HomeMy WebLinkAbout0067 MEGAN ROAD - Health 67 MEGAN RD,
HYANNIS
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j COADION-UMALTH OF 1VI<tiSSACHUSETTS
Eh�CL-mT. OFFICE OF nN-mo.x;Ym.�'TAL AFF.�MS i
•• _ 'DEPARTMENT OF ENVIRONMENTAL PROTECTION
MICE WL\'TER STR_r".BOSON MA 0210c t6I',292Z&n,
TRUDT COXZ1-
Secrew%
ARGEO PALL CEUI CCI DAVID B STP:'HS
Governor 6111 Cosnt 4umner
SUBSURFACE SEWAGE DISPOSAL SYST NSPECTION FORM '
PART-A
CERT1FICAT10N
Property Address: 67 Megan Rd. , Hyannis Nance of Osman M=a I i w i Pc
Address of Ownar:_ same
Date of 4tspeetion: i,2.—s.'� � .�
Name of bopector:(Please Prime►Wm. E. Robinson Sr.
1 am a DEP approved s bsspaPan to Seeoon 16—W of TWO 51310 CUR 15.000)
Company Name: Wm. E . R o ins on et is S env i ce
Mailing Address: PO Box 1 0 9. Cent -ryil MA
Telephone Number: -Z7 K_8 7 7 6
CERTIFICATION STATEMENT
1 certify that 1 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.e:perience in the proper function and
maintenance of on-site sewage disposal systems. The system:
/. ( Passes
Conditionally Passes
Needs Further Evaluation By the Local Approving Authority
_ Fails
Inspector's Signature
Date: / 0 3 ra j
The System inspector shall submit 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
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Rec,-cwd P.M. .
SUBSURFACE SEWAGE DISPOSAL SYSTEM NSPECTION FORM
PART A
6N I IACATION leonti►and!
Noperty Address: 67 Megan Rd. , Hyannis
Jwner:
Dow ofInspection: Mysliwiec
6 G v
NSPECTION SUMMARY: Check OAS, C, or D:
A. SYSTEM PASSES:
L/I have not found any information which indicates that'sny of the failure conditions described in 310 CMR 15.303 exist. Any failure
criteria not evaluated are indicated below.
COMMENTS:
B. YSTEM 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.
Indicate s.no. or not determined(Y.N,or NO). Describe basis of determination in all instances. If'not determined*.explain why not.
The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate of
Compliance Iattachedl indicating that the tank was installed within twenty 120)years prior to the date of the inspection: or
the septic tank,whether or not metal,is cracked,structurally unsound.shows substantial infiltration or exfihrstion. or tank
failure is imminent. The system will pass inspection N the existing septic tank is replaced with a complying septic tank as
approved by the Board of Health.
Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipets)
or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of
health).
broken pipets)are replaced
obstruction is removed
distribution box is levelled or replaced
The system required pumping more than four times a year due to broken or obstructed pipets). The system will pass
inspection if(with approval of the Board of Health):
broken pipelsl are replaced
obstruction is removed
rCt �.SG� Gj 2/9.~.
Page 2 of I1
'J SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION fic ntinued)
Property Address: 67 Megan Rd. , Hyannis
Owner: Mysliwiec
Date of Inspection: 0 G
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
ublic health, safety and the environment.
11 YSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES N ACCORDANCE WITH 310 CUR 15.303(1)(b)THAT THE SYSTEM
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 IAND 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 is within 50 feet of a private water supply well.
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 (approximation not valid).
3' THER
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SUBSURFACE SEWAGE DISPOSAL SYSTEM WSPECTION FORM
PART A !
CERTIFICATION Icononued)
Property Address: 67 Megan Rd. , Hyannis
Data of bupg es l i w i e c@ �y
D. SYSTEM FAILS:
You m indicate either "Yes" or "No" to each of the following:
II rave 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
Backup of sewage into facility or system component due to an overloaded oreloggad SAS or cesspool.
Discharge or pondmg 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 112 day flow.
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped_.
Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation.
Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
Any portion of a cesspool or privy is within a Zone I of a public well.
Any portion of a cesspool or privy is within 50 feet of a private water supply well.
Any portion of a cesspool or privy is less-than 100 feet but greater than 50 feet from a private water supply well with no
acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for
coliform bacteria, volatile organic compounds,ammonia nitrogen and nitrate nitrogen.
