HomeMy WebLinkAbout0055 MELBOURNE ROAD - Health 55 PAELBOURR!E FtGl�►D; HYANNIS
A
i
r
.f
n
Q
i � G
f
G
{
2-0
{
S
E �
n
c`s
cr
car in
S.McGlame
55 Melbourne Rd.
HyWis,MA 02601
Above-Grade Building Sketch
Borrowei/Client McGlame Sean&Stacey
Pfoperty Address 55 Melbourne Road
City West H annis ort County Barnstable State MA Zip Code 02672
Lender North American Mortgage Company
Dimensions are Approximate
Rooms are not to Scale
12:0'
10.0'
Bath
Dining
Bedroom Bath Kitchen Area \
24.0'
28.0'
Living Room
Bedroom Bedroom
14.0'
20.0'
24.0'
M.
06-01-2009 a 01 = 30s:�
(rz�00 PC) �
DEED RESTRICTION
0
04 WHEREAS, Sean P. McGlame and Stacey J. McGlame, of 55 Melbourne Road, Hyannis, MA
are the owners of 55 Melbourne Road, located at Barnstable (Hyannisport), Barnstable County,
C_ MA (hereinafter referred to as Lot 49 and being shown on a plan entitled"Subdivision of Land
>1 in Barnstable, MA for C.K.M. Associates", duly recorded in Barnstable County Registry of
x Deeds in Plan Book 25.0, Page 143.
a WHEREAS, Sean P. McGlame and Stacey J. McGlame, as the owners of said lot have agreed
a, with the Town of Barnstable Board of Health to a restriction as to the number of bedrooms
�4 which can be included in any home built on said lot as a pre-condition to obtaining a disposal
o works construction permit in compliance with 310 CMR 15.000 State Environmental Code, Title
-° V, Minimum Requirements for the Subsurface Disposal of Sanitary Sewage;
v
L, WHEREAS, the Town of Barnstable Board of Health, as a pre-condition to granting a disposal
works construction permit for a septic system in compliance with 310 CMR 15.200, State
Environmental Code, Title V, Minimum Requirements for the Subsurface Disposal of Sanitary
o Sewage, and authoring the issuance_ of a building permit for the construction of a single family
�4 home on this property, is requiring that the agreement for the restriction on the number of
ra bedrooms in any house constructed on the lot be put on record with the Barnstable County
Registry of Deeds by recording this document.
NOW THEREFORE, Sean P. McGlame and Stacey J. McGlame, do hereby place the following
0 restriction on his above-referenced land in accordance with his'agreement with the Town of
a_
Barnstable Board of Health, which restriction shall run with the land and be binding upon all
successors in title:
1. 55 Melbourne Road, Hyannisport, MA may have constructed upon the lot a house
containing no more than three (3) bedrooms. Sean P. McGlame and Stacey J. McGlame agree
that this shall be a permanent deed restriction affecting Lot 49 located on 55 Melbourne Road,
Hyannisport, MA and being shown on the plan recorded in Plan Book 250, Page 143.
For title of Sean P. McGlame and Stacey J. McGlame, see the following deed: Book 12168,
Page'245.
Executed as a sealed instrument this 1st day of June, 2009.
Sean P. McGlame
j
S acey J. AcGlaj&e
i
f�
t
COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, ss.
On this ?%day of June, 2009, before me the appeared the above named, Sean P. McGlame, who otherwise was personallyknown
be
the person whose name is signed on the preceding or attached and acknowledged notaryned public, personally
document was signed voluntarily for its stated purpose. O�'l dged to me that 0 me said
J,
John B. o kins, Notary Public
i
Co fission Expires: 07102115
COMMONWEALTH OF MASSACHU SETTS
BARNSTABLE, ss.
On this day of June, 2009, before me the undersigned not public,
appeared the above named, Stacey J. McGlame, who,otherwise was person notary
known to
� ":_ be the person whose name is signed on the preceding or attached and acknowledgedpers me to
onally
said document was signed voluntarily for its stated purpose. to me that
Notary Public
My Commission Expires:
r
LO•C TION SEWAGE PERMIT NO.
let%
VILLAGE
I N S T A LLER'S NAME & ADDRESS
*Owl. Allot
BUILDER OR OWNER j,
'K .
