HomeMy WebLinkAbout0137 MEGAN ROAD - Health 137 Megan Road
Hyannis
A= 292-284
r
TOWN OF BARNSTABLE {
LOCATION I :3 2 ✓11 SEWAGE
VILLAGE ASSESSOR'S-MAP & LOT,42z-
INSTALLER'S NAME&PHONE NO. 3
SEPTIC TANK CAPACITY 5
LEACHING FACILITY: (type) (size)
NO.OF BEDROOMS
BUILDER OR OWNER
PERMTTDATE: COMPLIANCE DATE:
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) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished b (;iAk.
i
O ,
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
137 Megan Road
Property Address
Sergio Haibara
Owner Owner's Name
information is Hyannis MA 02601' 09/03/12
required for every y
page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form.Inspection forms may not be altered in any
way.Please see completeness checklist at the end of the form.
Important:When A. General Information:
filling out forms
on the computes,
use only the tab 1. Inspector:
key to move your
cursor-do not Michael Kellett
use the return Name of Inspector
key.
Aardvark Environmental Inspections
r� Company Name
PO Box 896
Company,Address
„ East Dennis MA 02641
City/Town State Zip Code
508-385-7608 SI 3742
Telephone Number t.icense Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true,accurate and complete as of the time of the inspection.The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of ,
Title 5(310 CMR 15.000).The system:
® Passes ElConditionally Passes El Fails'; '•
❑ Needs Further Evaluation by the Local Approving Authority ' = '
09/05/1.2
lnspecfors Sign Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection.If the system is a shared system or
has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the
report to the appropriate regional office of the DER.The original should be sent to the system owner
and copies sent to the buyer,if applicable,and the approving authority.
""This report only describes conditions at the time of inspection and under the conditions of use
at that time.This inspection does not address how the system will perform in the future under
the same or different conditions of use.
t5ins•11/10 Title 5Wn,,wnForth:Subsurface Sewage Disposal System•Page 1 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
137 Megan Road
Property Address,
Sergio Haibara
Owner Owner's Name
information is required for every Hyannis MA 02601 09/03/12
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary:Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® 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 exist.Any failure criteria not evaluated are
indicated below.
Comments:
B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass"section need to be
replaced or repaired.The system,upon completion of the replacement or repair,as approved by
the Board of Health,will pass.
Check the box for"yes","no"or"not determined"(Y,N, ND)for the following statements.If"not
determined,"please explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally
unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent.System will pass
inspection if the existing tank is replaced with a complying septic tank as approved'by the Board of
Health.
v
*A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND(Explain below):
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
137 Megan Road
Property Address
Sergio Haibara
Owner Owner's Name
information is required for every Hyannis MA 02601 09/03/12
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes(cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below):.
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
is Required b the Board of Heath:
C) Further Evaluation q i y
❑ 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)thatthe system is not functioning in a mannerwhich 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
1✓ins•1111g Til3e 5 MUM Inspection Form:Subsurtace Sewage Disposal Srs�m•Page 3 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
137 Megan Road
Property Address
Sergio Haibara
Owner Owner's Name
information is required for every Hyannis MA 02601 09/03/12.
page. Cityfrown State Zip Code Date of Inspection
B. Certification (cunt.)
I 2. System will fail':unless the Board of Health(and`Public Wafter Supplier,if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment
❑ The system has-a septic tank and soil absorption system(SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of'a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well"*.
Method used to determine distance:
*"This system passes if the well water analysis,performed at.a DEP certified laboratory,for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must
be attached to this form_
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes"or"No"to each of the following for all inspections:.
Yes No
❑ 0 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'/Z day flow
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
s Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
137 Megan Road
Property Address
Sergio Haibara
Owner Owner's Name
information is Hyannis MA 02601 09/03/12
required for every y
page. City/Town State Zip Code Date of Inspection
B. Certification (cant.)
Yes No
❑ ® 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 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 Tess than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This,
system passes if the well water analysis,performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.].
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails.I have determined that one or more of the above failure
criteria east as described in 310 CMR 15.303,therefore the system fails.The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure..
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems,you must indicate either"yes"or"no"to each of the following„in.addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area.(interim Wellhead Protection
Area—IWPA)or a mapped Zone II of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,
or answered'yes"in Section D above the large system has faded.The owner or operator of any large
system considered a significant threat under Section E or faded 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.
t51ns•11/10 Title 5 Official Inspectlon Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System form-Not for Voluntary Assessments
137 Megan Road
Property Address
Sergio Haibara
Owner Owner's Name
information is required for every Hyannis MA 02601 09/03/12
page. City(rown State Zip Code Date of Inspection
C. Checklist
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 normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined?(If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components,excluding the SAS,located on site?
