HomeMy WebLinkAbout0045 MELBOURNE ROAD - Health 45 MELBOURNE RD., HYANNISA
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COMMONWEALTH OF MMSACHUSET S JUN
E ECUTIVE OFFICE OF ENWIRONMENTAL AF��AIRS 2 1 2��� �
DEPARTMENT T Or E VYJT0NMENTAL PROTEC I ON TOWN DF
ONE WINTER STREET.BOST014 MA 02108 (617)292.6500 NEgI1H�p9114E
ARGEO PAUL CELLUCCI DIi.'ir1D B.tr79tum
Governor 1I)IJVS111MACE SEWAGE DISPOSAL SYSTEM SISPECTIOM FOAM Conssisdonor
PART A
C8I'1flRCATIOM
FiMorly Ad*on: y w e "'p2 Mama of O.dnor o r a t i ( 1✓0 w
1 '� Address of otsnra.:,
IDow of lbr101,11 n: yap 03 ' .
Nuace of .:� A G lf Gofvo�
l am a OE d sys9oaan b etor purauartt'o 1p 16. 91 TIUa 6(3101CMNt I i.WO)
coo""Naooa: kr R ~ dq q 5
Eel
jqr
-rdslpltorts MttaSwe:
i certify that I have personally Inapacac!the sewage disposal system at this address and that the Information reported beiove in u1i r, acaa•at-e
and complete as of the time of Inspeetiott. The Inspection was performed based on my training and experience in this props,hmc•t on and
mel~, once of on-sits sewega disposal ivatems. The system:
Passes
Conditionally Penis"
Weeds Further liVoluation By the Local Approving Authority
Fails
faaprsaan.'a : ' ®arm: 4G1A
The System Inspector shall submit a copy of this Inspection report to the Appr+o'Ang Authority(Board of Health or OEP)wkNn thing (301+lrei,s of
cornislating this inspection. if the systsir Is a shared system or has a design flow of 10,000 gpd or greater,the inspector lout thr, .ryataet owner
shell submit the report to the appropriate regional office of the Department of Environmental Protection. The Original should loci vowt to to
systrM+n owner and copies sent to the buyer,if applicable, and the approving authority.
NOTES AND COMMENTS
revised 9/2/98 rap 1ofll
"mod em K".*4 P.;w
SMURFACE UWAGE DISPOSAL SYSTEM OWNCTION FORM
PART A
CM I WI'.ATIOM IgWdkaead/
Onto of .J �� /Co q p A/�
Ilrlyl9ECTI6 S11 O71M1AR9h AI, Cw or
A. MTWA ice:
�I I have net found any informialm which Indicates that any of the failure conditions described in 310 CMR 15.30:1 e.Kls;. Aiey•hodure
T� criteria not awNueled are indhmled!below.
COMM OM
IL SYSTM COMRM4AOMAUY PASSES:
One or more system eomporeints as described In the"Conditional Pass"section to be replaced or repaired. 'rove sopstarn, Mann
complation of the replaceme!1t or repair,as approved by the hoard of.Health it pass.
h ,c*te yea. no,or not determined M N.or ND). Describe basis of datermi on In all Instances. If "not determined",e>t:plrsin rrhy not.
.... T11s s�tic tank is rretal,unless the owner or operaas provided the system inspector with a copy of a,oiutificatse of
Compliance(attachadl Indratinp that the tank instanod within twenty 1301 years prior to the date(W t#se I rspeciior!:or
Ste septic tall*, whether or not meth, b od.structurally unsound,shows substantial infutradon or srxflh.,i'tion, -xr,teen*
failure Is Imminent. The system win s inspection if the existing septic ten*is replaced with a complying u0ptic tarsk its
approved by the hcead of Health
Seswate backup oy reakout or high static water level obsetrved In the distribution box is due to broken car*1310:'uclod pl;aalsl
orn, 'settled or ufNven distribution box. The system win pass Inspection if(with approval o-f id?s; Bosenl of
broken pipels)we replaced
obstruction is removed
distribution box Is ievWW W replaced
ye¢rra!t pump}nh more than four times a yew slue to broken or obstructed Opals). The systern rnll peas.
