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Home My WebLink About0244 MEGAN ROAD - Health 244 MEGAN ROAD, HYANNIS A= 291270 • o I I` i i , \ COMMONWEALTH OF MASSACHUSETTS 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 Property Address:244 Megan Rd. Hyannis Owner's Name: (_harl es _. ,Tani e Brawn Owner's Address: Game Date of Inspection: Name of Inspector: (please print) wi 1 1 i am R_ • Rob i nson Sr. Company Name: William E. Robinson Septic Service Mailing Address: P O Box 1089 Centerville, MA Telephone Number: (5 0 81 7 7 5-8 7 7 6 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 tooSection 15.340 of Title 5(310 CMR 15.000). The system: G� Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Date: �—o,�� J Inspector's.Signature: �i, �, � ` The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that . time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 244 Megan Rd. Hyannis Owner: Brown Date of Inspection: .7 "6- Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. Sy em 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 repa'. d.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answe yes,no or not determined(Y,N,ND)in the for the following statements.If"not determined"please expla' . e septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally sow o d,exhibits substantial infiltration or exfiltration or tank failure is imminent.System will pass inspection if the exist" g.tank is replaced with a complying septic tank as approved by the Board of Health. *A in tal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indic ling that the tank is less than 20 years old is available. N explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstru ed pipe(s)or due to a broken,settled or uneven distribution box.System will pass inspection if(with approv 1 of Board of Health): broken pipe(s)arereplaced obstruction is removed distribution box is leveled or replaced ND a plain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass ' spection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND a in: Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 244 Megan Rd. Hyannis Owner: Brown Date of Inspection: G Z 3--C7 C. rther Evaluation is Required by the Board of Health: onditions exist which require further evaluation by the Board of Health in order to determine if the system is failin to protect public health,safety or the environment. 1. S tem will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the sy tem 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. S stem will fail unless the Board of Health(and Public Water Supplier,if any)determines that the syste 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 s rface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone I 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 pr vate water supply well". Method used to determine distance *This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform acteria and volatile organic compounds indicates that the well is free from pollution from that facility and he presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other ilure criteria are triggered.A copy of the analysis must be attached to this form. 3. ther: 3 Page 4 of I 1 Y OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 244 Megari Rd. Hyannis Owner: Brown , Date of Inspection: —Z. 3—0 D. System Failure Criteria applicable to all systems:. You ust indicate"yes"or"no"to each of the following for all inspections: Yes o _ 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 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. [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.] (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E Large Systems: be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gp Yo must indicate either"yes"or"no"to each of the following: (Th following criteria apply to large systems in addition to the criteria above) 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(I.nterim Wellhead Protection Area—IWPA)or a mapped Zone lI of a public water supply well . a you have answered"yes"to any question in Sertina E the system is considered a significant threat,or answered `yes"in Section D above the large system has famed.The owner or operator of arty large system considered a s nificant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 1 .304.The system owner should contact the appropriate regional office of the Department. 4 y Page 5 of 1 I J OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 244 Megan Rd. yannis Owner: Brown 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 / 9. Y Were any of the system components pumped out in the previous two weeks V/ 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? • _AZ _ 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: Yes no Existing information.For example,a plan at the Board of Health. Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)] 5 Page 6 of l l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 244 Megan rd. Hyannis Owner: Brown Date of Inspection: FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):3 Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms):3G 6 Number of current residents: ,c<A Does residence have a garbage grinder(yes or no): Is laundry on a separate sewage system(yeas or no):Ao [if yes separate inspection required] Laundry system inspected(yes or no): Seasonal use:(yes or no):&o Water meter readings, if available(last 2 years usage(gpd)): 2000 132,750 gal. Sump pump(yes or no): X,0 1999 135,000 gal. Last date of occupancy: 6 -W-z CO M ER CIAL/INDUSTRIAL Type of stablishment: Design ow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease ap present(yes or no):_ Indus ial waste holding tank present(yes or no): Non- anitary waste discharged to the Title 5 system(yes or no):_ Wai meter readings,if available: Last ate of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Was system pumped as paWbf the inspection(yes or no): If yes,volume pumped:gallons--How was quantity pumped determined? Reason for pumping: O TYP OF SYSTEM Septic tank,distribution box,soil absorption system _Single cesspool _Overflow cesspool Privy _Shared system(yes or no)(if yes,attach previous inspection records, if any) _Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight tank _Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: /13 -3-&- Were sewage odors detected when arriving at the site(yes or no): lL c> 6 Page 7 of 11 a OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 244 Megan Rd. Hyannis Owner: Brown Date of Inspection: G BU ING SEWER(locate on site plan) Depth elow grade: Materi Is of construction:_cast iron _40 PVC_other(explain): Distan a from private water supply well or suction line: Co ents(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK:V(locate.on site plan) Depth below grade: /'� Material of construction:—concrete_metal_fiberglass_polyethylene —other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions: T 6 Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: z� Scum thickness: 11 ' Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or b�ffle:/&a r How were dimensions determined: Q /1 Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity;liquid levels as related to outlet invert,evidence of.leakage,etc.): >� r/ 7d GREAS TRAP:_(locate on site plan) Depth bel w grade:_ Material o construction:_concrete metal_fiberglass_polyethylene_other (explain): Dimensio s: Scum thi ess: Distanc from top of scum to top,of outlet tee or baffle: Distan a from bottom of scum to bottom of outlet tee or baffle: Date last pumping: Comm nts(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as relat d to outlet invert,evidence of leakage,etc.): 7 Page 8 of l l OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 24470 Megan Rd. Hyannis Owner: BrQwn Date of Inspection: -0 TIG T or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth elow grade: Materi of construction: concrete metal fiberglass_polyethylene other(explain): Dimensions: Capac1 gallons Design low: gallons/day Alarm resent(yes or no): Alarm evel: Alarm in working order(yes or no): Date f last pumping: Co ents(condition of alarm and float switches,etc.): 7 DISTRIBUTION BOX: 7 (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): PUMP HAMBER: (locate on site plan) Pumps n working order(yes or no): Al in working order(yes or no): Co ents(note condition of pump chamber,condition of pumps and appurtenances,etc.): 8 s Page 9ofII OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 244 Megan Rd. Hyannis Owner: Brown Date of Inspection: SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why: Ty/leaching pits,number: leaching chambers,number: leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number: innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil,condition of vegetation, etc.): l ,p ►�, '.� l CESS OLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number nd configuration: Depth—t of liquid to inlet invert: Depth of s lids layer: Depth of s m layer. Dimension of cesspool: Materials o construction: Indication o groundwater inflow(yes or no): Comments is condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: (locate on site plan) Materials f construction: Dimensi s: Depth o solids: Comme is(note condition of 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: 244 Megan rd. —ITyannis Owner: Brown 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 yLl 3 b � Ll Vl 5y 10 ` Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 244 Megan rd. Hyannis Owner: rown 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: btained 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: 11 Commonwealth of Massachusetts Executive of Environmental Affairs DEP Department of Environmental Protection SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM f D � PART A :� FC V CERTIFICATION 03 1906 Property Address: ayy , ,t�V't Address of Owner: MAcs - (if different) 3ttr,-c� Date of Inspection: C ��t- WA • �='� 3Z Name of Inspector: Michael DeDecko Company Name, Address and Telephone number: Atlantic Environmental P.o Box 2384 • M ashpee Ma 02649. Tel : (508)4771420 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection . The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. The system -k Passes ---• Conditionally Passes -•-- Needs further evaluation by the local Approving Authority ---- Fails UInspector ' s Signatur . WDate: \ ►`t q1% The system Inspector shall submit a copy of this inspection report to the Approving Authority 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 or the Department of Environmental Protection. The original should be sent to the system owner and copy sent to the buyer, if applicable and the approving authority. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: a4y Rcgnr,� Owners : CfKQwlm— D ate of I nspection : t i\"k INSPECTION SUMMARY: Check A,B.C,or D A) SYSTEM PASSES: �\ I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CM 15.303. Any failure criteria not evaluated are indicated below B)SYSTEM CONDITIONALLY PASSES: ---- One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair, passes inspection. Indicate yes, no, or not determinate CYR or ND). Describe basis of determination in all instances. If "not determinated", explain why not. ---- The septic tank is metal, cracked, structurally unsound, shows substantial infiltration or exfiltration , or tank failure is imminent. The system wiH pass inspection if the existing septic tank is replaced with a conforming 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 pipe(s)or due to a broken,settled or uneven distribution box. The system will pass inspection if (with approval of the Board of Heakh). ----- broken pipe(s) 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 pipe(s). The system will pass inspection if(with approval of the Board of Health): ----- broken pipe(s)are replaced ----- obstruction is removed 9 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address : any Owner : Date of Inspection : ,`�o a`cio. C) FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: ---- Conditions exist which require further evaluation by the Board of Health in order to de- termine if the system is failing to protect the public health-,safety and the environ• -- ment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETYAND THE ENVIRONMENT: -- Cesspool or privy is within 50 feet of a surface of water --•- Cesspool or privy is within 50 feet of a bordering vegetated wetland or a small marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNC- TIONING INAMANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT. ---- The system has a septic tank and soil absorption system and is within 100 feet to a surface water supply or tributary to a surface water supply. ---- The system has a septic tank and soil absorption system and is within a Zone I of a public water supply well. •--- The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. --• The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water supply well,unless a well water analy- sis 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 notrogen is equal to or less than 5 ppm. D)SYSTEM FAILS: -• 1 have determined that the system violates one or more of the following failure criteria as defined in 310 CM 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what win be necessary to cor- rect the failure. --- Backup of sewage into facility or system component due to an overloaded or or clogged SAS or cesspool. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: ayy IAtAft\_� Owner: Date of Inspection : 'r 1 iy1y� D)SYS T E M FAI LS (continued) -• 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 over- loaded or clogged SAS or cesspool --• Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 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 Soil Absorption System,cesspool or privy is below the high groundwater elevation. -- Any portion of cesspool or privy is within 100 feet of a surface water supply ortributary 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 ana- lysis. 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. h• r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: M(c&Q Owner: D ate of I nspection E) LARGE SYSTEM FAILS: The following criteria apply to large systems in addition to the criteria above : The design flow of system is 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 foNowing conditions exist : --- 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 - f WPA)or a mapped Zone I I of a public water supply well. The owner or operator of any such system shall bring the system and facility into full compli- ance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please, consult the local regional office of the Department for further information. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: ��41*3 Owner: eatj ec� Date of I nspection: Check if the following have been done : -x Pumping information was requested of the owner , occupant and Board of Health. --x None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during the period. Large volumes of water have not been introduced into the system recently or as part of this inspection. -•x As built plans have been obtained and examined. Note if they are not available with N/A. --x The facility or dwelling was inspected for signs of sewage back-up. --x The system does not receive non-sanitary or industrial waste flow. ••x The site was inspected for signs of breakout. ••x All system components, excluding the Soil Absorption System,have been located on the site. -••x The septic tank manholes were uncovered, opened and the interior of the sep- tic tank was inspected for conditions of baffles or tees,material of construc- tion, dimensions,depth of liquid, depth of sludge, depth of scum. --x The size and location of the Sal Absorption System on the site has been deter- mined based on existing information or approximated by non-intrusive methods --x The facility owners and occupants if different from owner were provided with information on the proper maintenance of Subsurface Disposal System. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: ayy Yu&;Ar t,J Owner: �ettzo'CA ., Date of Inspection: RESIDENTIAL: Design flow : 330 gallons Number of bedrooms : 03 Number of current residents: 0 Garbage grinder (yes or no) : No Laundry connected to system (yes or no):�.ke_S Seasonal use (yes or no) : 1�0 Water meter readings, if available: w Last date of occupancy : COMMERCIALANDUSTRIAL : Type of establishment: Design flow : gallons/day 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 : Other: (Describe) ............................................................................................................ Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: System pumped as part of inspection (yes or no) :......f�A.C...... if yes,volume pomped: ..................... gallons Reasonfor pumping :.......................................................................................:.................... SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: a%A LX c Owner: rgLw%v-rL_ D ate of inspection: i r l�A YI b TYPE OF SYSTEM X Septic tank/distribution box/soil absorption system Single cesspool --• Overflow cesspool -- Privy --• Shared system (yes or no) (if yes, attach previous inspection records, if any) --- Other (explain). ......................................................................................... APPROXIMATE AGE of all components,date installed (if known)and source of information Wa;&..ac�c....... I....W'.)'a...Q.svr....�.ti`1t��......................................................... . ................................................................................................................................................ ................................ Sewage odors detected when arriving at the site : (yes or no).....!�.. SEPTIC TANK : ...!SS..... (locate on site pla , Depth below grade: .14" Material of construction: ..k.. concrete ......... metal ........ FRP ........ other (explain) ................................................................................................................................................ Dimensions: 5 S. Sludge depth:..a..'!....... , Distance from top of sludge to bottom of outlet tee or baffle:....3 a:................... Scum thickness :.....I................. , Distance from top of scum to top of outlet tee or baffle: ..........t.i?......................... Distance from bottom of scum to bottom of outlet tee or baffle :......MS.."............. Comments : (recommendation for pumping , condition of inlet and outlet tees or baffles, depth of liquid level in rel tion to outlet invert, structuralintegrity,evidence of leakage,etc ) .... .�?�..��..�. V►?!).�.,..� 10�1.. ..�3.�.`.s...�ra.L�T.1.s�Tka...�{..� ... ........................................................ .............. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 9 lky "rrN Owner:G-7Rjt ;t Date of inspection: 1\�t4`�tb GREASE -TRAP . .......NO... - -- - - - - - — --- -- - -- -- - - (locate on site plan) Depth below grade: ... rade: ... Material of construction: ........concrete.........metal........FRP........other(explain).... .......................................................................................................................................... Dimensions:............................... Scum thickness:........................ Distance from top of scum to top of outlet tee or baffle:....................................... Distance from bottom scum to bottom of outlet tee or baffle:............................... Comments: (Recommendation for pumping condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert,structural integrity, evidence of leakage, etc.)........................ ................................................................................................................................................ TIGHT OR HOLDING TANKS:....N.V... (locate on site plan) Depth below grade:............... Material of construction:........concrete........metal.........FRP..........other (explain).......... ............. ....:.............................................................................................................................. D imensio..ns ........................... Capacity:....................gallons Design flow:...............gallons/day Alarm level:............................. Comments: (condition of inlet tee, condition of alarm and float switches,etc.) ................................................................................................................................................ 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PAR T C SYSTEM INFORMATION (continued) Property Address: a Lv-% Owner:- Date of inspection: i A 1gb DISTRIBUTION BOX:..�{�� (locate on site plan) Depth of liquid level above outlet.invert: Comment: (note if level and distribution equal evidence of solids carryover, evidence ol leakage into or out of box, .1.,d� . ................................................................................................................................................ PUMP CHAMBER:... 4... (locate on the site) Pumps in working order: (yes or no)............... Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.).................... ................................................................................................................................................ ................................................................................................................................................ SOIL ABSORPTION SYSTEM (SAS):.111 ; ....... (locate on site plan, if possible; excavation not required, but may be approximated by non- intrusive methods) if not determined to be present, explain: ................................................................................................................................................ ....................................................................................................................................... Type: leaching pits,number: ..o` . .�rXta��1 S leaching chambers, numbe ......... leaching galleries,number:........... leaching trenches, number , length:..................... leaching fields, number,dimensions:................... overflow cesspool,number:.......... Comments: (note condition of soil , signs Qf hydraulic failure, vel of pondi ondition ofMegeta 'on, etc.) C .c�r�..a .S�.t.l...�l(�t�?�t Nc�.. .r� . .Q►. ....`1... �. ... ?�T''.5.14�lpt.,.. . ....... ...5 .In • SUBSURFACE WAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property address: '�� 1ratr' Owner: �vf-iL� Date of inspection: CESSPOOLS:.... (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: ..................... Indicator of ground water: .................... inflow (cesspool must be pumped as part of inspection) ................................................................................................. ................................................................................................. Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc........................................................................................................................................... ................................................................................................................................................ PRIVY : ... ?�..... (locate on the site) Material of construction: ................................... Dimensions: ...................... Depth of solids: ................ Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.). ................................................................................................................................................ SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: C1mu;cvL. Date of inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate at wells within 100' � Zyy a g _ � S Ay - III 3 �I DEPTH TO GROUNDWATER: Depth to groundwater: 15.0..feet Method of determi ation or approximative: . ........................................................................................... ................................................................................................................................................ ................................................................................................................................................ a � `LOC_AT1ON 5EWQ.C,E PERMIT_ MO.- ` 5 C ! I - - - - - els $UIL.DER-5-- ADDRE SSpe __.�,%_s-� ---D.1J►TE-.PERtv�1T.ISSUED_.-.�t_��'__-__ d '�. f 'Qs y � �� , Y � _ /'� `Y/r//®�/ �`i Pw.r .' ,��. � {. c„�il • . x TOWN OF BARNSTABLE � . i LC . ATION � �A /)�aoa -SEWAGE # VILLAGE zzy.a/JIgI ASSESSOR'S MAP & LOT / INSTALLER'S NAME & PHONE NO. 1G14'(1507V- SEPTIC TANK CAPACITY /ADD G �/ --/-7—i7 LEACHING FACILITY:(type) `�C / (size) 6e k16 NO. OF BEDROOMS PRIVATE WELL O PUBLIC WATER . BUILDER iOWNER- DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No t s � G� �, cv' r TOWN OF BARNSTABLE Lf%CATION ''I y SEWAGE # VILLAGE ASSESSOR'S MAP &LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) NO.OF BEDROOMS BUILDER OR OWNER PERMITDATE: COMPLIANCE DATE: 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 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 by 0 r� 04) C� a 4 j 4 Zyl 7,70 THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE App iratiou for Bi-tipoottl Evrlw Tomitrurtion Prrutit Application is hereby made for a Permit to Construct ( ) or Repair (' ) an Individual Sewage Disposal System at: ..... .�� .... / icslS--------•--• ----------•--- --• ------•---- -------------- - - ocation-Address �® U Il0 1"/ Lot No ,a! yam..---••- .....�---- -----------------------�---- -.ram--"- '�'''�------......-- !F�.d� --- O ner - .. Ad ,- a .............................................. -•••U��'�---- --- Z --- _7• - --- --•--•• ...... Installer Ad ress UType of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms--------------------------------------------Expansion Attic ( ) Garbage Grinder (r—}—/mod aOther—Type of Building ____________________________..No. of persons---------------------------- Showers ( ) — Cafeteria ( ) d Other fixtures. w Design Flow..............:.:.. ------------------gallons per person per day. Total daily flow............. WSeptic Tank—Liquid'capacity_1 _.gallons Length__-__--__._-__ Width________________ Diameter_._.___.___.-_ epth................ x Disposal Trench—No_____________________ Width-------------------- Total Length.................... Total leaching area....................sq. ft. Seepage Pit No.............1.----- Diameter._._.._..l0------ Depth below inlet----44........... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by................................................................... ------ Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water-.