® ❑ Were the septic tank manholes uncovered,opened,and the interior of the tank
inspected for the condition of the baffles or tees,material of construction,
dimensions, depth of liquid,depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different 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:
® ❑ 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)P1'0 CMR 15.302(5)]'
D. System Information
Residential Flow Conditions:
Number of bedrooms(design): 2 Number of bedrooms(actual): 2
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 220
t5ins•11/10 Title 5Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
_ Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
137 Megan Road
Property Address
Sergio Haibara
Owner Owner's Flame
information is Hyannis MA 02601 09/03/12
required for every y
page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 2
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes ® No
Laundry system inspected? ❑ Yes ® No
Seasonaluse? ❑ Yes ® No
Water meter readings,if available(last 2 years usage (gpd)):
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: Current
Date
Commercial/tndustrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft.,etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings,if available:
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
137 Megan Road
Property Address
Sergio Haibara
Owner Owner's Name
information is required for every Hyannis MA 02601 09/03/12
page. Cityrrown state Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information-
Pumping Records:
Source of information: 2 weeks per Owner
Was system pumped as part of the inspection? ❑ Yes ® No
If yes,volume pumped:
gallons
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/Alternative technology.Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)and a copy of latest
inspection of the VA system by system operator under contract
❑ Tight tank.Attach a copy of the DEP approval.
❑ Other(describe):
t5ins-11/10 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 o117
Commonwealth of Massachusetts
Title 5 Official Inspection Form
s, Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
137 Megan Road
Property Address
Sergio Haibara
Owner Owner's Name
information is required for every Hyannis MA 02601 09/03/12
page. City1rown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components,date installed(if known)and source of information:
1973 per BOH
Were sewage odors detected when arriving at the site?' ❑; Yes No
Building Sewer(locate on site plan):
Depth below grade: 2.1
feet
Material of construction:
® cast iron ❑40 PVC ❑other(explain):
Distance from private water supply well or suction line: feet
Comments(on condition of joints,venting,evidence of leakage,etc.):
Septic Tank(locate on site plan):
Depth below grade: - 1.2
feet
Material of construction:
® concrete ❑metal ❑fiberglass ❑polyethylene ❑other(explain)
If tank is metal,list age:
years
Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 1,000 gal
Sludge depth:
1"
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
137 Megan Road
Property Address
Sergio Haibara
Owner Owner's Name
informationr ev is Hyannis MA 0260t 09/03/12
required foery y
page. Citylrown state Zip Code Date of Inspection
D. System Information (cunt.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle
30"
Scum thickness
1"
Distance from top of scum to top of outlet tee or baffle
8"
Distance from bottom of scum to bottom of outlet tee or baffle 15"
How were dimensions determined? measured
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,
liquid levels as related to outlet invert,evidence of leakage,etc.):
The tank was sound and tight with tees in place and liquid at outlet invert.
Grease Trap(locate on site plan):
Depth below grade: feet
Material of construction:
❑concrete 0 metal ❑fiberglass El polyethylene El other(explain):
e y +
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
s Subsurface Sewage Disposal System Form Not for Voluntary Assessments
137 Megan Road
Property Address
Sergio Haibara
Owner Owner's Name
information is required for every Hyannis MA 02601 09/03/12
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cunt.)
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,
liquid levels as related to outlet invert,evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan):
Depth below grade:
Material of construction:
❑concrete ❑metal ❑fiberglass ❑polyethylene ❑ other(explain):
Dimensions:
Capacity:
gallons
Design Flow:
gallons,per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping:
Date
Comments(condition of alarm and float switches,etc.):
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t51ns-11/10 Idle 5 Official inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form-
s Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
137 Megan Road
Property Address
Sergio Haibara
Owner Owner's Name
information is required for every Hyannis MA 02601 09/03/1I2.