E. LA GE SYSTEM FAILS:
You mu t 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 god or greater(Large System)and the system is a significant threat to public
health and safety and the environment because one or more of the following conditions exist:
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 11 of a public
water supply well)
The OW Ter or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional
office of the Department for further information.
PaRriof11
. SUBSURFACE SEWAGE DISPOSAL SYSTESII INSPECTION FORM
f PART B
CHECKLIST
Prop"Add►ess: 67 Megan Rd. , Hyannis
Owner MysliWieC
Date of hupwbon:
Check if the following have been done: You must indicate either 'Yes" or "No" as to each of the following:
Yes No
Pumping information was provided by the owner. occupant,or Board of Health.
_ None of the system components have been pumped for at least two weeks on&the system has been receiving wermsl flow
rates during that period. large volumes•of water have not been introduced into the system recently or as part of this
inspection.
_ As built plans have been obtained and examined. Note if they are not available with NrA.
J _ The facility or dwelling was inspected for signs of sewage back-up.
_ The system does not receive non-sanitary or industrial'waste flow.
The site was inspected for_ p o signs of breakout.
All system components. excluding the Soil Absorption System, have been located on the site.
_ The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles
or tees, material of construction, dimensions.depth of liquid, depth of sludge, depth of scum.
The size and location of the Soil Absorption System on the site has been determined based on:
b'l _ Existing information. For example. Plan at B.O.N.
_ Determined in the field(if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable)
115.30213)(b))
3/ _ The facility owner land occupants,if different from owner) were provided with information on the proper.rnaintanaar"f
SubSurface Disposal Systems.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C ?
SYSTEM INFORMATION
Vop"Address: 67 Megan Rd. , Hyannis
Own"MysllWieC
Date of peetion:
FLOW CONDMONS
RESIDENTIAL:
Design flow: k/XO g.p.d.fbedroom.
Number of bedrooms Idesign):4-1 Number of bedrooms factual): 3
Total DESIGN flow 49,�-ed
Number of current residents:jZ-Z4
Garbage grinder!yes or no):,,4L v
Laundry(separate system) (yes or no1�O; If yes,separate inspection required
Laundry system inspected !yes or not
Seasonal use (yes or no):�i O
Water meter readings,if available (last two year's usage Igpd): 1 a 9 9_2 0 n n R8 ,500 a 1
Sump Pump(yes or no!-A,C� 1 998-1 999 90, 000 gal.
Last date of occupancy!--:G-t/
COM RCIALIINDUSTRIAL:
Type of stablishment:
Design f( w: god ( Based on 15.203)
Basis of eli flow
Grease tr p present: (yes or no)_
Industrial aste Holding Tank present: (yes or no)
Non•sanit ry waste discharged to the Title 5 system: (yes or no)_
Water me er readings.if available,
Last date of occupancy:
OTHER: ) escribe)
Last Oat of occupancy
GENERAL INFORMATION
PUMPI G RECORDS and slu, of formation:
System pumped as part of inspection: (yes or no)�L
If yes. volume pumped: gallons
Reason for pumping
TYPE OF SYSTEM
Septic tank%distribution boxisoil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system Ives or no) (if yes, attach previous inspection records.if any)
VA Technology etc. Attach COPY of up to date operation and maintenance contract
Tight Tank Copy of DEP Approval
Other
APPROXIMATE AGE of all components, date installed 01 known)and source Of information: / L,�—•
Sewage odors detected when arriving at the site: (yes or no) A, 0
J SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION leaneisnd)
"ropertyAddfess: 67 Megan Rd. , Hyannis
Owner: MvvsliwieC
Dote of htson:
BUILDING SEWER:
(Loot on site plan)
Depth below grade:_
Material of construction:_cast iron_40 PVC_other(explain)
Distance from private water supply well or suction line
Diameter
Comments: (condition of joints, venting, evidence of leakage etc.)
