Loading...
HomeMy WebLinkAbout0015 LINDA LANE - Health 15 Linda Lane Hyannis A=248-224 COMMONWEALTH OF MASSACHUSETTS ExECUTNE OFFICE OF ENVIRONMENTAL AFFAIRS �(�t3 DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE S OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: l5 Li A&_ Owner's Names tcc,(\ f? Owner's Address: oq 2 a Date of Inspection: Name of Inspector.(please print) Company Name: William E. Robinson Septic Service Mailing Address: P O Box 1089 Centerville. MA ^� Telephone Number: (508) 775-8776 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the informah n reported. below is true accurate and complete as of the time i e inspection w — p m of the inspect on.Th as 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 I5.340 of Title 5(310 Ct1IR 15.000). The system: t' Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Heanhw DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 16,000 gpd or greater,the inspector and the system owner shalt submit the report to the appropriate regional office of the DEP.The original should be seat to the system owner and copies sent to the buyer,if applicable,and the approxing 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. Title 5 Inspection Form 6/15/2000 page I r , w r Page 2 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SENVAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property.Address: Lk j Owner: ► ` �(�U t ` Date of Inspection: t1 jo Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. Sy em Passes: a I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exisL 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. Answer yes,no or not determined(Y,N,ND)in the for the following statements.if"not determined"please explain. The septic tank is metal and over 20 years old*or the septic tank(whether meta;or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. •A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to-broken or obstructed pipes)or due to a broken,settled or uneven distribution box.System will pass inspection if(with approval of Board of Health): broken pipes)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to bmkm or obstmcted pipes).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is rcmovw ND explain: Pag e3ofll OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 15 Q f\60 �n,. Owner: Date of Inspection: V ;v C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and theenvironment: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 4 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 be21th,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. _ The system has a septicatank and SAS and the SAS is within a Zone l 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 front a private water supply well— Method used to determine distance ••This system passes if the well water analysis,performed at a D£P certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other " failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other. m - , 3 r Page 4 of l l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: t 1 Owner: Dale of Inspection: tv L x 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 Static liquid level in the distribution box above.outlet invert due to an overloaded or clogged SAS or cesspool _ _✓Liquid depth in cesspool is less than b"below invert or available volume is less than%day(low v'Required pumping more titan 4 times in the last year NOT due to clogged or obstructed pipc(s).Number of times pumped _ t% 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 or 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 fret from a private water supply well with no acceptable water quality analysis.(This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.) Lam' (Yes/No)The system fails.I have determined that one or more o(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. . t"a E. Large Systems: To be considered a large system the system must serve a faci!ity with a design flow of 10,000 gpd to 15,000 gpd- You must indicate either"yes"or"no"to each of the following: ("I7te following criteria apply to large systems in addition to the criteria above) yes no — the system is within 406 feet of a surface drinking water supply _ ` the system is within 200 feet of a tributary to a surface drinking water supply w the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area--IWPA)or a mapped Zone 11 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 fatted.The U%Mcr or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. 