DATE PERMIT ISSUED • � ��,�
DATE COMSPLIANCE ISSUED_
_ .!y
`.i
G
g ♦� � �I�
. ,,
��- +�" I
.� __
d
�e
'�� .
� `
+ � 'I
F
��®I L i
X
u.. _ i
.... - __ .,t,d�_..,. �... ,- .. .�
No. '/ FEB...3..$..................
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
`1.............OF......0,9 N.,ZT. !.: ------------...................
Ailp iration for Ui4posal Workii Cnnnitru rtiun ranat
Application is hereby made for a Permit to Construct (X ) or Repair ( ) an Individual Sewage Disposal
System at:
...........,/ �...r�...... (F or3 ........ ...............�-�-••�-¢=9- --•--•------------------------................
Location-Address or Lot No.
.. -e S s.........---•--•••......... .................. &.&� ..........................................
Q/�/ ,O,w/ner Address
a ............................. -W t....1.4.�°_ 5............. ...................... . e/2�/�s S .............-..........................
Installer Address 70
Type of Building Size Lot. ___
--------------------Sq. feet
,V._,.. Dwelling—No. of Bedrooms......... ..............................Expansion Attic ( ). Garbage Grinder ( )
pa ' Other Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
`I"
Q' Other fixtures --•------•---------•------ -----
¢ O a 330
W Design Flow.........1................................gallons per lef.san per day. Total dajly flow.............................................gallons.
WSeptic Tank—Liquid capacity/®®®.gallons Length..-.C,.. Width.4-e 0._ Diameter................ Depth:.i;E-.-%-..
x Disposal Trench—No. .................... Width...;............... Total Length.............1....... Total leaching area....................sq. ft.
Seepage Pit No......./_........... Diameter---lO__._...__. Depth below inlet.....Cam............. Total leaching area:...Z19�2.sq. ft.
Z Other Distribution box (JC ) Dos i tyk )/J
'-' Percolation Test Results Performed by _------ --------- ................................. Date...�:?12 � � ..
aTest Pit No. i._. _Z.._.minutes per inch Depth of Test Pit--- ...... Depth to ground water------- __-------.
f= Test Pit No. 2..4 Z....minutes per inch Depth of Test Pit._1.44`.._.. Depth to ground water....... .............
f- -------• --------------------------- -•----------- -•-- ----------------
O Description of Soil T �J ------ -•• •-------2--------•-----.. _`. - � ®/L
x .............................
c., ---------------••----------- ------••--•---------------------- � afr
W ----••-----------------------------:-------•--------------------------------•------- --•-•---•----------•-----•--------------•---------------•-----------------•---........=......-•----------•----
UNature of Repairs or Alterations—Answer when applicable-----------------------------------------------------------------------------------------------
........................................................................................................................................................................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of'T`:1,ZJ 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has b�eeied by the board ofgielth.
Sld.._. ....... . ................ .............. .
Application Approved By. --------------•-------------•-------•-----------------------------. ...;.`_ 7
Date
Application Disappro d f t e following reasons-----------------------•--------•------------------------...---------------------•---•---•------............._...
. ................................ ..... ..... ...............`...-----•-----------------------...•----...-------------•---------•----•-----•-•-----............................... --•-----......
Date
PermitNo...................................-------...-----------_ Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS 3s
BOARD f�OF HEALTH
/.v....................OF...... :................................
Appliration for Dispnstal Works Tnnitrnrtinn Vamit
Application is hereby made for a Permit to Construct ()( ) or Repair ( ) an Individual Sewage Disposal
System a_t:.
% .._.............. ..EZr..----•-•-� O `'�� ................
Location-Address
or Lot No.
..................._.--•:_ ........ it. :_l._�_.................................................
... Owner
a � aress
L!�- NJ: � ......•_------J , ,
Indaller Address
UType of Building 2 Size Lot_j...Z.............70 6/........Sq feet
�., Dwelling—No. of Bedrooms............?_..................._..........Expansion Attic ( ) Garbage Grinder ( )
a`k Other—T
ype of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( )
Other fixtures .................................
rats --•-----•--•--------•------------------------------- ----------•--•------_........
