HomeMy WebLinkAbout0147 LAFRANCE AVENUE - Health 147.LAFRANCE AVE
HYANNIS
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OIL IONWEA1r-H OF MASSAC1 jSE'I j`S
Ind EXECIwVE OFFICE OF ENVIROiNMEIN'TAL AFFAIRS
i)EPARTMENT OF ENVIRONMENTAL PROTECTION
s•
TITLE 5
OFFICIAL INSPECTION FORM--NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: L
77
s' 33a�
Owner's Name:_�y e tin Li
Owner's
aLBO
Date of Inspection: — CIS-
Name of inspector:(please print)
Company Name: Orel r( /invtvntit (IVK%,S .'fW
Mailing Address: 6 °
t �k� Oc16 C(f
Telephone Number: 5 V O Z60 f
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 DEF 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 Approving Authority
Fails
Inspector's Signature: Date: 19 05
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 10,00
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.
<i •
Notes and Comments
r..... vim'
-• ice"
****This report only describes conditions at the time of inspection and under the conditions of us at that-rl r
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 Form 6/15/2000 page i
Page 2 of 11
OFFICIAL INSPECTION FORD--NOS'FOR VOI.,UNTARy ASSESSMENTS
SUBSURFACE SEWAGE DISFOSAL'SYSTEM INSPECTION FORM
FART A
CERTIFICATION(continued)
Property Address: o kwe A.-C
Owner: 40%
Date of inspection: Co I j(oS
Inspection Summary: Check A,B,C,D or E/ALWAYS complete an of Section D
A. System Passes:
I have-not found any information which indicates that any of the failure criteria described in 310 CNW
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 n to be replaced or
repaired.The system,upon completion of the replacement or repair,as approved by oard of Health,will pass.
Answer yes,no or not determined(Y,N,ND)in the for the following ments.If"not determined"please
explain.
The septic tank is metal and over 20 years old*or the se ' tank(whether metal or not)is structurally
unsound,exhibits substantial infiltration or exfiltration or tank ure is imminent.System will pass inspection if the
existing tank is replaced with a complying septic tank as- ved by the Board of Health.
*A metal septic tank will pass inspection if it is structura sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is a ' le.
ND explain:
Observation of sewage backup or b out or High stag water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken,settl or uneven distribution box.System will pass inspection if(with
approval of Board of Health):
b gipe(s)are.replaced
structioa is Temoved
distribution box is leueled or replaced
ND explain:.
The system requir pumping more than 4 times a year due to broken or obstructed pipe(s).The system will
pass inspection if(with proval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain:
2
Page 3 of 11
OFFICIAL INSPEC a ION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: /y C ,�V<
Owner: zoK
Date of Inspection: S
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 15303 b)that the
system is not functioning in a manner which will protect public health,safety and the vironment:
_ 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 sa marsh
2. System will fail unless the Board of Health(and Public Wa r Supplier,if any)determines that the
System is functioning in a manner that protects the public he th,safety and environment:
_ The system has a septic tank and soil absorption s tem(SAS)and the SAS is within 100 feet of a
surface water supply or tributary to a surface water s ply.
— The system has a septic tank and SAS and a SAS iswithin a Zone 1 of a public water supply.
— The system has a septic tank and SAS d the SAS is within 50 feet of a private water supply well.
_ The system has a septic tank and AS and the SAS is Iess than 100 feet but 50 feet or more from a
private water supply well**.Metho used to determine distance
"This system passes if thew water analysis,performed at a DEP certified laboratory,for coliform
bacteria and volatile organi ompounds indicates that the well is free from pollution from that facility and
the presence of ammonia itrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
failure criteria are tri red.A copy of the analysis must be attached to this form.
3. Other:
w'
3
Page 4 of is I
OFFICIAL INSPECTION F®RM'w-NOT.FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DHWQSAI STEM INSPECTION FORM
FART..A-
CERTINCATION'(cominued)
Property Address:
Owner: y —
Date of Inspection:_ ho
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all inspections:
Yes No
_ X 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
4�_ 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 I of a public well.
_ Any portion of a cesspool or privy is within 50 feet of a private water supply well.
Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis.fnis system passes if the well water.analysis,
performed at a DEP certified laboratory,for coliferm bacteria and volatile organic conqmmeds
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 S.ppm,provided that no other.Wure criteria
are triggered.A copy of the analysis must be attached to this form.)