SEPTIC TANK:_
(locate on site plan)
yl
Depth below grader 1/
Material of construction:-Concrete_metal_Fiberglass _Polyethylene_otherlexplain)
It tank is metal,list age_ Is age confirmed by Certificate of Compliance_(Yes/No)
Dimensions `
Sludge depth: e , /
Distance from top of sludge to bottom of outlet tee or baffle:
Scum thickness: 3_ /
Distance from top of scum to top of outlet tee or baffle: y r , 7
Distance from bottom of scum to bottom/of outlet tee or baffler
Now dimensions were determined: C L�✓ Thy. ��
:omments:
(recommendation for pumping, condition of inlet end outletes or bay/ffles. depth of liquid level in relation t outlet invert, structural integrity.
evidence of leakage. etc.) l�D � !Z d ) Y+f �',�Y /µ. Ip��o
lc.ty L 0
GREASE TRAP:
ocat(le on site plan)
Depth b low grade:_
Material f construction:_concrete_metal_Fiberglass _Polyethylene_other(explain)
Dimensio s:
Scum thickness.
Distance;rOm top of scum to top of outlet tee or baffle:
Distance rom bottom of scum to bottom of outlet tee or baffle:
Date of I st pumping:
Comm ts:
(reco endation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity,
evide ce of leakage. etc.)
Pate 7ofII
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM {
PART C
SYSTEM INFORMATION leandnued)
'ropertyAddress: 67 Megan Rd. , Hyannis
Owner: MysliWieC
Date of Inspection: L oL—G�GGp
TIGHT OR HOLDING TANK: (Tank must be pumped prior to, or at time of, inspection)
lioeat on site plan)
Depth elow grade:_
Materia of construction:_concrete_metal_Fiberglass_Polyethylene otherlexplain)
Dimensi ns:
Capacitl gallons
Design Pow gallonsrday
Alarm resent
Alarm evel: I Alarm in working order: Yes_ Na_
Dote f previous pumping
Com ents.
(co dition of inlet tee, condition of alarm and float switches. etc.)
DISTRIBUTION BOX:L✓
(locate on site plan;
Depth of liquid level above outlet invert:
Comments: ))
Incite if level and distribution is equal. evieepolids carryover, evidence of leakage into or out of box, etc.)
PUMP C AMBER:_
(locate on site plan!
Pumps in orking order: (Yes or No)
Alarms in Orkin9 order (Yes or No)
Comment :
(note can ition of pump chamber. condition of pumps and appurtenances. etc.)
Page 8 or I I
SUBSURFACE SEWAGE DISPOSAL SYSTEM WSPECTION FORM
PART C
SYSTEM WFORMATION(con6nulidl
+opertyAdd►ess: 67 Megan Rd. , Hyannis
Owner: MyS1iwieC
Date of Inspection:!;L— S s6 6 ,Z/
SOIL ABSORPTION SYSTEM(SASA
(locate on site plan,if possible;excavation not required,location may be approximated by non intrusive methods,
It not located, explain:
Type:
leaching pits. number:l�
leaching chambers,number:_
leaching galleries. number:_
leaching trenches. number, length:
leaching fields, number, dimensions:
overflow cesspool, number:_
Alternative system:
Name of Technology:
Comments:
Inote condition of soil, signs of hydraulic failure, level ponding. damp soil, condition of vegetatio`n,, etc )
..
CES LS:
Ilocate on site plan)
Number end configuration.
Depth-top of liquid to inlet invert:
Depth of solidslayer:
)epth of scum laver.
Dimensions of cesspool.
Materials of consttruction
Indication of groundwater.
inflov. Isesspoo(must be pumped as part of inspection;
Comments I
(note condition of soil. signs of hydraulic y c failure, level of ponding. condition of vegetation, etc.)
PRIVY:E
,Ilocate MateriaDepth o Dimensions:
CommeInote cos of hydraulic failure. level of ponding, condition of vegetation, etc.)
PaRf 9 of I I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION Ieantirs"d)
"brop
jwn ertyAddress:
Jwner: 67 Megan Rd. , Hyannis
ante of inspection: My S 1 i w i e C
o
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent reference landmarks or benchmarks
locate all wells within 100' (Locate here public water supply comes into house)
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SUBSURFACE SEWAGE DISPOSAL SYSTEMNSPECT FORM
PART C
SYSTEM/IIFORMATION Ieorte m"M
ropartyAddrass: 67 Megan Rd. , Hyannis
Owrw: Myys.lieiec
Date of Inspaeeon: I-A_;9'd ui
NRCS Report name
Soil Type_
Typical depth to groundwater
USGS Date website visited
Observation Wells checked Deep
Groundwater depth: Shallow Moderate
SITE EXAM Slope
Surface water
Check Cellir
Shallow wells
Estimated Depth to Groundwater20 Feet
Please indicate all the methods used to determine Nigh 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
Used USGS Data
Describe how you established the High Groundwater Elevation. (Must be completed)
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C0.1%M10\%%7-4LTH OF MaSSACHL:SETTS
_ EXECL 7E OFFICE OF LN-MON1'lENTAL.AFFAIRS
F
DEPARTMENT OF ENVIRONMENTAL PROTECTION
.-MP`
ONE 1MCM STR=-7.ROSTOIX MA 0210� 16l',2.42-Si(k,
TR.'DY COX-E.