..
W Design Flow........lb____________________________gallons per been per day. Total daily flow...............9__3.G gallons.
WSeptic Tank—Liquid capacitylO��.gallons Length_i6_-4_._ Width4"1��_. Diameter................ Depth_
x Disposal Trench—No_ ____________________ Width..................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No......I............ Diameter._l . ........ Depth below inlet....--�'J____......... Total leaching area....15�l2_2.sq. ft.
Z Other Distribution box ()t ) Dosing. tank
'-' Percolation Test Results Performed byfC- ('/ F/I.vN 1AIC___________________ Date___ .___�Z�� Z`
a ••••• ------....e_•---• ..............
Test Pit No. I._.G_...._..minutes per inch Depth of Test Pit___.r'��^ ____ Depth to ground water........-_ ...........
44 Test Pit No. 2..4 t_....minutes per inch Depth of Test Pit._f_ ____. Depth to ground water......
04 ........... -----------------------------------------•--• •-•-•...................
O Description of SOiI_.7 z z ..... . . �-�/ Q F�50/C... T3 S®i
---.._._.. .............
--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------•--••_....
U Nature of Repairs or Alterations—Answer when applicable----_•......................................................................_..................
...-----•---------•••••-•-•-••----...---_-•--••--•--•-•---•----------•--•--•••------••••....---•---•-••-...•-------------••-••--••••------------•---•••-•••---•--••-• ..................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the T provisions of T ': :;
p 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health
Si .tied
_.
Da{e
Application Approved By__., .._ �.._/�
Da
Application Disapprgmved or he following reasons---------------•----------------•-----------------------------------------/-----•---------------Y-�-----...------
II
-----•-•-------------------------------------------------------•-------.._Date .__..-------
PermitNo......................................................... Issued......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
f
!�+ .I.......... .. . .......... F/
(9rrtirirate jai nrnt �ittnrr
HIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ) or Repaired ( )
c..Me/..,--•-by -- 5e-k-•6/a6.H•'-5...........................................................................................------•--- •-----.......------------•--._._....._
,�+ �} Installer
has been installed in accordance with the provisions of TITLE j of The State Sanitary Cc e s described in the
application for Disposal Works Construction Permit Nov ,___:/1r.___________________ date :__ __ . .......................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A G GRANTEE THAT THE
SYSTEM WILL FUNCTION SATII /ACTO,,RY.
DATE... -------••-•_-•-_.. Inspector............. •--- R-- : --------------•------••-•----•-------•---____-
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF H ALTH
......... F 'r�:''"................
Obip sal Workii TUnntrnrtion frrutit
Permission is hereby grantedt
to Construct ) or Repair } an Individual Sewage Disposal System
at Nq<..,o- •-----..?------
Street /
as shown on the application for Disposal Works Construction Permit N :__2._ Date.
...............................................................----._...---....--------•-----•....__...
DATE................----- Y-Sfx....-------._...--------.....------
• •-•-• Board of Health
FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS
SOIL ', TEST INVERT ELEVATIONS NOT.Es= ~,
DATE OF``SOIL:; TEST
3 /2 8 Z INVERT AT BUILDING io/� FT ALL . WORKMANSHIP: AND MATERIALS
WITNESSED BY INLET SEPTIC TANK FT. SHALL CONFORM TO D.E.Q.E TITLE ' S
PER_COLATION RATEL=- MIN./INCH
OUTLET SEPTIC TANK /ao.3 FT. AND .THE TOWN OF-8���✓�-ad--- RULES
INLET DISTRIBUTION= BOX %�� / FT. AND REGULATIONS FOR SUBSURFACE
OBSERVATION HOLE I OBSERVATION ' HOLE 2 DISPOSAL OF- SANITARY SEWAGE
ELEVATION=/o/• oo ELEVATION= /o% / OUTLET DISTRIBUTION BOX FT.
pa INLET LEACHING PIT .93.7 FT.