(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 Systems:
To be considered a large system the system must serve a facility with estgn now of 10,000 gpd to 15,000
gpd• b
You must indicate either"yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to th a above)
yes no
the system is within 400 feet of a surface g water supply
_ the system is within 200 feet of a to to a surface drinking water supply
the system is located in a nitro sensitive area(interim Wellhead Protection Area—IWPA)or a mapped
Zone 11 of a public water y well
If you have answered"yes"to any estion in Section E the system is considered a significant threat,or answered
"yes"in Section D above the lar system has failed.The owner or operator of any Iarge system considered a.
significant threat under Sectio or failed under Section D shall upgrade the system in accordance with 310 CMR
15.304.The system owner ould contact the appropriate regional office of the Department.
4
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Page 5 of l i
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address:
Owner:_
Date of Inspection:
Check if the following have been done.You must indicate"yes"or"no"as to each of the following:
Yes No
Pumping information was provided by the owner,occupant,or Board of Health
Were any of the system components pumped out in the previous two weeks?
Has the system received
yst i ed normal flows in the previous two w �— p week period .
Have large volumes of water been introduced to the system recently or as part of this inspection?
t _ Were as built plans of the system obtained and examined?(If they were not available note as N/A)
_ Was the facility or dwelling inspected for signs of sewage back up?
Was the site inspected for signs of break out?
Were all system components,excluding the SAS,located on site?
_ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition
o the ba#Iles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum?
AL
_ Was the facility owner(and occupants if different from owner)provided with information on the proper
in tenance 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
-.ik- — 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 CUR 15.302(3)(b)]
5
Page 6 of I I
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
17
Property Address: m 0..0
is
Owner: �µ
Date of Inspection:_ �
fo/S off`
�—RESIDENTIAL FLOW CONDITIONS
Number of bedrooms(design): J7 Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms):
Number of current residents: &
Does residence have a garbage grinder(yes or no):
Is laundry on a separate sewage system(yes or no):-Zb [if yes separate inspection required]
Laundry system inspected(yes or no):kV
Seasonal use:(yes or no):/D
Water meter readings,if available(last 2 years usage(gpd)):
Sump pump(yes or no): 00
Last date of occupancy: 03
COMMERCIAIANDUSTRIAL
Type of establishment:
Design flew(based on 3I0 CMR I5.203): gpd
Basis of design flow(seats/persons/sq c.):
Grease trap present(yes or no):
Industrial waste holding tank p ent(yes or no):—
Non-sanitary waste dischar to the Title 5 system(yes or no):
Water meter readings,if ailable:
East date of occupant use:
OTHER(descri ):
GENERAL INFORMATION
Pumping Records
Source of information:
Was system pumped as part of the inspection(yes or no): N
If yes,volume pumped:_gallons—How was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM
)C 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 installed(if known)and source of information:
.41 J 7 zoo
Were sewage odors detected when arriving at the site(yes or no):14)
6
Page 7 of H
OFFICIAL .INSPECTION FORD—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
tt SYSTEM INFORMATION(continued)
Property Address: Cq"?
Owner: pV
Date of Inspection:_ fb j, y
BUILDING SEWER(locate on site plan) .
Depth below grade: oZ ( a
Materials of construction:_cast iron of 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: 0( (locate on site plan)
Depth below grade: p w
Material of construction:�c concrete metal fiberglass_polyethylene
—other(explain)
If tank is metal list age:— Is age confirmed by a Certificate of Compliance
certificate) P (yes or no):__ (attach a copy of
Dimensions:
Sludge depth:
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:— 6
Distance from bottom of scum to bottom of outlet tee or baffle,
How were dimensions determined: PA "w-wJ
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet' vert,evidence o'f leakage, )_
eA .
GREASE TRAP:_(locate on site plan)
Depth below grade:
Material of construction:_concrete_meta fiberglass_polyethylene_other
(explain):
Dimensions:
Scum thickness:
Distance from top of scum to to of outlet tee or baffle:
Distance from bottom of sc to bottom of outlet tee or baffle:
Date of last pumping:
Comments(on pump' recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels
as related to outlet ' vert,evidence of leakage,etc.):
7
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Page&of 1 i
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
Owner:_��+w�.
