HomeMy WebLinkAbout0019 NORRIS STREET - Health 19 NORMS STREET, HYANNIS
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SECTIONSENDER' COMPLETE THIS SECTION COMPLETE THIS DELIVERY
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(Ranter from service' 7 0 018 3 2 3 0 '0002 51 7 8 2°17 6 ,
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�p THE Tp�
Town of Barnstable Barnstable
Regulatory Services Department "'e'caC "
639•� ��� Public Health Division AlEO MA't a.
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200 Main Street, Hyannis MAI 02601 2007
Office: 508-862-4644 Thomas F.Geiler;Director
FAX: 508-790-6304 Thomas A.McKean,CHO
`0 UO3/2011
Moira L. Winroth
c/o Moira McAuliffe
1000 N US Highway 1
Jamacia 102
Jupiter, FL. 33477
IMPORTANT NOTICE
Re: 19 Norris St. Hyannis, MA. 02601
Map & Parcel 306-248
Dear Moira Winroth:
According to our records, your property at 19 Norris Street, Hyannis, MA has a septic
system (last inspected in 2001) and is not hooked up to the public sewer system. Public
sewer lines have been available in your neighborhood since 2003, Some time ago, you
were notified of your obligation to hook up and establish a sewer account with the town.
This letter directs you to connect your building located at 19 Norris Street, Hyannis,
MA, to public sewer on or before July 1, 2011.
Sewer connection permits are available from DPW- Water Pollution Control Division, .
617 Bearse's Way, Hyannis MA 02601 (508) 790-6335.
If you should have.any questions, please telephone me at 508-862-4644.
PER ORDER OF THE BOARD OF HEALTH
omas A. McKean, R.S., C.H.O.
Agent of the Board,of Health
�— TOWN OF BARNSTABLE
Il fas �- 90 -C)
OCA` ION SEWAGE # /
VILLAGE ASSESSOR'S MAP& LOT��
INSTALLER'S NAME&PHONE N/O/.�/y� ,, Q
SEPTIC TANK CAPACITY G yw
LEACHING FACII.TTY: (type) n � _(size) (6 U
NO.OF BEDROOMS u
BUILDER OR OWNER F
PERMITDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Wtsll and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility Facili (If an wetlands exist
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within 300 feet of leaching facility) ( c Feet
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LOCATION SEWAGE #�d
VILLAGE ASSESSOR'S MAP 6z LOT
INSTALLER'S NAME & PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY:(type) (()7Z PZ-t�_ GOSK` (size)
NO. OF BEDROOMS PRIVATE WELL OR PC WAT Rti✓
BUILDER OR OWNER
DATE PERMIT ISSUED:
DATE COLIPLIANCE ISSUED: 1 / O
VARIANCE GRANTED: Yes No
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:�TI01�7 f ST SEWAGE #
VILLAGE 2ezgc� ASSESSOR'S MAP & LOT "
-INStALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY f
LEACHING FACILITY: (type) ��l� (size)
NO. OF BEDROOMS •--%
BUILDER OR OWNER
PERMITDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any we l
wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetian an Lea g Facili (If any wetlands exist
within 3 f 1 �'nFeet
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INSTA LLER'S NAME i ADDRESS
BUILDER . OR OWNER
DATE PERMIT ISSUED I-Lf',
DAT E COMPLIANCE ISSUED
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No. `" 5 � Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
4plitatlon for MispoSal *pstrm Construction Vertu
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon/❑Complete System ❑Individual Components
Location Address or Lot No. fq A10T-rdS j4pnn,s Owner's Name,Address,and Tel.No.
Assessor's Map/Parcelsluf,11. _ - B
Installer's Name,Address,and Tel.No. 5'��' Designer's 4ame,Address,and Tel.No.
Pv. x f?o y arsfoins 1W is O
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures 0 Id
Design Flow(min.required) gpd Design flow provided gpd
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank T pe of S.A.S.
Description of Soil 71-7
Nature of Repairs or Alterations(Answer when applicable)
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmenta de d not to place the system in operation until a Certificate of
Compliance has been issued by this Board of Health. l/
Signed Date
��<`
Application Approved by Date "�o'+Q
Application Disapproved by Date
for the following reasons
Permit No. Date Issued
j No. Fee
tr THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
01pplication for Misposal *pstem Construction Permit
r
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon/❑Complete System ❑Individual Components
Location Address or Lot No. I9 /\10 r r1_5 h1�CUJf16 Owner's Name,Address,and Tel.No.
c y})v;rem U...5.Nq
Assessor's Map/Parcel && jtg XL( .Ju?,iec 33 o - / ilk
Installer's Name,Address,and Tel.No. VP Designer's ame,Address,and Tel.No.
Pa Rax r?vy ctr 5f,Ps ;l(s A4 0D
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) gpd Design flow provided gpd
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank A T pe of S.A.S.