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened)(locate on site plan):
Depth of liquid level above outlet invert
Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any
evidence of leakage into or out of box,etc.):
No box presenr
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
Comments(note condition of pump chamber,condition of pumps and appurtenances, etc.):
Soil Absorption System(SAS)(locate on site plan,excavation not required):
If SAS not located,explain why:
t5ins-11/10 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
137 Megan Road
Property Address
Sergio Haibara
Owner Owner's Name
information is required for every Hyannis MA 02601 09/03/12
page. City/Town state Zip Code Date of inspection
D. System Information (cont.)
Type:
® leaching pits number. 1
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number,length:
❑ leaching fields number,dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of
vegetation,etc.):
This system has a 6'x6'precast pit surrounded by V of stone.There was 20"between the inlet invert
and the liquid.
Cesspools(cesspool must be pumped as part of inspection)(locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
cl Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
.' 137 Megan Road
Property Address
Sergio Haibara
Owner Owner's Name
information is required for every Hyannis MA 02601 09/03/12
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,
etc.):
Privy(locate on site plan):
Materials of construction.
Dimensions
Depth of solids
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,
etc.):
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
137 Megan Road
Ov T.rt Address
� �i] YICba
Sergio Helbara
owner
information is awnees Name
regtared for every Hyannis MA 02601 09/03/12
page. Cdylrom Syabe
Zip Code Date of Inspection
D. System Info»l�ion {cunt.)
Sketch Of Sewage Disposal System:Provide a view of the sewage disposal system,including ties tD
at least two permanent reference landmarks or benchmarks.Locate all wells within 100 feet Locate
where public water sup enters the building
.g.Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
t ,
a1 -
30`
T@e 5 0MkW Nan Form:SWxuft B sMW ngposM eysL_.pate 15 or,7
Commonwealth of Massachusetts
u Title 5 Official Inspection Form
s Subsurface Sewage Disposal System Form Not for Voluntary Assessments
137 Megan Road.
Property Address
Sergio Haibara
Owner Owner's Name
information is required for every Hyannis MA 02601 09/03/12
page_ Citylrown state Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
❑ Surface water
® Check cellar
❑ Shallow wells
20.0
Estimated depth to high ground water: feet
feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked,date of design plan reviewed: Date
❑ 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:.
USGS maps show an elevation of over 20.0 feet
Before filing this Inspection Report,please see Report Completeness Checkliston next page.
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
137 Megan Road
Property Address
Sergio Haibara
Owner Owner's Name
information is required for every Hyannis MA 02601 09/03/12
page. City/Town state Zip Code Date of Inspection
E. Report Completeness Checklist
Inspection Summary:A,B, C,D,or E checked
® Inspection Summary D(System Failure Criteria Applicable to All Systems)completed
® System Information—Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins•11/10 Title 5 Oftial inspection Form:SubsuRace Sewage Disposal System-Page 17 of 17
r t
2 9 2-
TROY WILLIAMS
SEPTIC INSPECTIONS
Certified by MA Department of Environmental Protection (508) 385-12500
19 Hummel Drive
South Dennis, ' A 026bO
COMMONWEALTH OF MASSACHUSE17S
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
I)EPARTMENT OF ENVIRONMEN'I'AL PROTECTION
o
TITLE 5
OFFICIAL INSPECTION FORM — NUT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Properh Address: 137 Megan Road
Hyannis,MA
Owner's Name: WinifredD. Connelly
Owner's Addres,: 265 Flaggler Drive 1
Marshfield,MA 02050 Q v
Date of Inspection: June 13,2001 O /+C `'eD
Name of Inspector: �ir RECEIVED
E
Troy M. Williams l`JJ/
Company Name: Troy Williams Septic Inspections
Mailing Address: 19 Hummel Drive ,jUN 18 2001
Telephone Number: South Dennis, MA 02660
(508)385-1300 TOWN OF BARNSTABLE
HEALTH DEPT.
CERTIFICATION S"TA'TEMEN'I'
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 the inspection. The inspection was performed based on my
training and experience in the proper function and maintenance of on site sewage disposal systems. 1 am a DEP
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The systcnr
Passes
Conditionally Passes
Needs further Evaluation b} the Local Appiovutg Authoiu)
Fails
Inspector's Signature: _ � /,_�, ,� Date: 6 // 3/O/
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of I lealth or
DEP)within 30 days of completing this inspection, If the system is a shared system or has a design flow of 10,000
gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the
DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving
authority.
Notes and Continents
Although system meets the minimum requirements set forth by the Massachusetts Department of
Environmental Protection,certification is not to be construed as a guarantee of future working condition
of system,piping or components. This inspection represents the conditions of the system on the Date of
Inspection noted above.