4 c Q ti Page 5 of 1 I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: Owner: !HCUI'tiC VN , 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 f i �-/ 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 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? T 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 stze and location of the Soil Absorption System(SAS)on the site has been determined based on: sT Yes/n0 _✓ _ Existing information.For example,a plan at the Board of Health. Determined in the field(if any of the failure criteria related to Part Cis at issue approximation of distance is unacceptable)13 10 CMR 15.302(3)(b)] 5 Page 6oflt OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 5 c1bn_'VL_ t Owner• f 1Cl.a't G� u Date of Inspection: :v a,--c FLOW CONDITIONS RESIDENTIAL, y Number of bedrooms(design): Number of bedrooms(actual): .73 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x I#of bedrooms): v '� Number of current residents: / Does residence have a garbage grinder(yes or no):A O Is laundry on a separate sewage system(yes or no): [if yes separate inspection required) Laundry system inspected(yes or no):_f Seasonal use:(yes or no): ,v* 1 Water meter readings,if available(last 2 years usage(gpd)): 1 IOD� o`�S�O " Sump pump(yes or no):✓s' Last date of occupancy: COMMERCIAUINDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no). Industrial waste holding tank present(yes or no):— Non-sanitary waste discharged to the Title 5 system(yes or no):_ Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Was system pumped as part of the inspection(yes or no): ` If yes,volume pumped: — allons—How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM ✓Septic tank,distribution box,soil absorption system _Single cesspool Overflow cesspool Privy _Shared system(yes or no)(if yes,attach previous inspection records,if any) _Innovative/Altemative 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: Were sewage odors detected when arriving at the site(yes or no): 6 OFFICIAL INSPECTION i;otw—NO•I- FOR VOLUNTARY ASSLSSNILNTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION DORM t'ART C SYS•I LI'lI INFORMATION(comuwcd) Property Address: 15 UI(1( 17-L1VTt S Date of Inspeetlon: BUILDING SE1VE11(locate un site plan) 3 mot"Dcpdt below grade: ' Materials of construction:_cast iron ✓'40 PVC_odicr(cxplaut): Distance Gom privale scaler supply well or suction line:_ Coru»cnts(on conditiun of juints,Veiling,evidence of leakage,Etc.): SEPTIC TANK: ✓' (lucate on site plan) Depth below grade: it f �o.c:' "f ju• F,r L�fiz J Material of eonstructiun:_cuncicic n►etal fiberglass_polyedi}•leiie _u►hci(cxplain) — — If tank is metal list age:_ Is age confirmed by a Cenibcatc u(Cuugtfiance (ycs or nu):—(anach a copy of certificate) Dimensions: rSTrZ` L� j fa ,s. Sludge depth: ' Dislanee front top of Sludge Io buuum of Mid1ec or bafltc: ' ` Scurn thickness: I" Distance front top of—scull,to wp of uutict ice or bafltc: _�, Distance Gom buuum of scum to buuum of uutict tee or baffle: z Ilow were dinicnsions delcrniincd: �Pwd re�tr „L Comments(on pumping r e c of ittic nJ atioirs,inlet and outlet tee ur ba(ltc cunditit,tt,strut tut al intcp ty,Iiituid I C v C I% as related 10 uutict invert,evidence of Ieakage,Etc.): "'•tttJ ' RS'3'- js�„='�v`::v �_ ��3�5 rld9� .PLC.:� �i7 �+f 11-�.ic ��� ��*:J. _ i-{rt-�. �o.,f•- ��tav1 �c.: �,tc �,• �-3 y zz,; , -- _ GREASE TKAI."V�( cane un site plan) Depth below grade:_ Material of eonstruchun:____concrete uulcl fiberglass Iiul}ediylene Witt- (Explain): — Dintcnsions: Scum thickness: Distance Gom top of scum to lop of uulicl Icc or ba(llc:Distance from bullum of scum to buuum of uutict icc or b_afltc: Dalc of last pumping: Cununenls(on pumping reconuncndatiuns,ililet anti 01,1116 tcc ur bafltc condittc-:t,structural integrity,liquid Icvd3 as related to oullcl instil,evidence of leakage,etc.): 7 ],age 8 of I I r , OI.IFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSL••SSNIENTS SUUSUIVACL SLWAGL DISPOSAL SYSTLNLINSPLCTION FORNI 'ART C SYSTEM INFORMATION(continued) rropertyAddress: « �� �� Owner: Ualc of lospcc f� TIGHT or HOLDING TANK: /(ark must be purnpcJ at ti"it of iospcction)(tucatc oil site plan) Depth below grade: hlatcrial of construction:,_•__concrete_utctal_fiberglass_))ofyctl►ylcnc otlrcr(cxplain). Dimensions: Capacity: eaIlons Design flow; gallurrs/Jay Alarm present(yes of no): Alarm level: Alarm.in svurkim order Date of last pumping: 6 (J-cs or nv): Cununcrrts(condition of alarm and float swilclres,cit.): DISTRIBUTION I10\:_r (if present must be ol)cned)(loeate orr site plan)' DcpUr of liquid level above uutict imVcrt: C?tt Conuncnts(note if box is level aril distribution to outlets equal,ally cvidcnce of solids carr)-over,any evidence of Icakav intu or out of box,ctc.): vel �t;�'/ L a• �(m;.