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HomeMy WebLinkAbout0057 KENNEDY CIRCLE - Health 57 Kennedy Circle, Hyannis P 267118,, III d 1 e 1 �y I� „I Q lip t �I a Commonwealth of Massachusetts W Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments i'i' ✓�� C�r'✓ "Property Address �--� j 6A �OV Owner Owner's Name / � S ✓ l o information is required for every Gt vJ t j U �d 6 O page. City/Town State Zip Code Date of Irispection / .e Inspection results must be submitted on this form. Inspection forms may'not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information on the computer, use only the tab 1. Inspector: key to move your / cursor-do not use the return a✓�� O �// key. Name of Inspector Company Name /C) Company Address ---- — �/ --- /� v C7 6 City/Town L3�0.�?=C� State Zip Code Telephone Number License Number B. Certification i certify that I have personally inspected the sewage disposal g p 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 srn a DEP approved systern Inspector pursuant to Section 15.340 of Title 5(310 15.000). The system: Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority Inspecto s Signature Date e The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system 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. ****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. t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 �� Y v Commonwealth of (Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments c'" � �Y2✓1 yJ g L" � Ccr Property Address Owner Owner's Name I .5 a✓OVA information is required for every _ / n Q �q�tAt f page. LAY/I own State Zip Code Date of I specti B. Certification (cont.) ob Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) 7em P es: have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)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 old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 Commonwealth of Massachusetts F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,A In 4 Property Address Y( �r Owner Owner's Name information is required for every Q✓t 41 t Q� (� aLl page. City/Town C7 State Zip Code Date of I spect on Bo Certification (cunt.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if Pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ 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 f=l Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ 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 ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 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. I. 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 surtace water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage /Disposal System Form - Not for Voluntary Assessments Property Address /✓ Owner S V},s Name a rc�v" information is Owner required for every A a✓t H! page. City/Town State Zi Code P Date o Inspec ion B. Certification (cont.) 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. [I 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 fecal coliform bacteria indicates absent 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: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No" to each of the following for all inspections: Yes No ❑ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ElStatic 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 t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments C Property Address Owner Owner's Name information is /�/7 / required for every _ ��✓�� �f Oa 6 0� a- page. City/I own State Zip Code Date of nspection Bo Certification (cont.) Yes No ❑ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ Ly' 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. ❑ [9 Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ D-3//"" Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ EI 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 fecal coliform bacteria indicates absent 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 and ain of custody must be attached to this form.] he system is a cesspool serving a facility with a design flow of 2000gpd- ❑ 10,000gpd. ElThe 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 Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd_ For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. 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. t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Oft Title 5 official Inspection Form Subsurface Sewage/Disposal System Form -Not for Voluntary Assessments M Property Address Owner 4'��G S ��✓7 mat Owner's Name ') / information is every required for eve / 4�✓1 f I page. City/Town State Zip Code Date of Inspecti n C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes ❑ P ing information was provided by the owner, occupant, or Board of Health ❑ re any of the system components pumped out in the previous two weeks? ❑ ��s the system received normal flows in the previous two week period? �ve large volumes of water been introduced to the system recent) or as art of ❑ Y v p this inspection? 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 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 en determined based on: ❑ 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(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 3 30 t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M S7 A-eoPie c/ Property Address G J G✓c9v Owner Owner's Name information is ' required for every G,n h/I 69 a o 1 a /,;L i page. City/Town State Zip Code Date of Inspection D. System Information Description: 0 ffDo Number of current residents: Does residence have a garbage grinder? ❑ Yes No Is laundry on a separate sewage system? (Include laundry system inspection information in this report.) ❑ Yes D No Laundry system inspected? ❑ Yes Seasonal use? Yes ❑ No Water meter readings, if available(last 2 years usage(gpd)): Detail: Sump pump? ❑ Yes No Last date of occupancy: Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins.doc-rev.6/16 ,Tdiie 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address