""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 pace I
c
r Page 2 of I I
` OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENT'S
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
137 Megan Road
Property Address: Hyannis, MA
Winifred D. Connelly
(.)w'urr: June 13, 2001
Date of Inspection:
Lispectiun Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. /System Passes:
I have not found any information which indicates that any of the failure criteria described in 310 CN'1R
I.).303 or in 310 CNIk 15.304 exist. Any failure criteria not evaluate arc indicated below.
Comments:
B. System Conditionall)• 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 1oard of Health, will pass.
Answer )cs. no w not determined(1',N,NI)) in the for the following statc-i i6nis. If"not determined" please
explain. )
septic tank is metal and over 20 ),cars old* or the septic tan whether metal or not) is structurally
unsound. exhibits substantial infiltration or exfiltration ur tank failur is imminent. System will pass inspection if the
existing tank is -placed with a complying septic tank as approve y the Board of 1-lealth.
'A metal septic tank will pass inspection if it is suuctura11 su id, nUl 1Caklll Anil II a ( Crlllll'alc U1 onll)11a11CC
indicatin- that the tank is less than 20 years old is available
ND explain:
_ Observation of sewage backup or brea ut or high static water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken, settle or uneven distribution box. System will pass inspection if(with
approval of Board of Health):
__ oke11 pipe(s)are replaced
Obstruction is removed
_ distribution box is leveled or replaced
ND explain.-
'I
_ he sysici equiicd pumping inure titan-I tinics a year due to broken or obstructed pipe(s). 7 he system will
pass inspectiot (with approval of the Board of health):
broken pipe(s)are replaced
obstruction is removed
ND explain:
2
Page 3 of I I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 137 Megan Road
Hyannis, MA
Owner: Winifred D. Connelly
Date of fraspectiun: June 13, 2001
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 sysiem
is failing to protect public health, safety or the environment.
1. System will pass unless 11oard of Health determines in accordance with 310 CNIR 15.3 (1)(b) that the
system is not functioning ill a manner which will protect public health,safety and tt /ens iromnent:
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. S}'stem will fail unless the Board of Health (and Public Wa r Supplier,if airy)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 stem (SAS)and the SAS is within 100 feet of a
surface �N titer supply or tributary to a surface water rpply.
'File system has a septic tank and SAS - the SAS is within a Zone 1 of a public water supply.
The system has a septic tank and S and the SAS is within 50 feet of a private water supply well.
'1 he systern has a septic tan nd SAS and the SAS is less than IOU feet but 50 feet or more fiuro a
private water supply well". thud used to determine distance
*phis systern passes if e well water analysis, performed.at a DEP certified laboratory, for colifonn
bacteria and volatile ganic compounds indicates that the well is free from pollution from that facility and
the presence of a onia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other
failure criteria a triggered. A copy of the analysis must be attached to this form.
A I
3. Other:
3
Page 4 of 1 I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
137 Megan Road
Property Address: Hyannis,MA
Winifred D. Connelly
Owner: June 13, 2001
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
Ba,:l.u1) 01 SCbva�c ludo laC duty or system component due to overloaded or clo-Led SAS or cesspool
Discharge or ponding of effluent to the surface of the ground or surlace waters due to art overloaded or
clo�_!_ed SAS or cesspool
H14 Static liquid level in the distribution box abo�c outlet invert due to an overloaded or slugged SAS or
/ cesspool
v' . Liquid depth in cesspool is less than 6" below invert or available volume is less than '/2 day flow
Required pumping more than 4 times in the last year NOT due to clogged or-obstructed pipe(s).Number
of times pumped------_
Any portion of the SAS,cesspool or privy is below high ground water elevation.
_ 6(Lq Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
/v/I Any portion of a cesspool or privy is within a "Lone I of a public well.
a Any portion of a cesspool or privy is within 50.feet of a private water supply well.
------ 11-1 Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water
supple well with no acceptable water quality analysis. (This system passes if the well water analysis,
performed at a DEP certified laboratory, for colifonn bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria
are triggered. A copy of the analysis must be attached to this forma
/v o (Ycs/No)The systew falls. I llavc determined that one or more of the above failure criteria exist as
dc-cribed in ,10 CNIR I S.303. therefore 01C S.vstum fails. The system o\�ner should contact the Board of
Ilealth to determine what will be necessary to correct the failure.
R
E. Large Systems:
To be considered a large system the system must serve a facility with a d ign flow of 10,000 gpd to 15,000
r gpd.