Top f BOTTOM LEACHING PIT ,9.37 FT.
DESIGN CALCULATIONS
NUMBER OF BEDROOMS . . . .. . . . . . . . . . . . . . 3 '
i
s� GARBAGE DISPOSAL UNIT....
TOTAL ESTIMATED FLOW (1LGAL./BR./DAY x,7- BRA.. •33� GAL./DAY
�JEo/CaA•eSc ��
REQUIUD SEPTIC TANK CAPACITY.... . ¢ GAL.
ACTUAL SIZE OF SEPTIC TANK TO BE INSTALLED.... ioaa GAL.
LEACHING AREA REQUIREMENTS '
gg g _ 14 ��^ S9 SIDE WALL AREAde_,�GAL./S:F.
) BOTTOM AREA L2 GAL./S.F.
/% ,�/z 6 �i✓cavn�rE2,EoJ LEACHING CAPACITY ( BOTTOM SIDEWALL 7 GAL.
�.3•i¢ x S z x /> �• �3/¢ x Gx/o x.2•S� S�9�7 GAL.
RESERVE LEACHING CAPACITY.. . . . . . . . . . . . . . . . . . . . . . .
T O P OF
FOUND.
ELEV.=/C?3.S CONCRETE 4�' SCH. 40 CLEAN SAND
COVERS MI C "PITCH CONCRETE
N
1/8 PER. FT. COVER w` �� Ui � �,
2% MIN. PITCH
12 MAX. a -:�, '/'' 1Cs�
i v _=r 4,
2. .LAYER OF I/8- I
FLOW LINE �. p .w 41
_ WASHED STONE ,.:: ao f
r i n _L z ' o n o' u u �cnlz Y•-c�:� ''c�`�iC., /�
4 CAST IRON — /9 0 3/4- 1 I/2
PIPE - MIN. PITCH 'o w va WASHED STONE
I/4�� PER FT DIST. v n �_- o ' PRECAST LEACHING '
BOX . o� caw n o BASIN OR EQUIV.
n �— -
�..,
0 O w 0
/aoo GAL MASS,
SEPTIC T R. J. 0 EAR INC. RLS RS
TANK. o fr ¢'C H . N, . •�
_.. . . :. 1346 ROUTE
PROFILE OF GROUND WATER TABLE EAST DENNIS, MASS.
SEWAGE DISPOSAL SYSTEM JOB No: cLIENT.�ffy�y„�.
NOT TO SCALE [DATE ��G SHEET,- OF,,-- -
I - I
Mi
,� I3
i
L OT -,4eE3
`. r I
� Q
o Q/
� � h
\ �,� H2O� \�\ • oe��.�
�O rC 4/47E^ 1 i
Q �•r/1�� �� � V �
4 \�
: r
r �
a
LDT SO
/✓o,TES:
_�: .G''o�lo,CiAivG,F wiry Locq,C Zocii�uC '
Q.
JJ;vnE:i cn �
' O'HE/ _'N `J 0'Fs-hi�iJ
No.All
LEGEND
EXISTING SPOT ELEVATIONS OAO 1
EXISTING CONTOUR--- 0- --
FINISHED SPOT ELEVATIONS
FINISHED CONTOUR 0 PROPOSED PLOT PLAN
APPROVED: BOARD OF HEALTH MASS.
DATE AGENT
R. J. O'HEARN, INC., RL S, RS
1348 ROUTE 134
EAST DENNIS, MASS.
DATE: 9 SCALE'
JOB N0. r9k`aS-A5- CLIENT: s�
DR. BY SHEET-L OF Z
rAsBuilt Page 1 of 1
J
LO j TION �hA SEWAGE PERMIT NO.
VILLAGE
INSTA LLER'S NAME i ADDRESS
F4*1.3 �..�e 's S��wsa� _ 3!�► G...� 1.1. u_,A.1,
BUILDER OR OWNER
DATE PERMIT ISSUED
DATE COMPLIANCE ISSUED_
I
16
L-7j4y„�►K 11�.1�.
http://issgl2/intranet/propdata/prebuilt.aspx?mappar=268247&seq=1 6/4/2013
COMMONWEALTH OF MASSACHUSETTS 7
EXECUTIVE V
C E OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
ONE WINTER STREET, BOSTON MA 02108 (617)292-5500 0
00
0 6, t^ C a�
T Q
UDY _
to,
�c9 Secreta iyy
ARGEO `g
.Govenior UL CELLUCCI .. _ VID B.