•) s CG>..:�i�c�7;•,. /t�i .ra ir r!•� A;� 9G 4141r:-4 r, �.� t 0r, rt� f f'��J,I K I'UMP CRAMBLII: A}(locate on site plan) PUMPS in working order(ycs or nu):_ Alanns in working order(ycs or no): Con►►ncnts(uutc condition of pullip chantbcr,tunditiun of pumps and appurtenan(es,cic.): Page 9 of I! OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS I` SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM DART C SYSTEM INFORMATION(continued) Property Address tS Lt owner: Date of Inspection: SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation-not required) If SAS not located explain why: Type leaching pits,number:_ -7 leaching chambers,number. leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number: inn ovative/altemative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): �01 � wa-i :/Ll�s N� '•i. 1J.0 4;.T�-Z's:r�:- ,tiJ �t {}� Y-:.�•,�. �-l�nLc/�;.: {.e.s�v2. 4� 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 or no): 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.): 9 Page 10 of I OFFICIAL INSPECTION FORM=NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL:SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 4`� t'S Owner: N16-v",Ll Date of Inspection: E a � ` 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. n �40056 , j { r fj f� Lei _ 10 Page 11 of"I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: y=) U,- Owner. Date of Inspection: lcs SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water .a� 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 propertylobservation 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: _ fv^wav(l�•..;.iv- C�e.:�[..}z�,.. -tom,,..'-4j..'.c cSi�.�l;s�r.�t �;; C=Gtt,;�l,ti T�k 1�7v--: ��- b.._,���(i 11 Town of Barnstable �p THE Tpk Regulatory Services BARNSUBM ; Thomas F. Geiler,Director Mnss. Public Health.Division Thomas McKean, Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 This septic system inspection report was completed by a private inspector who is certified by the State of Massachusetts, Department of Environmental Protection. Although the Town of Barnstable Health Division received the original/copy of this report; this Division does not warranty the functionality of the septic system in the future not does this Division agree with any technical observation s and interpretations contained within this report. In addition,by receiving this report the Town of Barnstable Health Division does not automatically approve the number of bedrooms listed within this report. The actual number of bedrooms approved at a particular property would-be listed on the"Disposal Work Construction Permit". If you should have any questions regarding this report,please contact the certified Septic System Inspector who conducted the inspection. '' I . I COMMONWEALTH OF MASSACHUSETTS v�s ` EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION /� aq Property Address: 15 Linda Lane _ Hyannis Owner's Name: Louis Cote Owner's Address: ; �+ Date of Inspection: ;71- . Name of inspector:(please print) W i 1 1 i am ._ Robinson sr. Company Name: William E. Robinson Septic Service h Mailing Address: P O Box 1089 Centerville, MA Telephone Number: (508) 775-8776 rn 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/Passes ection 15.340 of Title 5(310 CMR 15.000). The system: Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: „ Date: 06-- 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 seat 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. Title 5 Inspection Form 6/15/2000 page 1 f 1 Page 2 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 15 Linda Lane Hyannis Owner: Louis Cote Date of Inspections Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. Sys m Passes: , 1 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 repaire The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer y s,no or not determined(Y,N,ND)in the for the following statements.If"not determined"please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,a ibits substantial infiltration or exIlltration or tank failure is imminent.System will pass inspection if the existing tai&is replaced with a complying septic tank as approved by the Board of Health. •A metal s ptic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating i hat the tank is less than 20 years old is available. ND expla' O servation of sewage backup or break out or high static water level in the distribution box due torbroken or _ obstruct pipe(s)or due to a broken,settled or uneven distribution box.System will pass inspection if(with approv