You must indicate either"yes"or"no" to each of the following:
(The following criteria apply to large systems in addition to the criter above)
yes no
the system is within 400 feet of a surface drinking ater supply
the system is within 200 feet of a tributary to surface drinking water supply
the system is located in a nitrogen sensi ve area(interim Wellhead Protection Area- 1WPA)or a mapped
Zone 11 of a public water supply we
It you have answered"yes" to any quest' n in Section E the system is considered a significant threat,or answered
"yes" in Section D above the large sy em has failed. The owner or operator of any large system considered a
significant threat under Section.E failed under Section D shall upgrade the system in accordance with 310 CMR
15.304.The system owner shou contact the appropriate regional office of the Department.
4
Page 5 of 1 I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 137 Megan Road
Hyannis,MA
Owner: Winifred D. Connelly
Date of Inspection: June 13, 2001
Check if the following have been done. You must indicate"yes"or"no"as to each of the following:
Yes No
Y_ !'..::,i--ing information was provided by the owner. occupant. or 13uat,1 of I LaI;1,
Were any of the system components pumped out in the previous two weeks
Has the system received normal flows in the previous two week period '?
Have large volumes of water been introduced to the system recently or as part of this inspection '.'
Were as built plans of the system obtained and examined? (If they were not available note as N/A)
_ Was the facility or dwelling inspected for signs of sewage back up?
Was the site inspected for signs of break out ?
Were all system components, excluding the SAS. located on site
Were the septic tank manholes uncovered, opened,and the interior of the tank inspected for the condition
of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum ?
V __ Was the facility owner(and occupants if ditterent from owner)provided with intunnation 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 infortation. For example, a plan at the Board of Health.
_ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance
is unacceptable)[310 CMR 15.302(3)(b)]
5
y
Page 6 of I 1
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 137 Megan RoadHyannis,MA
Owner: Winifred D. Connelly
Date of Inspection: June 13, 2001
. FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): Number of bedrooms(actual): _
DESIGN flow based un 310 CMR 15.203(for example: 1 10 gpd x# of bedrooms): r226
Number of current residents: D ( t P,-,ov
Does residence have a garbage grinder(yes or no): No
Is laundry on a bcl411ate sewage system (yes (e no) Ara (if yes separate inspection required)
Laundry system inspected(yes or no): A,
_IZ.7
Seasonal use: (yes or no): Alb
Water meter readings, if available(last 2 years usage (gpd)): 00 s"�Q
Sunlp pump(yes or no): nio r—� -
Last date of occupancy:
COMMERCIAL/INDUSTRIAI.
'Type of establishment:
Design flow(based on 31.0 CMR 15:203): gpJ
Basis of design flow(seats/persons/sgft,etc.):
Grease trap present(yes or no):__ - - ----- - -------
lndustrial waste holding tack present(yes or no):
Non sanitary waste discharged to the Title 5 systr -(yes or no):
Water meter readings, if available:
.....
Last date of occupancy/use-
OTHER(describe):
GENERAL. INFORMATION
Pumping Records
SUnl,:l of Ill fOrlllall011:/�u �.,.,�, "f �, ��, >:- ) p`✓,` / �6�.
"'as system pumped as part of the inspection(yes or no): _s.�
If yes, vulunle pumped: gallons -- Ilow was quantity pumped determined?
----- ---------
Reason for pumping:
_7E OF SYSTEM
Septic tatil:, +f�, soil absorption systen
Single cesspool
Overflow cesspool
_ Privy
Shared system(yes or no)(if yes,attach previous inspection records, if ally)
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
�o1f'}all
(1components. date installed (if known)and source of information:
Were sewage odors detected when arriving at the site (yes or no): /da
6
Page 7 of 1 I
OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 137 Megan Road
Hyannis,MA
Owner: Winifred D. Comietly
Date of Inspection: June 13, 2001
BUILDING SEWER(locate on site plan)
Depth bclo�� grade: 1d „4
Materials of construction: cast iron _ 40 PVC other(explain): 1;
Dilluim .• fron. 1-a 1%ate water supply well or suction line: _ AjZ,9
Comments(on condition of joints, venting, evidence of leakage, etc.):
/""�✓_���. ..-__t-t h a S G._i'1 ✓._ .-� L/ _ —C_-�('__ u.�--- -`!-
SEPTIC TANK: (locate on site plan)
Depth below grade: I '
Material of construction: ✓concrete_metal_fiberglass__polyethylene
--other(explain)
If tank is metal list age: _ Is age confirmed by a Certificate of Compliance(yes or no): (anach a copy of
certificate)
Dimensions: .$ 'Xy `X6'
Sludge depth: — S''
Distance from top of sludge to bottom of outlet tee. or baffler" _
Scum thickness: a 11
Distance from top of scum to top of outlet tee ur bath,: "
Distance from bottom of scum to bottom of outlet tee or baffle:
I ltm were dimensions determined:
Comments(on pumping recommendations, inlet and outlet tee or baffle condition.. structural integrity, liquid levels
as related to outlet invert, evidence of leakage, etc.y
�Qh.s r G'f /
L 't It f- .La1_�r._-'� .-T2.s.t._�..�.• e� C...0•..:�i_.(..