Date of Inspect@on•--
TIGHT or]HOLDING TANK; (tank must be pumped at time o inspection)(locate on site plan)
Depth below grade:
Material of construction: concrete metal rglass_polyethylene other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallo day
Alarm present(yes or no):
Alarm level: Alarm in orking order(yes or no):
Date of last pumping:
Comments(condition of and float switches,etc.):
DISTRIBUTION BOX; b/C (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert:106ti
Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of
leakage into r out of box,etc.):
4X Was 1'evet Ec Ics 4 so &t aw Ac,S k O ca 42�4
PUMP CHAMBER: (locate on site plan)
Pumps in working order(yes or no):.
Alarms in working order(yes or no):
Comments(note condition of pum ber,condition of pumps and appurtenances,etc.):
8
Page 9 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SE*AGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: y) le
o •s
Owner: R
Date of Inspection:
SOIL ABSORPTION SYSTEM(SAS): /0 (locate on site plan,excavation not required)
If SAS not located explain why:
Type
leaching pits,number:_
_ leaching chambers,number: `(
leaching galleries,number:
leaching trenches,number,length:
leaching fields,number,dimensions:
overflow cesspool,number
innovative/altemative system Type/name of technology:
Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation,
etc.):
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 groundw er inflow(yes or no):
Comments(note co ition 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 co ition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
9
1
Page 10 of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: /4(7 Lp, i,, oce n t: X., -
4-4 S
Owner: ��n
Date of Inspection: Q �p J
SKETCH OF SEWAGE DISPOSAL.SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or
benchmarks.Locate all wells within 100 feet_Locate where public water supply enters the building.
36 6°
�g
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an - ,
Pa:e 11 of 11
OFFICIAL INSPECTION FORM—NOT FOIE VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: q 7 L. �GKM
(116F
Owner: Kew"
Date of Inspection: LJ O
SITE EXAM
Slope W.
Surface water k)O
Check cellar 04.45
Shallow wells 4�
Estimated depth to ground water 940 feet
Please indicate(check)all methods used to determine the high ground water elevation:
Obtained from system design plans on record-if checked,date of design plan reviewed:
Observed site(abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health-explain:
Checked with local excavators,installers-(attach documentation)
_ Accessed USGS database-explain:
You must describe how you established the high ground water elevation.
0 SCE' -S t,�- e l e J�
11
EG
TOWN OF BARNSTABLE
LOCATION SEWAGE # 2
VILLAGE / �/GZ'`?`I/`S ASSESSOR'S MAP &'LOT. Z-70
INSTALLER'S NAME&PHONE NO. A91 '�O 7/"
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) Zw4iL iaa�5a'3 � �_ (size) 10'IY
NO.OF BEDRMOR
_
BUILDER O ,,
PERMITDATE: COMPLIANCE DATE: M y
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) 4 4 Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by 60t
Reams'
VON
i�
P®�f
' .
Z-70-05 6Q
No. mo__&D Fee /
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
ZippCication for Mi!gpool *p!tem (Construction Vertu
Application for a Permit to Construct( )Repair( y)Upgrade( )Abandon( ) T Complete System 1:1 Individual Components
Location Address or Lot No. p, J Owner'sTN7e, dress and Tel.No.
Assessor's Map/Parcel
Installer's Name,Address,and Tel.No./r Designer's Name,Address and Tel.No.
Azo_heze,�o)
7
Type of Building:
Dwelling No.of Bedrooms 17 Lot Size sq.ft. Garbage Grinder( �
Other Type of Building Rio.of Persons Showers( ) Cafeteria( )
Other Fixtures Design Flow // gallons per day. Calculated daily flow 172
311�9 gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank / Type of S.A.S.
Description of Soil 457
Nature of Repairs or Alterations(Answer when applicable)
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 Certifi-
cate of Compliance has been issued by is Boar
Signed Date Az l
Application Approved by Date
Application Disapproved for the following reason
Permit No. r Date Issued
°� •_
No. Fee1101,
f
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: �\
- Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
2pprication for Mizpogar *pgtem Construction. Permit
Application for a Permit to Construct( . )Repair Upgrade( )Abandon( ) LJ Complete System El Individual Components
Location Address or Lot No. IzI 7
/ �Q, Owner'sAe.,Zdress Tel.No.
Assessor's Map/Parcel
Installer's Name,Add s,and Tel No.,/ / Designer's Name,Address and Tel.No.