Owner G S 4✓0V Owner's Name CA information is 4 /�f required for every G V1adll / /� oa 6 o f page. City/Town State Zip Code Date of In pecf n D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: !Q��2_0 Was system pumped as part of the inspection? ❑ Yes o If yes, volume pumped: gallons How was quantity pumped determined? ------ __ Reason for pumping: Type of Sys Septic tank, distribution box, soil absorption system 0 Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �14 -e C/ Property Address / Ct r n�C­� S Owner Owner's Name information is � �required for every q ✓1 �J page. City/Town6CEF Date of Inspectio Do System Information (cont.) Approximate age of all components, date installed if known)and source of informatio Were sewage odors detected when arriving at the site? ❑ Yes No Building Sewer(locate on site plan): Depth below grade: / feet Material of construction: ❑ cast iron 40 PVC ❑ other(explain): Distance from private water supply well or suction line: to feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below gr V feet Materia construction: concrete [:] metal ❑ fiberglass ❑ ether ex ain polyethylene ( p! ) y ❑ If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 01 Sludge depth: — 7 t5ins.doc•rev.6/16 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for VoluntaryAssessments {/ram //./1No c// ents Property Address Owner G S G✓4Vc� Owner's Name information is o d bO/ / required for every (,�i/JvJ(f / r page. City/Town a State ZipCode Date of I spect n D. System Information (cont.) Septic Tank(cont.) l✓ Distance from top of sludge to bottom of outlet tee or baffle 3c� Scum thickness L e sj !� Distance from top of scum to top of outlet tee or baffle Q Distance from bottom of scum to bottom of outlet tee or baffle U 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.): g y' (4 V rim oJC/ / Aov1, /l/b Grease Trap(locate on site plan): Depth below grade: feet 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: Date t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of V Commonwealth of Massachusetts N W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address Owner S .9 rDV� Owner's Name information is �q required for every page. City/Town State Zip Code Date of In ectio D. System nformation (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank roust be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene El other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address Ale", Owner �' S G✓O(/� Owner's Name / information is required for every Oc) 6 V I c)— a2 a�AV/if I / page. City/Town State Zip Code Date of In pectio D. System Information (cont.) Distribution Box(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(locate on site plan): Pumps i��working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form -Not for Voluntary Assessments c S , Property Address Owner Owner's Name / information is //� v required for every yt h lS � 6 / � �,/ / page. City/Town State Zi Code p Date of Inspection ®o System Information (coot.) Type: y 1-1 leaching pits / number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: --- --- ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): 40 v-1 o , Cesspools (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 ❑ No t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments C4M 'yeye ��v I Property Address Owner Owner �GS a✓0(/G� 's Name information is required for every g,�✓1tI �j ��(��� 02 a I page. City/Town State Zip Code Date of Inspection Do System Information (coot.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.):. 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.): t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 r Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage DisposalSystem Form - Not for Voluntary Assessments A_fe Property Address / IY/l V/ / Owner G S A 0 v l� Owner's Name / 0 4 t l information is �� required for every r page. City/Town State Zip Code Date of I pecti D. System nformation (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two anent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where p is water supply enters the building. Check one of the boxes below: hand-sketch in the area below ❑ drawing attached separately I n A b k� sr t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address /Y Owner S G/-0✓c� Own e r s N ame ,yA !!'' information is C/ required for every � I 6 Q � � a page. �clI wn State Zi Codep Date of I pection System nformation (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells �b Estimated depth to high ground water: feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ served site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health -explain: c':�2S ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must desc/rib how you established the high ground water elevation: OV I^ G 01 r �d /(ia �0 -t64 J, l0G a C'l Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins.doc-rev.6/16 Title 5 Official Inspection form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments l / Property Address Owner Owner's Name information is required for every Q Y1 k1 IS page. City/Town State Zip Code Date of I pecti in E. Report Completeness Checklist Inspection Summary:A, B, C, D, or E checked 2"1Ins ectio ummary D(System Failure Criteria Applicable to All Systems)completed L� S em Information — Y n Estimated depth to high groundwater Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins.doc•rev.6/16 Title 5 official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 F %IZ3 � O COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL A -t&j S L DEPARTMENT OF ENVIRONMENTAL PROTECTION t i0AP it• LOT TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A C�A� CERTIFICATION Property Address: 57 Kennedy Circle West Hyannisport Owner's Name: Bernard Garbauskas Owner's Address: Date of Inspection: 8/11/2004 Name of Inspector: (please print) Patrick T. Sullivan Company Name: Ready Rooter Mailing Address: P.O. Box 371 Sandwich,MA 02563 Telephone Number: (508)888-6055 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The System: Passes Conditionally Passes Needs Further Evaluation by the Local Authority Fails Inspector's Signature: �rr.