____._-______----__._. rZ Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 0 Description of Soil--------------------------------------------------------------------------•------------.-----------.......----------•--•------•------•-•----.............-•-•----.----- x w UNatu of Repairs.or Alterations—Answer when applicable_.__._.._ '� ..__.____ -:....___..lo __..L 4 . Agreement: ti 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 hA ben is ued y th board of health. Signed .. lba--------- ----..� ................ r� o'�`y'�-- Due Application Approved By ........... Application Disapproved for the following reafons: .... .... ...... .......... ............ . . ......... ..................... -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ........................................ Permit No. -------I.Q.---,31 U�� / -- .. Issued ........................ ....................................... Dace II Al - No...... -..CA.. L/ Fss..� ... �...... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE s r 1 Ap.pliration for Uhnipniittl Wnrizi Tomitrnrtion Frrmit Application is hereby made for a Permit to Construct ( ) or Repair (>�/) an Individual Sewage Disposal System at: `f-------- s�'� �'... �0 ��L)V�j/4,j -Address ( ' . � Lot N t`E � j o. C - ......--- � r-L. jar __ ......................................... - r... Owner Address t-671 25Z sf 7W L 1� �/1/I t rM I L(_J a •-•••-••••-••.•••-••---••---•---•-•....•-------•••••---••-•-----•-•----•--•••-----•---••--•-••---- •--------•---•-•---•--•-... ••-•••........... . Installer Address d Type of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms___-_-_•____-___--�----------------_-Expansion Attic ( ) Garbage Grinder `04 4 Other—Type of Building No. of persons............................ Showers — Cafeteria p't Other fixtures ---------------------------------- W Design Flow.....................5: -----------------gallons per person per day. Total daily flow-------------_��- !" _-_ZZ gallons. WSeptic Tank—Liquid capacityl4�___galIons Length---------------- Width---------------- Diameter................ Depth__---_______._.. x Disposal Trench—No. .................... Width----------.......... Total Length............ Total leaching area....................sq. ft. 3 Seepage Pit No---------.---/...... Diameter--------IKQ-_�._ Depth below inlet.....am---- Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. I................minutes per inch Depth of Test Pit-------------------- Depth to ground water........:............... fX4 Test Pit No. 2................minutes per .inch Depth of Test Pit.................... Depth to ground water__..-_---__--_...__-_--. a ._.......•---------------------•-••----...------•••------•-•-•-•--------------•---••......----•-•---......................................................... 0 Description of Soil........................................................................................................................................................................ x W --•-••------------------------------------------•-•------------------------------------•-•--•--•---•-------•----------------------------------------•-•---•---------•------•--••-••---•--.............. UNature of Repairs or Alterations—Answer when applicable-----------4--b-A---------- ----------lojaQ_:�_�___®__ L- . •-�•- .r! Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with 4 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�h s�be n is ued •y the board of health. Signed ............,/.�f i ....t --- `tIt /U &..f P - / C ............----------------_. ---- ..._/..Date:...-../.. Application Approved BY ---------- -�� v / (------��/ �... .................................................................................... to Application Disapproved for the following reasons- -------------------------------------------------------------------------------..................................................... «a•""` Date PermitNo. 1. ..-_ .�...-7o�]------------------------ Issued --------..-------------------------------------------------------- Date —._—_.---.------.------------------- ----- ------------.---.—, .--`---- —.— ---.----� THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE VYErtifirate of C omplianve THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (� ) b %....fir✓ - ..LJuo. GfJ:ca.S�J'--Luc r i� y .... Installer /� —,i1 ill -r--J f.�IS at --------------------------- ------------... -- yy--------- �/d ---------- - .. .. �` `' _------- - - 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. j -------.&_.Y..I-L----- dated ...._............................._...._.. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATI EACTORY. ;<' ` L,� 7 J �- DATE 1... 7r..... - /--------- ---...--- Inspec or. ..... - � ---,-------------------D__------------------------------------------------ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH cqy TOWN OF BARNSTABLE NO...... FEE........................ Biopooal orl; �onotr rtion rrmit %�Ut_e r G.rr.t?; �.�Permission is hereby granted------------------ - -•-<_...G ' _ . .....•----• --- . t......------------.......... to Construct ( ) or Repair ( ) an Individual Sewage Disposal System IV Street as shown on the application for Disposal Works Construction Permit D-a-twed------&_"_3�--_7c;/--•.- 9.,gd—of aHe alth DATE......................... ••---------------•---- FORM 36508 HOBBS&WARREN.INC..PUBLISHERS