Dr foC��i ceq r�s�`=
7
Type of Building: p
Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( )�
Other Type of Building L�`�� �� No.of Persons Showers( ) Cafeteria( )
Other Fixtures a
~� Design Flow gallons per day. Calculated daily flow J 3� gallons.
Plan Date Number of sheets Revision Date
Title _
Size of Septic Tank ���C 4' Type of S.A.S. ` �� �" ti_-n1
Description of Soil 4�/r3e,,YX /
Nature of Repairs or Alterations(Answer when applicable) r/ /L� lew
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 Certifi-
cate of Compliance has been issued b is Boar f He Ith.
Signed r' ,�i e��+ y,��` Date `
Application Approved by 4_1 / �ilr�/i���?.C�f Date
Application Disapproved for the following reasons _ t
`
o.
Permit N 1/ X Date Issued
THE COMMONWEALTH OF MASSACHUSETTS � �� '-'�7
BARNSTABLE, MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERT ,that the On-site Sf wageDis osal System Constructed( )Repaired(�Upgraded( )
Abandon (L by �D�
at l A- /19 r e has�y een constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. C - l�-'�dated
Installer Designer A cy
The issuance of this re t shall of be construed as a guarantee that the sys�,m-will function designed r
Date A7 s fir# (�C./ Inspector 11:� i! ���1/�- ! � u L Z��i'f ff.4i�� 1 -�
CJ ,
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
33iopogaf 6potem Conotructton Permit
Permission is hereby granted to Construct( )Repair l )Upgrade )Aban on( )
System located at f Z/ 7 Lal r4;Wee 67b A
and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to
comply with Title 5 d the following local provisions or special conditions. f
Provided:Cons cliot mustybe completed within three years of the date of th s e
Date: , �J f l/ Approved by
6/
i `• ll�6199 • ,
NOTICE: This Form Is To Betse'd For the Repair Of Failed
-Septic Systems. Only. -
CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL
WORKS CONSTRUCTION PERMIT(WITHOUT DESIGNED PLANS)
hereby certify that the application for disposal worsts
construction permit signed by me dated 1/�l���� concerning the
property located at meets all of the
following,criteria:
✓ 11he failed system is connected to a residential dweilin only.
,. There are no commercial or business
uses,associated with the dwelling.
/7"ie
soil is classified as CLASS I and the pe.—coiation rate is less than or_quaff ;o minutes xr incl
VThem are no wetlands within 100 feet of he Proposed septic system
7ne:e are no private wells within 1:0 feet of the oroposed septic system
4 acre is no increase in flow and/or change in use proposed
/There are no.variances.requested or needed.
The bottom of the proposed leaching facility will not be located less than Lve feet above she
ma..=um adjusted groundwater table elevation. (Adjust the groundwater table using the:ritaptor
method when aIicable].
/If-the S.A.S. will be located with 250 feet of any vegetated wetlands, the bottom of the proposed
P .
leaching facility will not be located less than fourteen(14) feet above the ma:dtnum adjusted
groundwater table elevation,
Please.complete the following:
A) Top of Ground Surface Elevation(ruing GIS information) 5-3 . Z'
B) G.W.Elevation Zt/,? +the MAX.High G.W. Adjt=ent. Z • _ Z. _
DIFFERENCE BETWEEN A and B 3 Q ,/
SIGNID : DATE:
(Sxtch proper lLaa of"m on back).
I
✓�f �GQP ��If�ry��.�
001 Q
I .