of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced lain: e system required pumping more than 4 times a year due to broken or obstruTted pgrc(s).The system will pass ins cction if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is rcmoved ND expl in: Page•3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 15 Linda Lane Hyannis Owner: Louis Cote Dale of Inspection: �O- 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 iling to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: _ Cesspool or privy is within 50 feet of a surface water _ Cesspool or privy is 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 sy tem is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. _ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. _ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more front a private water supply well'• Method used to determine distance '*This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and - the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.'A copy of the analysis must be attached to this form. Other: 3 Page 4 or 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 15 Linda Lane Hyannis Owner: Louis Cote Date of Inspection:/.-- — 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 _ Static liquid level in the distribution box above.outlet invert due to an overloaded or clogged SAS or cesspool Liquid depth in cesspool is less than 6"below invert or available volume is less than 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 I00,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 watrr supply well with no acceptable water quality analysis. (This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] (YeslNo)The system fails. 1 have determined that one or more ofthe 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. Large Systems:be considered a large system the system must ser c a facility with a design flow of 10,000 gpd to 15,000 d. ou must indicate either"yes"or"no"to each of the following: 1h a following criteria apply to large systems in addition to the criteria above) es no _ the system is within 400 feet of a surface drinking water supply — the system is within 200 feet of a tributary to a sm-face drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone 11 of a public water supply well If ou have answered"yes"to any question in Section E the system is crosidered a significant threat,or answered "y s"in Section D above the large system has failed.The owner or operator of any large system considered a sig ificant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15 04.The system owner should contact the appropriate regional office of the Department. 4 Page S of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART.B CHECKLIST Property Address: 15 Linda Lane yannis Owner: Louis cote Date of Inspection: Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes No/ _ PPumping information was provided by the owner,occupant,or Board of Health Were any of the system components pumped out in the previous two weeks? Has the system received normal flows in'the previous two week period? t/ Nave large volumes of water been introduced to the system recently or as part of this inspection?:. —7 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 tanl: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? _ �as the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no _ Existing information.For example,a plan at the Board of Health. Determined in the field(if any of the failure criteria related to Part Cis at issue approximation of distance. is unacceptable)[310 CMR 15.302(3)(b)) 5 1 Page 6 of l i OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 15 Linda Lane Hyannis Owner: Louis Cote Date of Inspection: a --9 G 5 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):.J Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x 4 of bedrooms): Number of current residents: Does residence have a garbage ' der(yes or no):A/ Is laundry on a separate sewage system(yes or no):/ fd [if yes separate inspection required] Laundry system inspected(yes or no):w_ Seasonal use:(yes or no):Ae! LT 3 —4 v Water meter readings,if available(last 2 years usage(gpd)): Sump pump(yes or no):k Last date of occupancy: i� COMMERCl/hm UST L Type of establi : Design flow(b 31 CMR 15.203): gpd Basis of designe s/persons/sgft,etc.): Grease trap pre or no):_ Industrial wasttank present(yes or no):Non-sanitary wchatged to the Title 5 system(yes or no):Water meter re if available: Last date of oc /use:OTHER(desc GENERAL INFORMATION Pumping Records Source of information: /V Was system pumped as part of tKe inspection(yes or no) If