teupection If(with sfsprovai of the howd of Hoahh):
woken phWs)we replaced
*bethmoon Is removed
revised 9/2/98
SUBSURFACE SEWAGE DISPOSAL iYSTE M WSPFCTION FOEAsIt
PART A
CERI RCATMN(eernctl"Mad
Owmar: v 4 0
Dow of,l sp am :5-1026100
C. IFURTHEM EVALUATION EN REQUSIM AT THE BOARD OF HEALTH:
Conditions exist which require further evaluation by the Board of health in order to determi tM system is fallma us l;;'otect live
public haatth, safety and the arMronment.
11, SYSTUA WILL PASS UNLESS(WARD OF HEALTH a ACCO WITH 310 CUR IL302(Ift)TIN►'I THE SI fly
a NOT 0 A MANNEI1 V041 CII WILL PROTECT TW PUBLIC TIf AND SAFETY AND IM fJW111A;Ofllll;9d0T:
Cesspool or privy Is within 50 feet of surface water
Cesspool or privy is within 50 feet of a bordering vepe d watland or a sett marsh,
21 SYSTIFAI VALL FAIL UNLES111 194EfF HEALTH(AND PUMLIC WATER SUMM,OF ANY)DETWMNES TEHM'lnitm S'1fS'IF w is
FUNCTIOaOW IN A 1 M THE PUBLIC HEALTH AND SAFM AND THE E W1111dONfYIBMT:
The system has a see a tsoil abeofpdon system tAli>gb and the SAS.1s within 100 fast of a surfeN:e weir.-or:euplr19 or
tributary to a su71000,
water supply.
'The cystern hasaic tank and soil absorption system and the 3AS is within a Zone I of s public water s;ipl; d well.
The eystam has .Oc tank and soil absorption oyster+and the SAS is within 60 feet of a private water sulk;ly was,
+, The system h s sapVc tank and sell absorption eyetarm and the SAS is less than 100 feat but 60 foot at nnoc 1 from a
private woter apply wall,urisss a wall water analysis for coliform bacteria and volatile organic compounds.in;l,cates dwi the
Z6 .
orn pollution from that facility and the preeent:e of arnnsorwo nitrogen and nitrate nitrogen lac •+pmr l to or lseu
Meihod used to determine distance ^lapproxfvnadon rot vaMl.
31 OTHER
revised 9/2/98 Polp3ofis
StISSURFACE SEWAGE DISPOSAL SYSTON SISPECY110111 FONM
PART A
CO v UlICATION loaerilrwvilli
r
plalta �w�. �-���lbc►vf-r+� P�
Osrt�s:r: .=�o�i
OMo pal letopsedea: --��`�
0. :rase[[FALB:
You mast indlc m either 'Yee"or"No* to each of the following:
I hove determined that one or mare of the following failure conditions exist as described in 310 CMR 16.303. Th,s bait'!•for tKis.
determination Is identifled bofcw. The Board of Health should be contacted to determine what will be necessary is cori r;ct t)wi ia[i,ue.
Yes No
_ Backup of sewage hito facility or system component due to an overloaded or dogged SAS or cesspool.
_. Discharge or panding of effluent to the surface of the ground or surface waters due to an overloaded or cioggii I SAS or
cesspool.
Static liquid level In the distribution box above outlet In to on overloaded or clopgod SAS or cesainci.
Liquid depth in cassi7ool Is lose than d" below or ava8able volume Is leas than c;2 day Now.
.� RoWlred pumping prows than 4 times 4lte last your JW clue to clogged or obstructed pipets).
Number of dines pwl**d
._ Any portion of the Sall Ab rpt)on System,cesspool or privy Is below the high groundwater elevation.
Any portion of a cos *of or privy is*[thin 100 fast of a surface water supply or tributary to s surface rvai*,r nupoy.
a Any portion of **spoof or privy Is within a Zane I of a puble won.