TOWN OF BARNSTABLE
LOCATION l7 SEWAGE #
j VILLAGE ASSESSOR'S MAP & LOT Z�� 1Z�
`. INS.TALLER'S NAME&PHONE NO. bl-�� �J C�,J.5T 7
SEPTIC TANK CAPACITY
LEACI�T"..:G cerrrr rrY; (typs) JGa�Li�a.?5r3 ��� (size) �� 7� �a
NO:OF BEDROO 3
BULL O OWNER ff
PERMITDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility
✓fit' Feet
Private Water Supply Well and Leaching Facility (If any wells exist
i on site or within 200 feet of leaching facility)
Feet
Edge of Wetland and Leaching Facility (If any.wetlands exist
4 Feet
within 300 feet of leaching facility)
Furnished by b�
sel
Lh;
V/1
t r 0C �!F Xe,>a r 3o� �
`v" <000
COMMONWEALTH OF MASACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAI AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
ONE WINTER STREET BOSTON MA 02108(617)292-3500
TRUDY COXE
Secretary
ARGEO PAUL CELLUCCI DAVID B.STRUHS
Governor Commissioner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
Property Address: 147 LAFRANCE AV. HYANNIS, MA 02601 9-10 d
Name of Owner RICHARD AND PRISICILLA CROCKATT
Address of Owner: 4746 EWING RD.CASTRO VALLEY CA.94546-1000
Date of Inspection: 9121/00
Name of Inspector: JOHN GRACI
I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000)
Company Name: SEPTIC INSPECTIONS
Mailing Address: P.O.BOX 2119 TEATICKET,MA.02536
Telephone Number: 508-564-6813 FAX 508-564-7270
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 Evaluat' n By the Local Approving Authority
X Fails
Inspector's Signature: V/ Date: 10/11/00
The System Inspector shall 4mit a copy of this inspection report to the Approving Authority(Board of Health or DEP)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 copies sent to the'buyer,if applicable,and the approving authority.
NOTES AND COMMENTS
"The inspection is based on criteria defined in Title V code 310 CMR 15.303.My findings are of how the system is performing at the time of inspection.M,
inspection does not imply any warranty grguarantee of the longevity of the septic system and any of its component's useful life."
THE SYSTEM FAILS TITLE V INSPECTION. THE STAIN LINES IN BOTH CESSPOOLS INDICATE THE CESSPOOLS HAVE BEEN FULL OVER THI
PIPES,THE CESSPOOLS HAVE NO EFFECTIVE LEACHING LEFT.
• r
1 -f.
revised 9/2/98 Paae 1 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 147 LAFRANCE AV. HYANNIS, MA 02601
Name of Owner RICHARD AND PRISICILLA CROCKATT
Date of Inspection: 9/21100
INSPECTION SUMMARY: Check A, B, C, or,D:
A. SYSTEM PASSES:
I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist.Any failure criteria not
evaluated are indicated below.
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 o
the replacement or repair,as approved by the Board of Health,will pass.
Indicate yes,no,or not determined(Y,N,or ND).Describe basis of determination in all instances. If"not determined",explain why not.
nla The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate of
Compliance attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection;or the
septic tank,whether or not metal,is 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 complying septic tank as approved
by the Board of Health.
n/a Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s)o
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
Wa 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
i4
:S
V, ; 1i
revised 9/2/98 Page 2 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 147 LAFRANCE AV. HYANNIS, MA 02601
Name of Owner RICHARD AND PRISICILLA CROCKATT
Date of Inspection: 9/21/00
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 the public health,
safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 15.303(1)(b)THAT THE SYSTEM I:
NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT ThE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
Cesspool or privy is within 50 feet of 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 AND SAFETY AND THE 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 soil absorption system and the SAS is within a Zone I of a public water supply well.
The system has a septic tank and soil absorption system and the SAS i3 within 50 feet of a private water supply well,
y
The system has a septic tank and soil absorption system and the SAS 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,Method used to determine distance n/a (approximation not valid).
3) OTHER
n/a
revised 9/2/98 Paoe 3 of 11
1
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 147 LAFRANCE AV. HYANNIS, MA 02601
Name of Owner RICHARD AND PRISICILLA CROCKATT
Date of Inspection: 9/21/00
D. SYSTEM FAILS:
You must indicate either"Yes"or"No"to each of the following:
X I have determined that one or more of the following failure conditions exist as described 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.
Yes No
X _ Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool.
_ X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool.
_ X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
- X Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow,
_ X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped n/a.
_ X Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation.
- X Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
_ X Any portion of a cesspool or privy is within a Zone I of a public well.
_ X Any portion of a cesspool or privy is within 50 feet of a private water supply well,
- X 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.
f
E. LARGE SYSTEM FAILS:
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:
The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health
and safety and the environmerit'because one or more of the following conditions exist:
Yes No
- X the system is within 400 feet of a surface drinking water supply
_ X the system is within 200 feet of a tributary to a surface drinking water supply
X 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 upgrade the system in accordance with 310 CMR 15.30412). Please consult the local regional office of
the Department for further information.
revised 9/2/98 Paoe 4 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 147 LAFRANCE AV. HYANNIS, MA 02601
Name of Owner: RICHARD AND PRISICILLA CROCKATT
Date of Inspection: 9121100
Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following:
Yes No
X _ Pumping information was provided by the owner,occupant,or Board of Health.
