depth of liquid level above outlet invert: Comments: (note if level and distributer; c:;:::', evidence of solids ca nover, evidence of leakage into or out of box, etc.) OJc NG 0C/0-rb �j,i,/jcic moo? P9t'�f�.✓<-PUMP CHAMBER:CHAMBER: /V 0 (locate on site plan) Pumps in working order:(yes or no) Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) (revised 8/15/95) 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: ,` 1�,;_ Owner: CApj 89N4t Date of Inspection: , / SOIL ABSORPTION SYSTEM7(SAS): rS (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: Type: leaching pits, number: leaching chambers, number:_ leaching galleries, number: leaching trenches, number,length: leaching fields, number, dimensions: overflow cesspool, number: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,etc.) o U 2 hl L 0 .0, L L •-Dle Y CESSPOOLS: _ YES (locate on site plan) 1 Number and configuration: (/J ze C Depth-top of liquid to inlet invert: O Depth of solids layer: 2� Depth of scum layer: U Dimensions of cesspool: / _5 Materials of construction: L UC Indication of groundwater: ,fy U infl w (cesspool must be pumped as part of inspection) /'V /'—iLo.v� 7J 'Y Ovi�i 7 ,DiP� ✓hi?! .vcT BL vj I �j ti !E' ;k' C.. ?<rr 6Pie:9f s /ryy y yer- Comments: (note condition of soil, sign; of hydraulic failure, level of ponding, condition of vegetation, etc.) A) G PRIVY: _ (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) (revised 8/15/95) 8 r— - SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: C f)Pz Date of Inspection: 9.)' y S SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' o 0 I i 1 O y=0✓R a F,;75 JF DEPTH TO GROUNDWATER Ai 0 Depth to6oundwater: J�- feet method of determination or approximation: l ef7' #4 L L J• AAIJ u 6- -- TfST- /10Ll IVoT CV OL#Al (revised 8/15/95) 9 r TOWN OF BARNSTABLE COMPLIANCE: CLASS: 1.Marine,Gas Stations,Repair satisfactory 2.Printers BOARD OF HEALTH 3.Auto Body shops S' O unsatisfactory- 4.Manufacturers C°COMPANY & �r� t, (see"Orders") 5.Retail Stores 6.Fuel Suppliers ADDRES 12 lass: 7•Miscellaneous QUANTITIES AND STORAGE (IN=indoors;OUT=outdoors) MAJOR MATERIALS Case lots Drums Above Tanks Underground IN OUT IN OUT IN OUT #&gallons Age Test Fuels: Gasoline,Jet Fuel(A) Diesel, Kerosene, #2(B) Heavy Oils: waste motor oil(C) new motor oil(C) transmission/hydraulic Synthetic Organics: degreasers Mis-t7Z-hTeou 0a �(o� S S0Z, DISPOSAL/RECLAMATION REMARKS: 1. Sanitary Sewage 2.Water Supply a y let4 S Town Sewer *ublic O On-site OPrivate 3. Indoor Floor Drains YES-No O Holding tank:MDC O Catch basin/Dry well O On-site system 4. Outdoor Surface drains:YES NO ORDERS: O Holding tank:MDC :Catch basin/Dry well O On-site system 5.Waste Transporter Name of Hauler Destination Waste Product YES NO 1. 2. Person(s) In a wed nspector / Date TOWN OF BARNSTABLE QM�'�n v uT SEWAGE #LOCATION IP7 VILLAGE l / ASSESSOR'S MAP&LOT i// °o Y INSTALLER'S NAME&PHONE NO._ _R©�£� /P�$f SEPTIC TANK CAPACITY fi n r--3 LEACHING FACILITY: (type) pPkf c4;r ��TS 1 iJ( L:5U NO.OF BEDROOMS BUILDER OR OWNER /�/4P /eC�l��t- AO fG PERMTTDATE: ;i' S �' 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//N c o 0 �Q .. .,y, � � :. . o ��► � �