yes,volume pumped:__gallons--How was quantity pumped determined? Reason for pumping: _ TYP F SYSTEM eptic tank,distribution box,soil absorption system _Single cesspool Overflow cesspool Privy _Shared system(yes or no)(if yes,attach previous inspection records,if any) _Innovative/Altemative 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: Were sewage odors detected when arriving at the site(yes or no):�p 6 Page 7 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 15 Linda Lane Hyannis Owner: Louis Cote Dale or Inspecllon: BUILDINGS V/ER,(Ioo on site plan) Dcpdi below adMaterials o constcast iron 40 PVC_ogler(explain): Distance ont prisupply well or suction lute: Comme is(on conjousts,venting,evidence of leakage,etc.): SEPTIC TANK; (locate on site plan) Depth below grade: ! t Material of construction:_✓concrete metal fiberglass_polyethylene _odscr(cxplain) —' If tank is metal list age:_ Is age confsrnted•by a Certificate of Compliance(yes or no):certificate) —(attach a copy of Dimensions:_/;�j, r Sludge depth:_— el— Distance S-- from top of sludge to bottom of outlet Ice or bank:_g,G, Scum thickness: Distance from top of scum Io top of outlet tee or baffle: Distance Gorn bottom of scum to bottom of outlet ice or baffle:� � / I low were dimensions deter"nsincd: C2 P L f r,v,— ,r,j Comments(on pumping recommendations, inlet and outlet ice or baffle condition,structuual integrity,liquid levels as related to�outlet invert,evidence of leakage,etc.): 110/1 GREASE TRAP:_(locate ' site plan) — Depth below grade:_ Material of eonsimClion: concrete metal fiberglass�tolyellylene__ogler (explain): — — Dimensions: Scull)thickness: Distance front lop f scum to top of outlet Ice or baffle: Distance from b om of scum to bottom of outlet Ice or baffle: Date of last pu ping: Conunents( pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels as related I outlet invert,cvidcncc of leakage,etc.): I 7 'age 8 of I I OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFOIWATION(continued) Property Address: 15 Linda Lane Hyannis Owner: e Date or Inspection: TIGHT or lIOLD G TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below gra C: Material of cons ction:,concrete` metal fiberglass_polycihylene other(explaut): Uimcnsions: Capacity: gallons Design Flow: gallons/day Alarni presc t(yes or no): Alarm level Alann in working order(yes or no):_ Date of las pumping: Conunen (condition of alann and float switches,ctc.): DISTRIBUTION BOX: Z if resent( p must be opcncd)(Iocate on site plan) Dcpih of liquid level above outlet invert: Conunenis(note if box is level and distribution to outlets equal,an)-evidence of solids carryover,any evidence of - leakage into or out of box,cic.): PUMP CHZd Cate on site plan) Pumps in wr no):Alarms in wr no):Comments ump chamber,condition of pumps and appurtenances,eic.): • Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 15 Linda Lane Hyannis Owner: Louis Cote Date of Inspection: G SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why: Type aching pits,number:_ gg leaching chambers,number:(, leaching galleries,number: Teaching trenches,number,length: leaching fields,number,dimensionst&= overflow cesspool,number: innovative/alternative system Type/name of technology: Comments of condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): / , „✓ / e ld �ti r,. if CESSPOOLS: (cesspool must be mped 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 in ow(yes or no): Comments(note condition f 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 conditionj soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): 9 Page 10 of 11 ., OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 15 Linda Lane Hyannis- Owner: Louis Cote Date of Inspection: 6—27--G S' SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building. u � r 1 10 Page I 1 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS -. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 15 Linda Lane Hyannis Owner. Louis Cote Date.of Inspection: SITE EXAM Slope Surface water Check cellar. Shallow wells ) Estimated depth to ground water 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: hecked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: 11 AV -Pane 4 4. Slown 40 wade Pot- 67 >2 10360 31 N , ; (ax, a.d:-- _ . . 0 Cattotta N �7 - - 0� w � 49 V O ZZ; �Pr arec✓ '� .. . . 1Z•LS .. . . ). d, 1/EN7 IZ1 )at It 55a No b 0 3:. Pot 70 - o ~:'no t 6 9 ed i Cow 3 0 qp d sJ.5 .l' vriu aitea_..,.. i %✓o c,�,��y,= 33a x o 74 :9pd -r.- _ `7ata.� _ r j .. .t: 1 all I pbo JOu_L . 1 . o e rl a fp. e'sv[.