X _ None of the system components have been pumped for at least two weeks and-the system has been receiving normal flow rates during that
period.Large volumes of water have not been introduced into the system recently or as part of this inspection.
X As built plans have been obtained and examined. Note if they are not available with N/A.
X The facility or dwelling was inspected for signs of sewage back-up.
X _ The system does not receive non-sanitary or industrial waste flow.
X _ The site was inspected for signs of breakout.
X _ All system components,excluding the Soil Absorption System,have been located on the site.
X _ The septic tank manholesuwere 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.The size and location of the Soil Absorption System on the site
has been determined based on:
X _ Existing information,For example,Plan at B4O,H,
a,
X _ Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable) 1 5.302(3)(b)]
X _ The facility owner(and occupants;if different from owner)were provided with information on the proper maintenance of SubSurface Disposal
Systems.
tv
M
revised 9/2198 Paoe 5 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 147 LAFRANCE AV. HYANNIS, MA 02601
Name of Owner RICHARD AND PRISICILLA CROCKATT
Date of Inspection: 9/21100
FLOW CONDITIONS
RF_SIDENTIAI
Design flow: 110 g.p.d./bedroom
Number of bedrooms(design): 3 Number of bedrooms(actual): n/a
Total DESIGN flow: 330 gpd
Number of current residents:0
Garbage grinder(yes or no):NO
Laundry(separate system)(yes or no): NO If yes,separate inspection required
Laundry system inspected(yes or no): NO
Seasonal use(yes or no): NO
Water meter readings,if available(last two year's usage): n/a gpd
Sump Pump(yes or no): NO
Last date of occupancy: 9/4/00
COMMERCIAL/INDUSTRIAL
Type of establishment: nla
Design flow: n/a gpd(Based on 15.203)
Basis of design flow:n/a
Grease trap present:(yes or no): NO
Industrial Waste Holding Tank present:(yes or no): NO
Non-sanitary waste discharged to the Title 5 system:(yes or no):NO
Water meter readings.if available: n/a
Last date of occupancy:n/a
OTHER: (Describe)
n/a
GENERAL INFORMATION
PUMPING RECORDS and source of information:
n/a
System pumped as part of-inspection:(yes or no):NO
If yes,volume pumped n/a gallons
Reason for pumping:n/a
TYPE OF SYSTEM
X 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)
I/A Technology etc.Attach copy of up to date operation and maintenance contract
_ Tight Tank Copy of DEP Approval
Other: n/a
APPROXIMATE AGE of all components,date installed(if known)and source of information:
1971
Sewage odors detected when arriving at the site:(yes or no), NO
revised 9/2/98 Paae 6 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 147 LAFRANCE AV. HYANNIS, MA 02601
Name of Owner RICHARD AND PRISICILLA CROCKATT
Date of Inspection: 9121/00
BUILDING SEWER:X
(Locate on site plan)
Depth below grade: 24"
Material of construction: _ cast iron _ 40 Pvc X other(explain)
Distance from private water supply well or suction line: n/a
Diameter: n/a
Comments: (condition of joints,venting,evidence of leakage,etc.)
TOWN WATER
SEPTIC TANK: X
(locate on site plan)
Depth below grade: 18"
Material of construction: X concrete_ metal_ Fiberglass_ Polyethylene_ other
explain: n/a
If tank is metal,list age Is age confirmed by Certificate of Compliance(Yes/No): NO
Age: n/a
Dimensions: 5'X 5'BLOCK CESSPOOL"
Sludge depth: n/a
Distance from top of sludge to bottom of outlet tee or baffle: n/a
Scum thickness: n/a
Distance from top of scum to top of outlet tee or baffle: 24"
Distance from bottom of scum to bottom of outlet tee or baffle: n/a
How dimensions were determined: MEASURED
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.) '�U
THE SYSTEM FAILS-THE OVERFLOW CESSPOOL HAS BEEN FULL AND IS PAST THE EFFECTIVE DEPTH OF LEACHING.