_ Any of a cesspool or privy Is within 60 feet of a private water supply wog.
_ An ®rtion of a cesspool or privy o less-thenands.100 feet but greater than 50 feet from a private water suluNy yr Ai*itfi mD
optable water quality analysis. If the well has been analyzed optabh,attach copy of wog warow ur alyais for
conform bactsria, voi.itlle organic compounds,anxnopila n and nitrate nitrogen.
E. LA AM MYS7�R FAILS:
you roust Indicpaso ehhsa"Yes'or"No" to.path of the owing.
The following crltedo apply to large ays n addition to the criteria above:
The system come a facility with a Ign flow of 10,000 gpd or greater(Large System) end the system Is a signilicas,t threat lip 1>rblk
health end sehty and the emviro n!beceuso one OP mo►s of the foibwlnp conditions exist:
Yes No
_ the system wkhin iM feet of a surface drinking wocar e►pply
the.y Is w:kNn 100 feet of a tributary to a surface driai Ling wow supply
system is locitwl In a n►trogan sensitive was llrnterim Willhesd Protection Area:IWPA)or a mapped i:ara of a Itrtiic
at VjPPiy win)
The ownar or aperstor of any such system sholl upprsdo the system in aecordsnes with 310 CMR 15.304(2). Please consuh:the I,tcsl regime.)
9ftli,of the Depo tmarit for further Infontiodon.
revised 9/2/98 P604of11
IR MURFACE 8 MAGE D1fMAL:YST1191111 NSPECTWN FORM
PART s
CHECKLOT
s Agewob
Chok i!the following have bon done: You must Indicate either"Yes" or ,Na' as to each of the following:
Va No
Pumping information was provided by the owner,occupant„or Board of Health.
None of the system.omponoro:e have been pumped for at least two weeks and the system has beenre*sivin3l'tonnah Ih)'N
rates during that period. large volumes of water have not been introduced into the system recemly or us h*rs,of this
Inspection.
An built plane have glen obtained and examined. Note if they are not available with NIA.
The facNhy or dwelling wee inspected for signs of**wags back-up.
The system does not receive non•sanhary or industrial waste low.
_ The alto was inspected for signs of breekout.
AN system components,excluding the Soil Absorption System,have been Iocated on the*Its.
The septic tank mardod"wore uncovered,opened,and the interior of the septic tank was Inspected for aorodhl m of bittlea
or tons,material of oonstruetlon.dimensions,depth of Nquiel, depth of sludge,depth of*cur".
The alte and location of the Soil Absorption System on the site has been daternhined based on:
Eslsting information. For example.Plan at Y.O.H.
7 _ Detarmined in the flelui(It any of the failure criteria related to Part C is at issue,approximation of distance is urnocs; 4*ii
t'i 5.S02t3 IM
The facility owner(and oocuperhts.if different from ownw)were provided with information on the proper rrupwj;I r&m;e I;f
Subsurface Disposal Systems.
rev-6: sed 9/2/98 lsrfl
tiUNWRFACE SEWAGE DISPOSAL SYSTEM WSPECTNM FORM
PART C
SYSTM WaKwAIu1rION
Pal► f/'�f e/boar �C0
Owner.
DM of hmpeador C
FLOW C0111101171100110
Design w:�flo d—,g.p.d.Awidroom.
Number of bodroo no Idsaign):__V Number of bedrooms Isctuel):.3
TOW DEsi®N Haar.:-rSli
Number,of omrent residents
Oatrbegs 9rtnder(yes w no):
Laundry("Dorm system) (yes or no):AL4 If yes, separate inspection required
Louaft systsrtt Inspected or no) V
seasonal use(yes or no):
IAtetow motor readings,6f av 6abie(test tovo year's usage(gpd): !