Secse:Z-�
ARGEO PALL CELLUM 11417D B STP_vc
. Caoeetao: tota:otss:oae-
SUBSURFACE SEWAGE DISPOSAL SYSTM NSPECTION FORM
PART'A
CERTIFICAT10N
Prop"Address: 67 Megan Rd. , Hyannis Name et Om m
Address of Owner: same
Date of Inspection: i 1.-
Name of hsvectw:IPkwe P*w Wm. E. Rob ins on Sr.
1 am a DEP approved s irrspaeeor m S=_' 15.340 all Tflle b pt0 CMR ISAW)
cernpamy Nacre: WID• E. Robinson a tic Service
>M-wwAd*mm: PO Box 0 9. Centerville MA
Talepfrone Number: �7 S—R77F'
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this addraas and that the informstion 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:
/C Passes
Conditionally Passes
Needs Further Evaluation By the local Approving Authority
Fails
urspector's Signature:
Oste: / —6 —
The Sys"m inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP►within thirty 130)days of
completing this inspection. If the system is a shared system or has a design flow of 10.000
9pd or greater,the inspector and the system owner
Shall submit the report to the a ppropriate regional office of the Department of Environmental Protection. The original should be sent to tine
system owner and copies sent to the buyer.if applicable.and the approving authority.
NOTES AND COMMENTS
Pnr 1 or 11
C:_ 113 o-Rn-,cw!Parer•
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM y
PART A
CER I RCATION Nearttinrad)
Nopaty Address: 67 Megan Rd. , Hyannis
Owner:
wte of fYtiom: My s l iw i e c
BiSPEC1 tON SUMMARY: Check CA-)B, C, or D:
A. SYSTEM PASSES:
�1 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.
COMMENTS:
B. YSTEM CONDITIONALLY PASSES:
One or more system components as described in the'Conditional Pass'section reed to be replaced or repaired. The system.upon
completion of the replacement or repair.as approved by the Board of Health,will pass.
Indicate s.no, or not determined(Y.N.or NO). Describe basis of determination in sU aetaness. If'not determined*.explain why not.
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 irrstalied within twenty 120)years prior to the date of the inspection: or
the septic tank.whether or not metal.is cracked.structurally unsound.shows substantial infiltration tir extiitte.on. or tank
failure is imminent. The system win pass impaction if the existing septic tank is replaced with a complying septic tank as
approved by the Board of Health.
Sewage backup or breakout or high mutie water level observed in the distribution box is due to broken or obstructed pipets)
or due to a broken.settled or uneven distribution box. The system will pass inspection if(with approval of the Board of
Health).
broken pipe(s)are replaced
obstruction is removed
distribution box is levelled or replaced
The system required pumping more than four tines a year due to broken or obstructed pipets?. The system will pass
inspection if(with approval of the Board of Health):
broken pipets)are replaced
�p obstruction is removed
Page 2 or I l
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION leanenued)
P operty Address: 67 Megan Rd. , Hyannis
Own": Mysliwiec
Date of btspeetin 0
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
ublic health.safety end the environment.
11 YSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CUR 15.303 111(b)THAT THE SYSTEM
NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
2 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) YSTEM 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 is within 50 feet of a private water supply well.
The system has a septic tank and soil absorption system and the SAS is less then 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 prim. Method used to determine distance (approximadon not valid).
3' THEF
Page 3 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ,
PART A
CERTIFICATION Ieontieued)
property Address: 67 Megan Rd. , Hyannis
owner: MV sIiwiec
Date of btapsetlon.