� Date: The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. Notes and Comments ****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. ' Page 2 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 57 Kennedy Circle West Hyannisport Owner: Bernard Garbauskas Date of Inspection: 8/11/2004 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D C. System Passes: __t,Xhave not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section eed to be replaced or repaired.The system,upon completion of the replacement or repair,as approved by a Board of Health,will pass. Answer yes,no or not determined (Y,N,ND)in the for the following s tements. If"not determined"please explain. The septic tank is metal and over 20 years old*or the septic tan whether metal or not) is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure ' imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved b the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, of 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 hig static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven istribufion box. System will pass inspection if(with approval of Board of Health): broken p' e(s)are replaced obstruc on is removed distri tion box is leveled or replaced ND explain: The system required pumping mo than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the oard of Health): broken pipe(s)are replaced obstruction is removed ND explain: Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 57 Kennedy Circle West Hyannisport Owner: Bernard Garbauskas Date of Inspection: 8/11/2004 C. Further Evaluation is Required by the Boar/Ba th: Conditions exist which require further evaluhe Board Health in order to determine if the system is failing to protect public health,safety or the envi 1. System will pass unless Board of Health s" accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner wh otect public health,safety and the environment: Cesspool or privy is within 50 feet of aaterCesspool or privy is within 50 feet of a vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if an y determines that the system is functioning in a manner that protects the public health,safety and env' onment: _The system has a septic tank and soil absorption system(SAS)and the AS 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 Z ne I of a public water supply. _The system has a septic tank and SAS and the SAS is within 0 feet of a private water supply well. _The system has a septic tank and SAS and the SAS is le than 100 feet but 50 feet or more from a private water supply well". Method used to determine di ance "This system passes if the well water analysis,perfo ed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that th ell is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen i equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis in st be attached to this form. 3. Other: Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 57 Kennedy Circle West Hyannisport Owner: Bernard Garbauskas Date of Inspection: 8/11/2004 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No Z Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool �L Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool o/ Static liquid level in the distribution box above outlet invert due to and overloaded or clogged SAS or cesspool Liquid depth in cesspool is less than 6"below invert or available volume is less than day flow _1Z Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped v! Any portion of the SAS,cesspool or privy is below high ground water elevation. 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 50 feet of a private water supply well. e/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 forma t30(Yes/No)The system fails. I have determined that one or more of the above 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 Systems: To be considered a large system the system must serve a facility with a desi 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 a ove) yes no the system is within 400 feet of a surface drinking water pply the system is within 200 feet of a tributary to a surfac drinking water supply the system is located in a nitrogen sensitive area nterim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Sectio E the system is considered a significant threat,or answered "yes"in Section D above the large system has fail .The owner or operator of any large system considered a significant threat under Section E or failed under ection D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the propriate regional office of the Department. Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 57 Kennedy Circle West Hyannisport Owner: Bernard Garbauskas Date of Inspection: 8/11/2004 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 Z Were any of the system components pumped out in the previous two weeks? Has the system received normal flows in the previous two week period? Have large volumes of water been introduced to the system recently or as part of this inspection? _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) _ 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 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 than 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)] Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 57 Kennedy Circle West Hyannisport Owner: Bernard Garbauskas Date of Inspection: 8/11/2004 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): Z3cD 6•�?�. Number of current residents:�Z Does residence have a garbage grinder(yes or no): Is laundry on a separate sewage system(yes or no):Qra[if yes separate inspection required] Laundry system inspected(yes or no): Seasonal use:(yes or no):._ e6e Water meter readings,if available(last 2 years usage(gpd)):Zszj=�'a �G,�,TJ, Sump Pump(yes or no):&) Last date of occupancy: C�, COMMERCIALANDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,et . Grease trap present(yes or no):_ Industrial waste holding tank presen yes or no): Non-sanitary waste discharged to e Title 5 system(yes or no): Water meter readings,if availa e: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: c`V-g=rj.