GREASE TRAP: _
(locate on site plan)
Depth below grade: n/a
Material of construction: _concrete_ metal_ Fiberglass _ Polyethylene_other
Explain: n/a
Dimensions:n/a
Scum thickness: n/a
Distance from top of scum to top of outlet tee or baffle: n/a
Distance from bottom of scum to bottom of outlet tee or baffle n/a
Date of last pumping: n/a
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.)
nla
f a
Ar,
i
revised 9/2/98 Paoe 7 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 147 LAFRANCE AV. HYANNIS, MA 02601
Name of Owner RICHARD AND PRISICILLA CROCKATT
Date of Inspection: 9121100
TIGHT OR HOLDING TANK: _ (Tank must be,pumped prior to,or at time of,inspection)
(locate on site plan)
Depth below grade: n/a
Material of construction: _concrete_ metal_Fiberglass _Polyethylene _other
Explain: n/a
Dimensions: n/a
Capacity: n/a gallons
Design flow: n/a gallons/day
Alarm present: NO
Alarm level:NIA Alarm in working order:NO
Date of previous pumping: n/a
Comments:
(condition of inlet tee,condition of alarm and float switches,etc.)
n/a
SL .
DISTRIBUTION BOX:_
(locate on site plan)
Depth of liquid level above outlet invert: n/a
Comments:
(note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.)
n/a
PUMP CHAMBER: _
(locate on site plan)
Pumps in working order:(Yes or No): NO
Alarms in working order(Yes or No): NO
Comments:
(note condition of pump chamber,condition of pumps and appurtenances.etc.)
n/a
revised 9/2/98 Pane 8 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 147 LAFRANCE AV. HYANNIS, MA 02601
Name of Owner RICHARD AND PRISICILLA CROCKATT
Date of Inspection: 9121/00
SOIL ABSORPTION SYSTEM(SAS): X
(locate on site plan,if possible;excavation not required,location may be approximated by non-intrusive methods)
If not located,explain:
n/a
Type:
leaching pits,number:(n/a)n/a
leaching chambers,number: (n/a)n/a
leaching galleries,number: (n/a)n/a
leaching trenches,number,length: (n/a)n/a
leaching fields,number,dimensions: (n/a)n/a
overflow cesspool,number: (1)5'X 5'BLOCK CESSPOOL
Alternative system: n/a
Name of Technology: n/a
Comments:
(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.)
THE OVERFLOW CESSPOOL IS PAST THE EFFECTIVE DEPTH OF LEACHING,THE STAIN LINES INDICATE THE CESSPOOL HAS BEEN FULL
OVER PIPE.
CESSPOOLS: _
(locate on site plan)
Number and configuration: n/a
Depth-top of liquid to inlet invert: n/a
Depth of solids layer: nla
Depth of scum layer. n/a
Dimensions of cesspool: n/a
Materials of construction: n/a
Indication of groundwater: n/a inflow(cesspool must be pumped as part of inspection)NO
Comments:
(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.)
n/a
PRIVY:
(locate on site plan)
Materials of construction: n/a Dimensions: n/a
Depth of solids: n/a
Comments:
(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.)
n/a
1w '
revised 9/2/98 Page 9 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 147 LAFRANCE AV. HYANNIS, MA 02601
Name of Owner RICHARD AND PRISICILLA CROCKATT
Date of Inspection: 9/21100
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent reference landmarks or benchmarks
locate all wells within 100'(Locate where public water supply comes into house)
50
revised 9/2/98 Facie 10 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 147 LAFRANCE AV. HYANNIS MA 02601
Name of Owner RICHARD AND PRISICILLA CROCKATT
Date of Inspection: 9/21/00
NRCS Report name: n/a
Soil Type: n/a
Typical depth to groundwater: nla
USGS Date website visited: n/a
Observation Wells checked: NO
Groundwater depth: Shallow_ Moderate_ Deep_
SITE EXAM _ Slope
_ Surface water
_ Check Cellar
Shallow wells
Estimated Depth to Groundwater 10 Feet+
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from Design Plans on record
Observed Site(Abutting property,observation hole,basement sump etc.)
Determined from local conditions
Checked with local Board of health
_ Checked FEMA Maps
Checked pumping records
Checked local excavators,installers
X Used USGS Data
Describe how you established the High Groundwater Elevation.(Must be completed)
USGS MAPS AND CHARTS-10+FEET
i.
revised 9/2/98 Paoe l l of 11