G. SYSTEM FAILS:
You m indicate either "Yes" or "No" to each of the following:
1 eve determined that
bed W°fe of the The Boardlowing of Mealthrlure conditions arxist as sho Id be contacted t deterna erwhatt will be necessary to correct the failure
ermination is identified
Yes No SAS or cesspool.
Backup of sewage into facility or system component due to an overloaded orebgged
Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS of
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 112 day flow.
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipels).
Number of times pumped_.
_ Any portion of the Soil Absorption System, Cesspool or privy is below the high groundwater elevation.
Any portion of a Cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
Any portion of a cesspool or privy is within a Zone 1 of a public well.
_ Any portion of a cesspool or privy,is within 50 feet of a private water supply well.
_ Any portion of a cesspool or privy is less-than 100 feet but greater than 50 feet from a private water supply well with no
acceptable water quality analysis. If the well has been analysed to be acceptable, attach copy of well water analysis for
calif arm bacteria, volatile organic compounds,ammonia nitrogen and nitrate nitrogen.
E. LA GE SYSTEM FAILS:
You mu t 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 environment because one or more of the following conditions exist:
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 11 of a public
water supply well)
The ow er 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.
c Pant 4 of I I
- SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
•• Property Address: 67 Megan Rd. , Hyannis
Owner: Mysliwiec
Date of Inspection: z _e)
r
Check if the following have been done:You must indicate either,'Yes" or'No' as to each of the following.
Yes No
Pumping information was provided by the owner,occupant,or Board of health.
_ None of the system components have been pumped for at least two weeks sn*the system has been receiving warmal flow
rates during that period. large volumes•of water have not been introduced into the system recently or as part of this
inspection.
_ As built plans have been obtained and examined. Note if they are not available with N:A.
_ The facility or dwelling was inspected for signs of sewage back-up.
_ The system does not receive non-sanitary or industrial waste flow.
_ The site was inspected for signs of breakout.
All system components,excluding the Soil Absorption System,have been located on the site.
The septic tank manholes were uncovered,opened,and the interior of the septic tank was inspected for condition of baffles
or tees, materiel 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:
Existing information. For example. Pion at B.O.N.
Determined in the field(if any of the failure criteria related to Part C is at issue.approximation of distance is unacceptable!
115.30213)1b)I
- _ The facility owner land occupants,if differeru from owner)were provided with information on the propermain*e..�., a ,f
SubSurface Disposal Systems.
PrRc5ofII
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM.
PART C
SYSTEM MIFORMATION
Iropei Address: 67 Megan Rd. , Hyannis
Own"' ysliwiec
Date of peCtion:
FLOW CONDITIONS
RESIDENTIAL:
Design flow: k/�<'o g.p.d.lbedroom. 7
Number of bedrooms(design): Number of bedrooms lactuall:,>
Total DESIGN flow 9 O
Number of current residents:.,/�-
Garbage grinder Ives or nol:,1-1i 0
Laundry(separate system) Ives or nofyb_O; If yes,separate inspection required
Laundry system inspected Ives or no;
Seasonal use(yes or no):/i,o
Water meter readings,if available (last two year's usage Igpd): _ 1 qc�7 n n fl R R - S 0[1_gal-
Sump Pump(yes or no!: _d 1 998-1 999 90,000 gal.
Lest date of occupancy: L':91- .f ►a C; L
COM RCIAUINDUSTRIAL:
Type of stablishment:
Design fljes.'gn
w opd ( Based on 15.203)
Basis of flowGreasetp present: Ives or no)
Industrial Waste Holding Tank present: Ives or no)
Non-sanit ry waste discharged to the Title 5 system: Ives or no)_
Water me er readings. if available:
Last date f occupancy:
OTHER:(�escribe?
Last dat of occupancy
11�+ GENERAL INFORMATION
PUMPIIt(G RECORDS and so ytc fpformation:
System pumped as part of inspection: Ives or no)ZL V
If yes. volume pumped' gallons
Reason for pumping
TYPE OF SYSTEM
—C Septic tank%distribution box/soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system (yes or not (if yes, attach previous inspection records,if any)
VA Technology etc. Attach copy of up to date operation and maintenance contract
Tight Tank Copy of DEP Approval
Other
APPROXIMATE AGE of all components. date installed lif known) and source of information: /12 7,
'P �"odors detected when arriving at the site: Ives or no) 4, r7
SUBSURFACE SEWAGE DISPOSAL SYSTEM WSPECTiON FORM
PART C
SYSTEM NFORMATION 1conwtsad)
'ropertyAddreu: 67 Megan Rd. , Hyannis
of�M �aliwiecDirte pem a/
BUILDING SEWER:
(Loc' an site plan)
Depth low grade:_
Material lot construction:_cast iron_40 PVC_other)explain)
III
Distance from private water supply well or suction line
Diamete�
Comments:Icondition of joints. venting. evidence of leakage,etc.)