Co�n
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Z "Ab si ri
PART A
CERTIFICATION
Property Address: 55 Melbourne Road, Hyannisport, MA Name of Owner: Anna Gentile
Address of Owner: P.O. Box 136
Date of Inspection: .Febr,iaq 8.- 1999 Worcester, MA 01613
Name of Inspector: (Please Print) James M. Ford
I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000)
Company Name: James M. Ford
Mailing Address: _P.a Box 49, Osterville, MA 02655-0049 Map;
Telephone Number: _(508)862-9400 Parcel:
Lot:
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accur(' F
and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function andmaintenance of on-site sewage disposal systems. The system:
PassesConditionally Passes
Needs Further Eval tion By the Local Approving Authority
Fails ,
Inspector's Signature: Date: February 9, 1999
The System Inspector shall subrz a copy of this inspection report to the Approving Authority(Board of Health or DEP)within thirty(30)days
of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner
shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the
system owner and copies sent to the buyer, if applicable, and the approving authority.
NOTES AND COMMENTS
revised 9/2/98 Page IofII
Primed on Recycled Paper
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
-, PART A
CERTIFICATION (continued)
Property Address: ,, 'SS Melbourne Road, Hyannisport, MA
Owner: t?Anna Gentile
Date of,Inspection: "February 8, 1999
INSPECTION/SUMMARY: Check A, B, C, or D:
t / •
A. SYSTEM PASSES.
III
`✓- I have noffound any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist. Any failure
criteria no 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.
Indicate yes,no, or not determined(Y,N,or ND). Describe basis of determination in all instances. If"not determined",explain why not.
The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate of
Compliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection; or
the septic tank, whether or not metal,is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank
failure is imminent. The system will pass inspection if the existing septic tank is replaced with a complying septic tank as
approved by the Board of Health.
_ Sewage backup or breakout or high static water level observed in the distribution box is due tobmken 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
Health)
4 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
revised 9/2/98 Page 2of11
rk
i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued).
Property Address: SS Melbourne Road, Hyannisport, MA
Owner: Anna Gentile
Date of Inspection: February 8, 1999
C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the
public health, safety and the environment. -
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 15.303(1)(b)
THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND
SAFETY AND THE ENVIRONMENT:
Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER,IF ANY) DETERMINES
THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND
THE ENVIRONMENT:
The system has aseptic tank and.soil absorption system(SAS)..and•the SAS is within 100 feet to asurface water supply or
tiibutary:to a surface water supply:
_ The system has a septic tank and soil absorption system and the SAS is within a Zone 1 of a public.water supply well.
The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well.
The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a
private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the
well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less
than 5 ppm. Method used to determine distance (approximation not valid).
3) OTHER
revised 9/2/98 Page 3of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: SS Melbourne Road, Hyannisporl, MA
Owner: Anna Gentile
Date of Inspection: February 8, 1999 '
D. SYSTEM FAILS:
You must indicate either "Yes" or"No" as to each of the following:
I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this
determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure.
Yes No
Backup of sewage into facility or system component due to an overloaded 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'h day flow.
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped_.
Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation.
Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
Any portion of a`cesspool or privy is within a Zone 1 of a public well.
Any portion of a cesspool or privy is within 50 feet of a private water supply well.
Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no
acceptable water quality analysis. If the well has been analyzed.to be acceptable,attach copy of well water analysis for
colifotm bacteria, volatile organic compounds,ammonia nitrogen and nitrate nitrogen.