Sump Pumil(yes or no):
Leer date of occupancy:
Type of establishment:
Deapin flaw: ag i eased on t 15.203)
Blois of design stow
Crease crop present:iyes w no),,,,_
Indugeold Waste melding Tank prosern: s or no)_
Non'saaaitwy waste discharged to Jo i system:;yes or no)_,
We t matey reedlr►gs,If _---
Last dots of occmponcy:
OT M.,(Desoriba)
'.oat ease at aeeup
9�AL/IFORMATIOM
PUlLYPM RECORDS and so rce of irifm melon:
system pumped as rt of inspection:(yes or no)_
if yes. vokame pumped: _golrons
Rsaeon for pumping:
✓— siopft i sol absorption system
SU40 coo
!Overflow cesspool
shared system(Yes or no) (If 1.1wa,ottaoh provlous inspection records,if any)
VA Technology etc. Attach co(i�y of up to slate operstion end mMntomknes contract
Tight Tank Copy of DEEP Approval
Other
APPVIO3MATE A®E of all components, dot@ Installed(if known)and aouree of information:
SemrISa*dare defected when wrivbV at the site:(yes or no)
revised 9/2/.98 rsersafti
HLOSURFACE UWAGE DISPOSAL SYSTEM WSPECTION FORM
PART C
STSTM fHFORMkTfON 4oailMaradf
Prep atq Ad*eu 7: 5-Aelj v e Ff7
Dow of btapser.re 5' �1OF
f9UlRMi i 111101:
(LoCrite an tilt plans
Depth belo a fFWs=D
Masora of construction:,--r east iron 11 40 PVC other 4expleln)
Distance from ,raft wader supply wall'x auction Inc - ----
Disarms,
Comp"Orts: ioondNiai of jaim.venting, evidence of leakage,ate.)
ltNrlllC TANK: .
4looa- an elte plans
i
Depth below grade.,
Matsrid of construction:,Z"ncreta-, Mmel_11bergless _Polyethylene_,.other(exploin)
If tw1k is nww,Not age_ is sga confirmed by Certificate of Conrpllanea (YealNe) -----
DMifra rta.
Sledlf/s depth: �/
DiStssnce tram top of yyn)ge to bottom cit outlet tea or baffle�z
Same thiaknna:_ I .,., n
Dietnnca from top of scum to top of oull-tt tea or be fie:-4, L
Disume from bottnnr of scum to botto n of outlet beMe:,1�
low,dknenalons were determined: d P
Common 8:
lroccrnmtndedon for pumping,condition of inlet ant outlet tees or belles, ds}pth of I d I"in relation to outlet invert, stnaclivul Integritr,
avkhme of leaks ate.)
_cs"""H�CJJ ,�k�! .� l a (1`F" ry r 7F61 -711p <L.
GM UM'TRAP:
lfocan on site plan)
Daptfi below ff eft—
Mat Ad of Construction:_concrete_.instal—piberglass ,rPol ane_other(cxplain)
plrt�intelorio:
•ours tMckness:
Dleornce from top of Scum to top of mAbvt toe
Disame from bottom of Bourn to bottan o we or be"m
Data of last puriiping:
Cannnorsts:
iracrpmrm lotion for pu .conditloit of Inlet and outlet toes or boffies,depth of liquid level in relation to outlet invert,structu,fl intagietr,
@"a"*of loafs*",ate
revised 9/2/99 PW7at11
I1IJeSURFACE UWASE DISPOSAL SYSTS11 1MS►IECT M FOM
PART C
D� SYSTEM MFOM%TM leorldrome
Dom ��r ��N
of
lr OR p TAILS: (Task must be pumped prior to, or at Vff*of, lnspactlen)
ilecato on aka plan)
below erods:_„�
Material of ean`truetlon:_concrete—instal—Fiber �Pof)rsthYleta_other(explain)
C"Oft.—gallons
Design ftw:.r,__,._,Sallonelday
Ak m,p pro""t
Alarm level: _ Alarm orkin4 order:Yes_ No—
Date of previous pumping: _.
Comneente:
icons~of inlet tee, on of dorm VW float swkcMs,ate.)