1
SEPTIC TANK:
(locate on site plan)
0
Depth below grader
Material of construction:_concrete_metal_Fiberglass _Polyethylene_otherlexplainl
It tank is metal,list age_ Is age confirmed by Certificate of Compliance_(Yes/No)
E 1 ,L
Dimensions:
Sludge depth:
Distance from top of sludge to bottom of outlet tee or bsffle:
Scum thickness: 3— /
Distance from top of scum to top Of outlet tee or baffle: z
Distance from bottom of scum to bottom of outlet tee or baffle-
how dimensions were determined: Tw—IC
-omments:
Irecommendation for pumping. condition of inlet and outlet tees or battles.depth of liquid level in relation outlet invert, structural integrity.
evidence of leakage. etc.) G -f / % r j'C f,�Vy ��;�. Ip>�
GR E TRAP:
fit cate n site plan)
Depth b low grade:_
Material f construction:_concrete_metal_Fiberglass _Polyethylene_otherlexplain)
Dimensio s:
Scum thi ness.
Distance rom top of scum to top of outlet tee or baffle:
Distance rom bottom of scum to bottom of outlet tee or battle:
Date of I st pumping:
COMM is:
treco endation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity.
evide ce of leakage.etc.)
. SUBSURFACE SEWAGE DISPOSAL SYSTEM NSPECTION FORM t
PART C
SYSTEM WFORMATION Isa'rr irwdl
"rop"Address: 67 Megan Rd. , Hyannis
'Owner: Mysliwiec
Dote of haltim ion:
TIGHT OR HOLDING TANK: (Tank must be pumped prior to,or at time of, inspection)
Iloeet on site plan}
Depth Blow grade:_
Materia of construction:_concrete_metal Fiberglass_Polyethylene_otherle=plain)
Dimensi ns:
Cava.it gallons
De/dition
ow gallons:day
Alaesen-
Alavel: Alarm in working order:Yes_ No
Darevious pumping
Cots:
Ico of inlet tee, condition of alarm and float switches.etc.)
DISTRIBUTION BOX:✓
(locate on site plan;
Depth of liquid level above outlet invert:
Comments:
(note if level and distribution is equal.evit) eep�olids carryover,evidence of leakage into or out of box, etc.)
PUMP C AMBER:_
(locate o site plant
Pumps in orking order: (Yes or No)
Alarms in orking order (Yes or Nw
Comment
Inote con ition of pump chamber. condition of pumps and appurtenances.etc.)
Page B of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM NSPECTION FORM
PART C
SYSTEM INFORMATION lcontirwW)
7opertyAddress: 67 Megan Rd. , Hyannis
Owner: Mysliwiec
Date of 4aspection:i 6 ,�
SOIL ABSORPTION SYSTEM(SAS):� ,
(locate on site plan,it possible:excavation not required,location may be approximated by non-intrusive methods i
If not located,explain:
Type:
leaching pits: number.
leaching chambers,number:_
leaching galleries. number:_
leaching trenches.number,length:
leaching fields. number, dimensions:
overflow cesspool,number.-
Alternative system:
Name of Techno)ogy:
Comments:
(note condition of soil,signs of hydraulic failure. level ponding. damp soil, condition of vegetation. etc ) l
CES LS:_
Ilocate on _ite plan?
Number and\configuration
.
Depth top of liquid to inlet rover•,:
Depth of solids layer:
)epth of scum 1 yer:
Dimensions of c:tsspool.
Materials of con ruction
Indication of grounowater.
inflow 1eessp001 must be pumped as part of inspection;
Comments
(note condition of soil, signs of hydraulic
t Y c failure, level of ponding. condition of vegetation, etc.)
rl
------------------
PRIVY:
loocate on site pla f
Materiels of con truction
Depth of solids Dimensions:
Comments:
Inote condition of oil. signs of hydraulic failure. level of ponding. condition of vegetation, etc.)