Description of Soil 4
�r
Ile_&1VV__f7%1U*e1%1e141%1. or
Nature of Repairs or Alterations(Answer when applicable)
Date last inspected: }
` Agreement: ,
�_...
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
—accordance with the provisions of Title 5 of the EnvironmentaLC--ad�not to place the system in operation until a Certificate of
Compliance has been issued by this Board of Health. /
Signed Date
Application Approved by r Date
Application Disapproved by Date
for the following reasons
Permit No. Date Issued -
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE,MASSACHUSETTS
Certificate of Compliance
THVby
TO CERTIFtY,that the On-site Sewage Disposal system Constructed( ) Repaired( ) Upgraded( )
Abandoned �_�v C' 4��` 00 I)S+
I q Nor r' I _ _
' at � ,� � `j has been constructed in accordance Y
i• with the provisions of Title 5 and the for Disposal System Construction Permit No..eb i t`075 dated 3
Installer Designer
#bedrooms Approved de n flow gpd
The issuance oft Is pe it shall not be construed as a guarantee that the system wi 1 func��a designed.
Date Inspector
i
-------------------------------- ------------------------------------- - -------------------------
- ---------
No. ,o S Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS
Misposal 6pstem Construction permit
Permission is hereby granted to Construct( ) Repair( ) Upgrade( ) Abandon(A -�
System located at_�9 416r'r)S
and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with
Title 5 and the following local provisions or special conditions.
Provided:Construction mu t be completed within three years of the date of this permit.
Date -a - Approved by
Ne*-Page i•* http://www.town.bamstable.ma.us/assessing/2011/HMdisplay.asp?...
TOWN OF BARNSTABLE
LOCATION M1(IS SEWAGE li `0 Q_
VILLAGE ASSESSOR'S MAP&I r
INSTALLER'S NAME&PHONE NO.
\
SEPTIC TANK CAPACITY 166W
LEACHING FACILITY:(type) 01 (size)
NO.OF BEDROOMS
BUILDER OR OWNER
PERMII'DAT'B: COMPLIANCE DATE: [O
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 awetlands exist Feet
within 300 feet of leaching facility)
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THE COMMONWEALTH OF MASSACHUSETTS
P4/4BOAR® OF HEALTH
TOWN OF BARNSTABLE
Z '60- Appliration for Di-oposal Works Tomitrudion ramit
Application is hereby made for a Permit to Construct ( ) or Repair ( - an Individual Sewage Disposal
System at:
Location-Address or Lot No.
................ ` �t ........................................
^-
.......................-•.............................. ...........................
w r5'TfG _ � f um ( ...........
........................-- ........4------....----•---•----•........--- ••----••----. -- --•--•---. ..---•--
Installer Address
UType of Building Size Lot---------------------.......Sq. feet
�-, Dwelling—No. of Bedrooms....__QZ.................................Expansion Attic ( ) Garbage Grinder ( )
`a Other—T e of Building ............. No. of persons--.....--......_........--.. Showers — Cafeteria
dOther fixtures ----------------------------------------------------------------•-------------------------•--------------------------------•-------------...----------
W Design Flow.......5�...................................gallons per person er day. Total daily flow.:-_�� ----.....................gallons.
WSeptic Tank- -Liquid capacity�.�� gallons Length---7....... Width....` ___.... Diameter................ Depth................
x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area...................sq. ft.
Seepage Pit No..�:-_l------------- Diameter---1.0L c--..... Depth below inlet-----4�*......... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by.......................................................... •------------- Date.................................------
Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water-.---------------.----.-
44 Test Pit No. 2.................minutes per inch Depth of Test Pit.................... Depth to ground water........................
a •----------------------------------------------------------------•--.....------------._._......._..........................................................
0 Description of Soil...............................................................................=........................................................................................
x
W
x --- ---------------------------------------------• ----- . -------
V Nature of Repairs or Alterations—Answer when icable.-- .....V.0--vV.. .-.......
6° ............ --------------------------------------------------------------------------------------------------------
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Compliance has been issued by the koard of health.
g "� :Si ned .. ------- e
Application Approved BY ----"-----------------
----------------------------------------------------
Application Disapproved for the following reasons- -- --------- ----------------------------------------------------------------------------------------- ----------------------
- --....................................... "----------------------
Dare
PermitNo. ......... `...s� 7�....................... Issued --------------------------- ..............................-----
Date
rwI Y _
THE COMMONWEALTH OF MASSACHUSETTS
e -BOARD OF HEALTH
TOWN OF BARNSTABLE
Appliration for Dispniitti Works Cfnnstrnrtion thrutit
Application is hereby made for a Permit to Construct ( ) or Repair ( `) an Individual Sewage Disposal
System at:
........... -__N J 1s„ -?-� - 15--------•---------------------------_.....------------.