E. LARGE SYSTEM FAILS:
You must indicate either "Yes" or"No" as to each of the following:
The following criteria apply to large systems in addition to the criteria above:
The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public
health and safetyand the environment because one or more of the following conditions exist:
g
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
The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional
office of the Department for further information.
revised 9/2/98 Page 4ofII
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 55 Melbourne Road, Hyannisport, MA E
Owner: Anna Gentile
Date of Inspection: February 8, 1999
Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: f '«, • y
Yes No
✓ _ Pumping information was provided by the owner, occupant, or Board of Health.
✓ _ None of the system components have been pumped for at least two weeks and the system has been receiving normal flow
rates during that period. Large volumes of water have not been introduced into the system recently or as part of this
inspection.
✓ As built'plans have been'olitained and examined. Note if they'are'not available with N/A.
✓ _ The facility or dwelling was inspected for signs of sewage back-up.
✓ _ The system does not receive non-sanitary or industrial waste flow.
✓ _ The site was inspected for signs of breakout.
✓ _ All system components,excluding the Soil Absorption System,have been located on the site.
✓ _ The septic tank manholes were uncovered,opened, and the,interior of,the septic tank was inspected for conditions of baffles
or tees,material of construction, dimensions,depth of liquid,depth of sludge;depth-of scum.''
The size and location of the Soil Absorption System on the site has been determined based on:
✓ . Existing information. For example, Plan at B.O.H. .
✓ Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable)
[15.302(3)(b)l•
✓ _ The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of
SubSurface Disposal Systems.
revised 9/2/98 Page 5of11
P 1
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 55 Melbourne Road, Hyannisport, MA
Owner: Anna Gentile
Date of Inspection: February 8, 1999 "
FLOW CONDITIONS
RESIDENTIAL:
Design flow: 110 g.p.d./bedroom.
Number of bedrooms(design): 3 Number of bedrooms(actual): 3
Total DESIGN flow n/a
Number of current residents: 1
Garbage grinder(yes or no): Yes
Laundry(separate system) (yes or no): No ; If yes, separate inspection required
Laundry system inspected(yes or no): Yes
Seasonal use(yes or no): Yes
Water meter readings, if available(last two yearg,usage(gpd): 1998-2,800 gals.; 1997-3,700 Aals.
Sump Pump(yes or no): No
Last date of occupancy: Unknown
COMMERCIALANDUSTRIAL:
Type of establishment:
Design flow: gpd(Based on 15.203)
Basis of design flow
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:
None on file-per treatment plant
System pumped as part of inspection(yes or no): No -
If yes, volume pumped: _gallons
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)
I/A Technology etc. Attach copy of up to date operation and maintenance contract
Tight Tank Copy of DEP Approval
Other
APPROXIMATE AGE of all components,date installed(if known)and source of information: 1982-per as built card.
--Sewage-odors detected when arriving at the site: (yes or no)-- -No.---.-
revised .9/2/98 Page 6of11
f
i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 55 Melbourne Road, Hyannisport, MA
Owner: Anna Gentile
Date of Inspection: February 8, 1999
BUILDING SEWER:
(Locate on site plan)
Depth below grade: .
Material of construction: _cast iron _40 PVC _other(explain)
Distance from private water supply well or suction line
Diameter
Comments: (condition of joints, venting,evidence of leakage, etc.)
SEPTIC TANK: ✓
(locate on site plan)
Depth below grade: 14"
Material of construction: ✓concrete _metal _Fiberglass _Polyethylene _other(explain)
If tank is metal, list age s Is age confirmed by Certificate of Compliance_(Yes/No)
Dimensions: 8' x 5' x 4'6" (1000gal.)
Sludge depth: 1"
Distance from top of sludge to bottom of outlet tee or baffle: 33"
Scum thickness: 0" _
Distance from top of scum to top of outlet tee or baffle: 10"
Distance from bottom of scum to bottom of outlet tee or baffle: 12"
How dimensions were determined Measuring stiek
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.) The inlet tee was present. An asphalt walk covers the outlet cover. There was no scum in the tank.
GREASE TRAP: None
(locate on site plan)
Depth below grade:
Material of construction: concrete _metal _Fiberglass _Polyethylene _other(explain) x
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:
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.)
revised 9/2/98 Page 7of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 55 Melbourne Road, Hyannisport, MA
Owner: Anna Gentile
Date of Inspection: February 8, 1999
TIGHT OR HOLDING TANK: None (Tank must be pumped prior to,or 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/day
Alarm present:
Alarm level: Alarm in working order: Yes_ No_
Date of previous pumping:
Comments:
(condition of inlet tee, condition of alarm and float switches,etc.)