_ Z
Pap(9 of I I
SUBSURFACE SEWAGE DISPOSAL SYSTEM MPECTION FORM e
PART C
SYSTEM NFORMATION Icanonwd)
Nop"Address: 67 Megan Rd. , Hyannis
Jwnar:
Jute of htspeetion: My s 1 iw i eC
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent reference landmarks or benchmarks
locate all wells within 100' (Locate here public water supply comes into house)
P
a E•.,q
�6 z3 ' ti
P499'I0 of I I
J�
SUBSURFACE SEWAGE DISPOSAL SYSTEM WSPECTiON FORM
PART C
SYSTEM MIFORMATION ICM0111radl
roparsr Addrass: 67 Megan Rd. , Hyannis
Om"W: M s.lieiec
te Da of kwob.eon:
NRCS Report name
Soil Type_
Typical depth to groundwater
USGS Date website visited
Observation Wells checked Deep
Groundwater depth: Shallow Moderate
SITE EXAM Slope
Surface water
Check Coll-at '
Shallow wells
Estimated Depth to Groundwater], 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
Used USGS Data
Describe how you established the High Groundwater Elevation. (Must be completed)
r
page 11of11
TOWN OF BARNSTABLE7��r
LOCATION SEWAGE #
I
VILLAGE�a'j ��nG� � �.�y�� ASSESSOR'S MAP & LOTS' 2� 2
INSTALLER'S NAME & PHONE NO. �,� �-,�,�y��,�,� S� cc_ �.F`17�
SEPTIC TANK CAPACITY 1. boo
LEACHING FACILITY:(type)5 k
rye
j
NO. OF BEDROOMS Z, PRIVATE WELL OR P B JC WATER_
BUILDER OR OWNER YV�ti/5�i�
j DATE PERMIT ISSUED:
DATE . COMPLIANCE' ISSUED: /
VARIANCE GRANTED:' Yes No
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Public Health erosion
Town of Barnstable
r PO Box 534
Hyannis, Massachusetts 02601
Fax(508)775-3344
Phone(508)�7F-6265
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TOWN OF BARNSTABLE
LOCATION 4 iS SEWAGE #
VILLAGE Lan Meer, AQAS) ASSESSOR'S MAP LOT2--r
INSTALLER'S NAME & PHONE NO. (.c. �]�• "17�i
SEPTIC TANK CAPACITY i 000
LEACHING FACILITY:(type)5 ►k- __ (size) S�svjc-
NO. OF BEDROOMS Z® PRIVATE WELL OR PUBLIC WATER_
BUILDER OR OWNER' `
DATE PERMIT ISSUED: b s
DATE COMPLIANCE ISSUED: �C�c�
VARIANCE GRANTED: Yes :; No
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No... �"_.l.. FEs.......3 0. 0 0.......
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Appliratiun for Di-li.puuttl Works Towitrur#iun Frrutit.
Application is hereby made for a Permit to Construct ( ) or Repair ( x) an Individual Sewage Disposal
System at:m e a-r)
67en Rd Hyannis
.... ..- y •---- -------------------•---•-------------.....---------••••--------
Location-Address or Lot No.
Jake MXsliwiec
-------------.......................................................................... •----•••-•--•-•------••------•-•--•-••-----------••--........------...-•••----•........-•••--•....
Owner Address
W W.E. Robinson Septic Service P.O. Box 1089 Centerville
-----------•------------•--•----------•--...---• ------------------------------------------------------------------------------•-•••--••-.......••-
Installer Address
Type of Building 3 Size Lot............................Sq. feet
Dwelling— No. of Bedrooms-----------------------------------------.--Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ---------------------------- No. of persons---------------------------- Showers ( ) — Cafeteria ( )
at Other fixtures ------------------------------- - -
W Design Flow--------------------------------------------gallons per person per day. Total daily flow--------------------------------------------gallons.
R: Septic Tank—Liquid capacity------------gallons Length---------------- Width---------------- Diameter--..------------ Depth---.._---._-----
W Disposal Trench—No. .................... Width.................... Total Length-------------------- Total leaching area.-.--_-_.-._-_--_---sq. ft.
x
Seepage Pit No--------._---------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by-------------------------------------------------------------------------- Date........................................
aTest Pit No. 1................minutes per inch Depth of Test Pit-------------------- Depth to ground water-------_--------------
(% Test Pit No. 2................minutes per inch Depth of Test Pit............--_----. Depth to ground water........................