��- •--'---L`�u__. t ✓. aj-<�c s_ -ALL /C[�_��_�t_ a I,__ •/�-c= s,- _5---`�-4..i Uh s
GREASE TRAP:_(locate on site plan)
Depth below grade:_
Material of construction: _concrete_metal_fiberglass lyethylene_other
(explain):____.
Dintensiuns: ---------- ---------- -
Scum thickness: -----
Distance from top of scum to top of outlet tee or ba
Distance from bottom of scum to bottom of out] ee or baffle:
Date of last pumping:
Comments(on pumping recommendatioi inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert,evidence of akage,etc.):
.7
Page 8 of 1 I
OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 137 Megan Road
Hyannis,MA
Owner: Winifred D. Connelly
Date of Inspection: June 13, 2001
TIGHT or HOLDING TANK: (tank must be pumped at time of ins ciion)(locate on site plan)
Depth below grade:
Material of construction: concrete metal fiberglass olyethylene other(explain):
Dimensions: _
Capacity: -----gallons
Design Flu�� _gallons/day
Alarm present(yes or no):
Alarm level Alarm in working orde yes or no):
Date of last pumping:
Comments(condition of alarm and floa witches, etc.):
DISTRIBUTION BOX:N�A (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert:
Comments(note if box is level and distribution to outlets equal)any evidence of solids carryover, any evidence of
leakage into or out of box, etc.):
�t/J J•�..- VtlX ✓�.n YL � .c r..�
PUMP CHAMBFIZ: _ (locate on site plan)
Pumps in working order(yes or no): _
Alarms in working order(yes or no):
Comments(note condition of pump chamber,condXbfpumpsand appurtenances,etc.):
8
Page 9 of 1 I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 137 Megan Road
Hyannis,MA
Owner: Winifred D. Connelly
Date of inspection: June 13, 2001
SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required)
If SAS not located explain w1j):
1)'P
7.
leaching pits. number: I— t, x L l_
leaching chambers, number:
_.—leaching galleries, number:
leaching trenches, number, length:
_ leaching fields,number, dimensions:
overflow cesspool,number:
innovative/alternative system Type/name of technology: _
Conunents.(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation,
k __ w r. J" T t�v A r a�. i H S
/Ic
.Sp,[..L..��isv�,CESSPOOLS: (cesspoole8 as pan of inspectio (locate on site plan)
NUMIM' and rontiguration:
Depth tup ofliquid to inlet inDepth ofsolids layer:
Depth ofscum Ia-er:Dimensions of cesspool.Materials ofconstruction: _Indication of groundwater inflo _Comments(note condition of sraulic 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 hydra/ilure, of ponding, condition of vegetation,etc.):
9
i
Page 10 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
137 Megan Road
Property Address: Hyannis,MA
Winifred D. Connelly
Owner: June 13,2001
Date of Inspection:
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.
s
10
"Page 11 of 1 1
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 137 Megan Road
Hyannis,MA
Owner: Winifred D. Connelly
Date of Inspection: Jtute 13, 2001
SITE EXAM ✓
Slope
Surface water ✓
Check cellar
Shallow wells
Estimated depth to ground water 14 V' feet Adjusted high ground water elevation — feet
Please indicate(check)all methods used to determine the high ground .cater 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:
)/ /��.:.
�j�.,.•✓..sh ;,��_ -f-•�=r /.G:I ti� G!- 3' '/5.a_ �1�r,.� e+ !C' ��, f`.,.e. �. ,7{'.r r._ /,.S�l.� r-..
(i✓�,) c.. ( j ci �ty.!...� C u, ...� L—Gr - [u c (1 '' .7 c✓.'.. . c. 1 S v [,�r�
11