� v3 Was system pumped as part of the inspection(yes or no): � If yes,volume pumped:gallons--How was quantity pumped determined? �-- Reason for pumping: b 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) _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 install d(if known)and source of information: Were sewage odors detected when arriving at the site(yes or no): '� Page 7 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 57 Kennedy Circle West Hyannisport Owner: Bernard Garbauskas Date of Inspection: 8/11/2004 BUILDING SEWER(locate on site plan) Depth below grade: _ Materials of construction:_cast iron v*14'0 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: ©" 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: i x x �; Sludge depth:_ ? " Distance from the top of sludge to bottom of outlet tee or baffle: Scum thickness: q rl Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: How were dimensions determined: v�3�,%,Z, r,�.•, �`i �•���e Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): I SCJ,-Z� GA e �Ja�iL c�/ :�n\t"Cr w..�L b�"CL�'� l.v.r ► lo'" la�l oc�J GREASE TRAP:_(locate on site plan) Depth below grade:_ Material of construction,_concrete_metal_fibergla _polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of ou/age,etc.): Distance from bottom of scum to botto baffle: Date of last pumping: Comments(on pumping recommendatlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 57 Kennedy Circle West Hyannisport Owner: Bernard Garbauskas Date of Inspection: 8/11/2004 TIGHT or HOLDING TANK: (tank must be pumped at time of' spection)(locate on site plan) Depth below grade: Material of construction: concrete_metal_fiberglas _polyethylene_other(explain): Dimensions: Capacity: /switches, Design Flow: Alarm present(yes or no): Alarm level: Alarm in o): Date of last pumping: Comments(condition of alarm an DISTRIBUTION BOX: (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: <0"1- Comments(not if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): ..I� �`�G../�, c� c�V�:� $7 C..l.r.r.�1 _C9U� J' 4J d— �n,'�v.l,� w•LL�`l��-..,r— PUMP CHAMBER: (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,conditio of pumps and appurtenances,etc.): d Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 57 Kennedy Circle West Hyannisport Owner: Bernard Garbauskas Date of Inspection: 8/11/2004 SOIL ABSORPTION SYSTEM(SAS): �- (locate on site plan,excavation not required) If SAS not located explain why: Type 4zleaching pits,number: leaching chambers,number: leaching galleries,number: leaching trenches, number, length: leaching fields,number,dimensions: overflow cesspool,number: innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation, etc.): r <---Q 7' o'er d,y ✓jk=) S`,T CESSPOOLS: (cesspool must be pumped as part of i 'ection)(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 no): Comments(note condition of soil, si s of hydraulic failure, level of ponding,condition of vegetation,etc.): PRIVY: (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of by ulic failure,level of ponding,condition of vegetation,etc.): Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 57 Kennedy Circle West Hyannisport Owner: Bernard Garbauskas Date of Inspection: 8/11/2004 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. a3 � ko ,� ;t ` S Z Z r r! J o. O 4s. \9, Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 57 Kennedy Circle West Hyannisport Owner: Bernard Garbauskas Date of Inspection: 8/11/2004 SITE EXAM Slope Surface water Check cellar L- ^ Shallow wells Estimated depth to ground water feet Please indicate(check)all methods used to determine the high ground water elevation: _A�btained from system design plans on record—If checked,date of design plan reviewed: J"•/ % "7Y Observed site(abutting property/observation hole within 150 feet of SAS) Checked with the local Board of Health-explain: Checked with local excavators, installers-(attach documentation) _LG"Accessed USG Sdatabase-explain: You must describe how you established the high ground water elevation: dam© G fi TOWN OF BARNSTABLE LOCATION SEWAGE # VILLAGE ASSESSOR'S MAP 6& LOT���� l� - y INSTALLER'S NAME & PHONE NO. Gfa- r- ruty ( �; tea; _ • YY Y, SEPTIC TANK CAPACITY j LEACHING FACILITY:(type) P)re,60 1^Vi — (size) !!6" t -� NO. OF BEDROOMS PRIVATE WELL O . 12&I�C-R T?E' .}, BUILDER OR-OWNER Ow' ,,- I•-�eG v vha.foc-� DATE PERMIT=`ISSUED: DATE_ COMP,LIANCEbISSUED; VARIANCE GRANTED: Yes ' No .2r w K THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Applirativit for UinVngal WorliB (famitrnrtinn 11amit Application is hereby made for a Permit to Construct ( ) or Repair (�_<an Individual Sewage Disposal System at: ........... ------ -------------------- G :S _ Y t................... L cation-i\ddkrss or Lot No. : ..._._.:.. :_ ... - rf P " Installer Address Type of Building 3 Size Lot............................Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building ____________________________ No. of persons---------------------------- Showers ( ) — Cafeteria ( ) a' Other fixtures _______________________________ _ _ W Design Flow............. ...............gallons per person per day. Total daily flow------- _` C _........ ---------gallons. WSeptic Tank—Liquid capacity.....__....gallons Length................ Width................ Diameter_------------- Depth................ x Disposal Trench—N - -------------------- Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No..______L........___ Diameter..__._.) _�_. Depth below inlet___-_�....._. Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) ►-' Percolation Test Results Performed by.......................................................................... Date------------------------------•-•••--- Test Pit No. I________________minutes per inch Depth of Test Pit-------------------- Depth to ground water........................ 