�►►- y - ems" N 4- Uh.e 6 :h qA c i par-� J-c,te r'Ccuti oR .C'a�ail, in Piya vt�, .. g iot ctoa 't J.. X ei tatzad .:)e i riq -Cot 67 a-: a.lwwn on Can 16 5/14 [tauattosv- r,..n. on.an a4zxwed dcttruti. Jate . .gq'ent: 50a/u. o j; '7r-7a i, !)ctv 11 10-2a-9S �ca.Cn 1 -30 i�eu. I !-$-9 S rl Capei ,cnee�r�u2c �r9 f 1a o�c hoad i ga,2Yt.L],, 0-60 f u LD 03G� Z01 1-2$3 0 , i S7ea.t pit #P-8 S72 :. 0 B=TABLE L ON `—`-'� �-�'� te% SEWAGE # 'Is — WATIE v AA ASSESSOR'S MAP&LOT-?Lea " z z 41 4INSTALLER'S NAME&,PHONE NO. L-Ouov SEPTIC TANK CAPACITY LEACHING FACILITY: (type) ra �� NO.OF BEDROOMS > B `X Z Z. ©BUILDER OR OWNER PERMITDATE: COMPLIANCE DATE:- 21 Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist or on site or within 200 feet of leaching facility) Feet Edge of Wedand and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) eet Furnished by i • tr a' No. Fee V 7 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS 0[ppYtcattou for 330;pogal *pgtem QConztructton Vermtt Application is hereby made for a Permit to Construct( )or Repair( )an On-site Sewage Disposal System at: Location Address or L N Owner's Name,Address and Tel.No. Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. I Lr,�,(.." _j Type of Building: Dwelling No.of Bedrooms Garbage Grinder Other Type of Building 1.✓CLOiQ No. of Persons Showers Cafeteria( ) Other Fixtures l Design Flow . ,em�ssv7 gallons per day. Calculated daily flow �LL gallons. Plan Date'/F2 — jam' Number of sheets f Revision Date Title Description of Soil j/?'li/ tiQF 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 iss by this B4 of Signed Date - 1­4 J Application Approved by Application Disapproved fort follo ' g reasons Permit No. f, 'V �� Date Issued No. s I Fee y a- THE COMMONWEALTH OF MASSACHUSETTS• PUBLIC HEALTH DIVISION''-TOWN OF BARNSTABLE., MASSACHUSETTS' 0(ppYication for -Bi!6pool *pgtem Cons�truction Permit- Application . is hereby made for a Permit to Construct( )or Repair an On-site Sewage Disposal System at:. P Y P ( ) g. P Y _ _�..� Location Address or L N Owner's Name,Address and Tel.No. o 7- 6 7 � L.17�,o Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. ,�{/tea � /�// �//,/J //r✓��/ ' Type of Building: 1. Dwelling No.of Bedrooms Garbage Grinder fOther Type of Building.- No. of Persons Sowers(�) Cafeteria( ) s Other Fixtures ti Design Flow gallons per day. Calculated daily flow �� gallons. 't Plan Date�/a —4 0 Number of sheets / Revision Date Title ,/ Description of Soil ✓�!e F_ .' Nature of Repairs or Alterations(Answer when applicable) Date last inspected: IS 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 iss by this Bg of ItAl t Signed Date ' eC9 tt Application Approved by 4 Application Disapproved fort folio ' g reasons '4 Permit No._7 fi '.V Date Issued THE COMMONWEALTH OF MASSACHUSETTS ti PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS 4 , Certificate of Comptiance - THIS IS TO CE TIFY,that the On-site Sewage Disposal System installed( Wr5r repaired/replaced( , )on / byC�a � ,�ct-• for L��. fpZ Li^ G as has been constructed in accordance f with the provisions of Titles and the for Disposal System Construction Permit No. `� dated Use of this system is conditioned on compliance with the provisions set forth below: f , _ , Z 2-7- No. — Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION BARNSTABLE. MASSACHUSETTS i . xi5p0al *pgtem Construction Permit Permission is hereby granted to w��s st S to construct(,1�)repair( )an On-site Sewage System loca&6 at and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. All construction must be completed within two years of the date below. E Date: l 2/2`7/9-5 Approved by 'r , i gown 40 ! Wide clz - --- _._ __-._. } 49.E gL.Sd <r 3� � .. .- _• Zo.t 67 b 4-9•Z I0360 > I f3�IZ'LS .gM I o Leo?W5�.e I Ca4.totta fw&Ute ; - .Cot 68 o N ro N (� gown tv _ .. rp IA. 49 �2' )SOo bST Se•i -RCS. I . � _. .Cott 70, .. _ No. 6'euicoo►x.�- - 3 Xo•t 69 �AAP o £�.tr,meted Cod ?�' - pd ;tomPeachina I soo 33oxo _ d Jo ck . . Uc ti ' 4'P✓c ,SR�p - q-per 44. a�� r to \Z$ I .. 10 19 A �........ .9 o OG�O 6 o vOGiv✓ `�YCJa?c+o E .1 V .� ;..,. Py � d Onu t' �'e'd•e ClG4 '-y.O CV... � 1. Z_ . , try✓ Ua�✓ AVILL cwo44.6 � c� °ems 0 7foKl . 2 6%sA 3 _. ` F 3'-+- �' �+- '3' -� .3• + 3!"1 I�VEi��'A�p1'7,25 e 6 j-i te:j�'t an, o zcuu,; -r v i't ycn - a I I_ _ P�Lo2C� tot 6 7 cvl: �20wa2 On pin 16 S�4 I ` ' S y o.n.�(.P.UCvtiIA�'li�. DYL.Cut riiLltf►112C� C��.1,CNh. Jc�ty I0-26-95 �Sco,On l '`-301 F I -$-9 S r-^,.� Cape i2c,!vta e�ri�u tsq lJci bot (;bad, Pga4wid., �Xl 02601 ` 5'eat pit #rP-$S'72 . : . ridge 9-21-95 No wa to t enco�un t i l -.Cep 2 n.in p e 1 " . : : . : - h I 49.4_ i & � 4)¢ aand 4,11 43,4 - eCGi LUr U 17 t CN0.3?4P0-. .��•. i