94 •-----. --------------..................................................................................................................................
Descriptionof Soil sand---------------••-------------------•-------------------------------------...------------------------------------------......------------------...
x
c,
W .....................------------------------------------------------------------------------............................----............................................................................
UNature of Repairs or Alterations—. Answer when applica e......-add precast le ------ -to.......................
---existing d-box--------------- �-.---� �
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 has been issued by the bo d of health.
Signed .�---i.1---------- ----------------------------- [,/...
-----�-....Da e................
Application.Approved By - -. 3-... .e�5--------
Application Disapproved for the following reasons: .......................................................................................................................................
---- ----------------------------------------------------------------------------------------------------------------------------- -------------------------------- --------------- --------------------_e-----------------
Permit No. ---------.9..J....---- 7-6---------- Issued .......... ......
Dare
No... FR$......3 0 0 0......
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Appliration for Di-ripwiMl Work.6 C omitrnrtum Permit
Application is hereby made for a Permit to Corstruct ( ) or Repair ( x) an Individual Sewage Disposal
System at:
67 �n Rd Hyannis
..........--•-----..........----------------------------•--•--•-----........-•................... ---------------------------------•-------•-••---------.........---•--......-••-•---------•--....--
Location-Address * or Lot No.
Jake Mysliwiec -
......................_.......................................................................... ---------------------------------------------------------•-------------•-----.-----------------
wner
a W.E. Robinson SeOpta.c Service P:O. Box 1089 Centerville
------------------------------------------------------------------• .........................
Installer Address
Type of Building 3 Size Lot............................Sq. feet
Dwelling— No. of Bedrooms--------------------------------------------Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons---------------------------- Showers ( ) — Cafeteria ( )
dOther fixtures --------------------------------------------------------------------------------------- ------------------------------------------•---•-•---•-......
w Design Flow............................................gallons per person per day. Total daily flow............................................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..._.----_..__------ Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
h_I Percolation Test Results Performed by-----------------......................................................... Date........................................
1
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........................
04 -------------------------------------------------------------------------------------•-•-••---.-----..........................................................
0 Description of Soil............sand--- ----------------------------------------•-------------------------------------------------------------------------------------............_..
x
w
UNature of Repairs or Alterations—Answer when applicable.-------add...precast leachpit___t
existing ,d-box /,-��rJ'-- .��-•
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 has been issued by the4boad of health.
Signed -lam � ----------------------------- ------
Application. / �....
�[e
Approved B �-t.-,-� cam.---.--,-�........................ _........... - 3= �T S----------
[)are
PP Y . ....
Application Disapproved for the following reasons: ......... ..... ......_..........................---------------------.:........----------------------.......
...... -- ... ..................... ...... ....... ............................................................................... ........................................
GDate
Permit No- ----------- ------`------ ---6----------- Issued --------- ---- r. � .....F- "------------
Date `
1
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
&rtifi ate of Q-1-umplinnu
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (x )
by--------W...0....Robinson =Seppt'_ Se v.i c -----
Installer
67 Meaghan Rd Hyannis - - _........... -----
has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in
the application for Disposal Works Construction Permit No. - ._- dated i ..-.t.....__.....
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE _' ..- .. - InspectP.r-.,- �_
��--� --------- -------------------
__�----Mysliwiek .�_----__ -- _,.-_,__---____.___,-_
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
pp TOWN OF BARNSTABLE
No....l.._��........�.�� FEE.-•-30.00---•................
%Vviial Ovrhp Tomitrurtion Verntit
W.E. Robinson Septic Service
Permissionis hereby granted------- -------•--- ----•--•-•------•-----•-- ---------------------•--------------------------------------.....................
to Construct ( ) or Repair (x ) an Individual Sewage Disposal System
6'7 Meaghan.Rd-----Hyannis.---..-•-•----------..---------------------------------------------------------------------------------------•--
at No. --------------
Street -7 Q
as shown on the application for Disposal Works Construction Permit No �:7q-,--- Dated_� ..... ............
................................. o_i7).....................................................
�r (� Board of Health
DATE........................)...-...
7
-FORM 36508 HOBBS Q WARREN.INC.,PUBLISHERS