44 Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water..._-__.___-.__---_-___. a ----------------------:...................................................................................................................................... 0 Description of Soil......................................................................................................................................................................... x x ---------------- ------------------------------------------------------------------------------------------------------------------ U Nature of Repairs or Al rations=Answer,when applica le._-.� r� i� c � } t � ........ 1 ar ----------------------------------------------------------------•---•---- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance ee ssued y the r health. Signe .....,--------- ----- --------- ---------- - - ---- ------------------------------------- - Date Application Approved By ----------- - -- ----------------------------------- ---- ---- .....//}re- r Date Application Disapproved for the following reasons- ---------------- ---------------------------------------------------------------------------------------- ----------------------------------------------------------------f--------------------- Permit No. Issued af.' ". `... P... ��te...... --------'�.......... ..... .. ........ Dare THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE C9er#ifirate of Compliance THIS IS TO CERTIFY, That.the Individual Sewag�Disposal Systein,constructed ( ) or Repaired by _...... ....... - -... :.� .: `.. ...... l' ... .. .-- i------- --�..�C— ' ----------- ------------------------------------------------------------------ ,_, 14 Installer at -----------------...._----- -....._-----. . ..----------t`--rvL,Vl-z- ... :,.c-c:.. ...-------------------l`=C'Y c-----------------------------------....-------- has been installed in accordance with the provisions of TITI. of The State Environmental Code as described in the application for Disposal Works Construction Permit No. _.-. .�. r,- --. ...... dated THE ISSUANCE OF THIS CERTIFICATE SHALL N T BE CON STRUA AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATEZI. ... _.... - - ... ... Inspector -----------------------------------.............................----------... ------------------------------------------------------------ -------------� THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 7 TOWN OF BARNSTABLE �. No ..j.......... FEE --- Dispos t (Works/.Tongtr ion!parAi/ Permission is hereby granted .`. 7.......((, - _.__...•=--=`•--.'.11( .................._.............................................. to Construct ( ) or Repair (-�)—a.n-Individual Sewage Disposal System at No.. •- !�• ` ` •... . C--� �� 1- --- •----- 1�{��_-v l----------------- F as shown on the application for Disposal Works Construction Permit o!� ✓. Dated..---/ `1"...'.. ..- -. ._ Board ofHealth DATE ........ ----- --•----------------••-- FORM 36508 HOBBS&WARREN.INC..PUBLISHERS THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Appliratinn for Dijpmml Wnrk,i Cnnnitrnr#inn rrrntit Application is hereby made for a Permit to Construct ( ) or Repair (�-<an Individual Sewage Disposal System at ...........:`a=.......-�...�. �r----G.L-' .�------•-- ----------------------- (t, ,• .S__ . . ................... L cation-Address or Lot No. �...t W 1 y} ! i j� Owner C > Y 11 /��l ru ..... 0� . l� l Y 1 a � / / l Addres / $4 i.._-•... ------ --!.... .... --- -••-••......---•.............. ........•-•-.. ----• = Installer ` Address VType of Building 3 Size Lot............................Sq. feet 0-4 Dwelling— No. of Bedrooms-----__•________•___________________________Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ---------------------------- No. of persons............................ Showers ( ) — Cafeteria ( ) P4 Other fixtures W Design Flow............. -------------- per person per day. Total daily flow_.___..����''D___................gallons. WSeptic Tank—Liquid capacity-__._--_----gallons Length________________ Width---------------- Diameter................ Depth................ x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. ��Seepage Pit No--------J........... Diameter.......Z. ----- Depth below inlet......_--......... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) 0-4 Percolation Test Results Performed by.......................................................................... Date........................................ 0.4 a Test Pit No. I--------------_minutes per Inch Depth of Test Pit-------------------- Depth to ground water........................ (i Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ P4 ....-•••••-------------------•-•-•----------------------••••---•-•-•-•--••-•-••••••••--••---............-•••-•------••----•••-••-•...._--••--......----....•. 0 Description of Soil........................................................................................................................................................................ W UNature of Repairs or Alterations—Answer when applicable,-___ L( � _�_`_-_L, �' __S`_f J...........!�u_ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Com e_has�ee-issued by the board of health. Signed -------------C-- � - - ( -� >`l." �'� ... ..-- �"j �` ``- ...............'- Dare I Application Approved By _------� �p��.^�`{.....�`� `� G/` ............. ...... ..... �� '".�� Application Disapproved for„the following reasons: ............................................ ...................... . . .......... .............--...... --------------------------------------------------------------------------------------------------------------------------------------------------------- ---------------------------------------------- ........................................ J Date Permit No. � _1_49 ��r--------------- Issued /`'. --- � --------- Dare