DISTRIBUTION BOX: ✓
(locate on site plan)
Depth of liquid level above outlet invert:
Comrrtents:
(note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.) The D=box was under an
asphalt walkway and was unaccessible.
PUMP CHAMBER: None
(locate on site plan)
Pumps in working order: (Yes or No)
Alarms ii working order: (Yes or No)
Comments:
(note condition of pump chamber,condition of pumps and appurtenances,etc.)
revised 9/2/98 Page8ofll
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 55 Melbourne Road, Hyannisport, MA
Owner: Anna Gentile
Date of Inspection: February 8,.1999 -
SOIL ABSORPTION SYSTEM (SAS): ✓
(locate on site plan,if possible; excavation not required,'location may be approximated by non-intrusive methods)
If not located, explain:
Type:
leaching pits,number: I -6'x 6'
leaching chambers, number:
leaching galleries, number:
leaching trenches,number, length:
leaching fields,number, dimensions:
overflow cesspool,number:
Alternative system:
Name of Technology:
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding,damp soil,condition of vegetation, etc.)
The pit was dry. The bottom to grade was 9'. There were no signs of failure. -
CESSPOOLS: None
(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(cesspool must be pumped as part of inspection)
Continents: (note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation,etc.)
PRIVY: None
(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.)
revised 9/2/98 Page 9of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
_ SYSTEM INFORMATION (continued)
Property Address: SS Melbourne Road, Hyannisport, MA
Owner: Anna Gentile
Date of Inspection: February 8, 1999
skETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent reference landmarks or benchmarks
locate all wells within 100' (Locate where public water supply comes into house)
IA
btck
�a to
304
revised 9/2/98 Page 10ofIt
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 55 Melbourne Road, Hyannisport, MA
Owner: Anna Gentile
Date of Inspection: February 8, 1999
NRCS Report name
Soil Type
Typical depth to groundwater
USGS Date website visited
Observation Wells checked
Groundwater depth: Shallow Moderate Deep
SITE EXAM Slope
Surface water
Check Cellar
Shallow wells
Estimated Depth to Groundwater 25 +/- Feet
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from Design Plans on record
✓ Observed Site(Abutting property,observation hole,basement sump etc.)
Determined from local conditions
Checked with local Board of Health
Checked FEMA Maps
Checked pumping records
Check local excavators,installers
✓ Used USGS Data
Describe how you established the High Groundwater Elevation. (Must be completed)
Hand augered down to 12'below grade and no water was observed. Using the Cape Cod Commission Technical Bulletin,
and the Barnstable Water Table Contour Map, the adjusted high groundwater level for 12'at this site (MI W 29, Zone C)
was 4.9'. The maps were showing approximately 25'to groundwater at this site.
This report has been prepared and the system inspected and passed as of.the date of inspection. This report is not a warranty
or guarantee that the system will function properly in the future. There have been no warranties or guarantees, either expressed,
written or implied, relating to the system, the inspection and/or this report.
revised 9/2/98 Page 11 of 11
l ¢
w
¢
f
ZK
h ;
a > a
¢ w
II � II
II
I p
m
LOT-' 0 1
W .
ot
.01
J W
oZ
1
I
• I II � .� � � fI R '
i I i
— LIB
a
I
z
I
3 '
� J
li I
l
i
� I
i If g
I)f a
Ty
—I
I �
� 1
mil'V P V
I'
_
I
I
I
—
t i
, I
. --- --.�. ------ --- --� — -- — -ice '
li i, � { I � a � z I I • I� I I I ,
I
a
I 13
gg
1
I '
E
R
1 '
i _
109ZO MH`s!uae-CH
VH aumoglow SS
aWBIDONi-S
1_Li rn
tr)
I
�j V
LLL
^\ , 0-.Z,
V '
j 1 -
1
I '
� k I,
/
V