OW p MW1 ll�
poce!e on ante plan)
-Ooot of"Wd)svel above outlet I"vO0ft:,Adi&
Canm"tontlr:
(r+oto.N level sued disabb equal. _idancs of solidest oa►r� ve► ✓nc_a of leeks a irKo or of te•f —M ^ _—
,---alit �.--�"/. _
VW;P
ikoosia on eke plan)
pumps in weekh order:(Yee Of li O)—
Alamos In work"order(Yes or NO)_
Com"onte• t on of pumps and appurtenances,etc.) --.--—
inotr condition of pump ohomber P"
re-vised 9/2/98 PW6of11
r
MISSURFACE SEWAGE DOPOM SYI),IMA iIMO'ECTIDM FORtIA
PART C
STEM NFOIMAATION IeerMMarodl
der �� r✓6 t96+//a Q
Outten:
090 en Irtyaatlau►
SOR.ASSOlr"M S'YSTBA CUM
(locate on alto plan,if poes(ble;sxcava cei not required,location may be approMmeted by non-Intrusive methods)
If not boasted,explain:
Type: Mae"pits,"Umber.-
b Wft ehernbere.nurnbae:-,,_-
loss"geflorles,nurreber:a
lose"trwtchas,number,lergph.
Isec"finial,number.dimenrbtns•
overflow oseepooi,rAm*w:__
Altsrrtetive systw: _
Metre of Technology:.
CerreteneMs:
(note condition of a gns of hydraulic f level of gondlnp, damp s*I con4pon f vegetation, etc,) 1 ( f 4
w - ,
e
(loss"on alto plan)
Murrdfsr end conAgursSon:,^,�,_•,
""°epd� xip of VipM to Inlet Invert:
spier of"no Iayar
uapeh of sc urn ISVW:
Dmwelons of cesspool:
Memorials of oonatrucdon:_��.
lndtea Won of grotrndwNW:ae-
inf)ow(cesspool loot be pad as part of Inspection)
Ceeraerente:
lorote cear don of as(I, of hydraulic failure,level of pending, condition of vegatstion, atc.)
PRfYY
thwate an site Nan)
Materials of cons -
Depth of a**&.ts Cwrmw :
inote conditbn of eigna of hydrauNc°bluer.Ievel of pond(ng,condition of vegetation, etc.)
revised 9/2/96 regtsoftt
INUBSURFACE BEWA43E OM!•OSAL=YSTVA WSSPECTION FORM
PART C
sYOTm wIaQMATION 6e'awliw"
�: �7�,
GKffM OF UWAME COMPOSAL MTIld:
iedude tkq to at least two peniowm t reference landmarks or benchrnorks
wee"all wells wiMain 900'ILo:ete where publk:water supply comes into house?
r
revised 9/2/98 �t�oru
r v
SUBSURFACE SEWAGE DOPOSAL SYS1'1A MISPECTMNt FORM
PAW C
! BvJt van VIIIFOFMATM feaftued
e tr � aol �Grl�� e-
Cho of,i Mp
Mac$ Report.mtw l -_—
$a Tynpe_ _e -- ---- -�------ ----- .r
Svcs depth to w4undwater--
UMasa Dose waba6to vietsd
Obaervaftn Web*hooked
Groundwater depth: Shagowr- Moderate
SITE EXAM Slope
surface water
Check Cellar
Shoilow Weft
EsOmated Depth to Gr*Wdwatsr-,QF4wt
piesse indicate an the methods used to dotarmine High Groundwater Elovation:
'' >> Obtained horn Daman#sane ore recax�d
e/ (*sawed Site(Abum"property,cl)eorvation hole,basamamt sump ate.)
�a Determined*at"local conditlona
t;haekad with local eloerd of hoe th
(:Mekad FEMA IWape
(:hooked pumping records
Chocked local sxcsvators;InSWIM!
Used USCS Oats
Oaecrllte how you astaNlshod the High Groundwater Elevation, tHM be compMted)
v'b
ze~vieed 9/2/98 ftvitdit
TOWN OF�BAQRNSTABLE
ON 5"N_c\Nn,_a one.1W�. SEWAGE #
/ �.LAGE 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 to the Bottom bf 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
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