Location-Address or Lot No.
O ner A ess
F 4.cq S� c VLc1�(
Installer Address
dType of Building Size Lot_-_._•-----••--•--••-_-•-_--Sq. feet
U Dwelling—No. of Bedroom
s..__._f12 ----
___________________-_ Expansion Attic ( ) Garbage Grinder ( )
`4 Other—T e of Building No. of persons............................ Showers — Cafeteria
P4 Other fixtures .........................
W Design Flow-------- ........................gallons per person per day. Total daily flow_____ �v----------------
--------gallons.
WSeptic Tank-Liquid capacitygallons Length....7...... Width_____`1_�..... Diameter................ Depth................
x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area_...................sq.'ft.
Seepage Pit No.......I............ Diameter....La........ Depth below inlet......4.(........ Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( ) ,
aPercolation Test Results t , Performed by-------------------------------------------------------------------------- Date........................................
Test Pit No. 1_.__.._.:------minutes per inch Depth of Test Pit____________________ Depth to ground water-----------.------------
44 Test Pit No. 2.................minutes per inch. Depth of Test Pit.................... Depth to ground water----------------_-------
Descriptionof Soil _' --------=----------------•--•------------------------------------------------------------------------------------------------......
x
c.,
W t ~f a
U Nature of Repairs or Alterations—Answer when ap licable__-_-+ _.._e_CI£ ----A J f.c_ y ------
------
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Compliance has been issued by the board of health.
Signed• -.�—.-` :`�. �� -..�J -- ----------- Ilo-la �t
Application Approved By c � r� -Mtee
Date
Application Disapproved for the following reasons: -------------------- ----------------------------------------------------------------------------�--------
Date
PermitNo. .------ ---..-- --711----------------------- Issued .------------------------------------------------------- ------
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Gez#tftrate of Tomplia rtre
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (
by....................... .!�+�0 �+`'`� �----- t--- -�-
------------------------------------------------------------------------------------.......................................
• Installer
at ..................... ------15T-=---------------- `l cti-h--w'i
has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in
the application for Disposal Works Construction Permit No. ------ ........ dated ------------------------------------------------
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE--------------- '�t7,!`,.J1� ------- ---- Inspector ........
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
No.'10.-176. FEE. ..........
Disposal Workii Tnn#r ion rruti#
Permission is hereby granted------. 0E.(r"4`^f 5 - --------------------------------------•------------.................-----...
to Construct ( ) or Repair ( l.) ndividual Sewage Disposal System
atNo........... ...... _,^,-Y,1.&-------f-•----......F "``.�5------------------------------------------------•-------------------------------..........--
PP P Street / n 7�
as shown on the a lication for Dis osal Works Construction Permit No._?_� ..___._ Dated.........................................
Board of Health
DATE................................................................................
FORM 36508 HOBBS✓4 WARREN.INC..PUBLISHERS
New Page 1 Page 1 of 1
✓ TO OF BARNSTABLE C,�r�
LOCATION ' f jS SEWAGE# `v -')2CL
VILLAGE ASSESSOR'S MAP&LO�!
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY LEACHING FAca rrY: (type) 4—• (sine) 660
NO,OF BEDROOMS
BUILDER OR OWNER 1
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 a�wetlands exist
within 300 feet of leaching facility)��l . /_��f! Feet
Furnished by
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http://www.town.bamstable.ma.us/assessing/2010/HMdisplay.asp?mappar=306248&seq=1 12/15/2010
DATE: 12/10/01
PROPERTY ADDRESS:- -Norris Norris Street
-- -------------------
Hyannis,Mass.
-- -
02601
------------------------
On the above date, I inspected the septic system at the above address.
This system consists of the following:
1 . 1 -1000 gallon septic tank.
2 . 1 -Distribution box.
3 . 1 -1000 gallon precast leaching pit. 6 ' X10 '
Based on my inspection, I certify the following conditions:
4 . This is a title five septic system. ( 78 Code )
5. The septic system is in proper working order '
at the present time.
6. The waste water is 72" below the invert pipe of the
'leaching pit.
SIGNATURE:1' J.
Name:-J . P .- Macomber Jr-----
Company: Joseph-P. Macomber &_
Son , Inc .
---- -- --- -
RECEIVED
Address;__B_o_x_66_ ___________
Centerville , Ma 02632-0066 DEC 2 0 2001
TOWN OF BARNSTABLE
Phone: 508-775-3338 HEALTH DEPT.
THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY
JOSEPH P. MACOMBER & SON, INC.
Tan ks-Cesspools-Leachflelds
Pumped & Installed
Town Sewer Connections
P.O. Box 66 Centerville, MA 02632-0066
. 775-3338 775-6412
0
O9-b7
COMMONWEALTH OF MASSACHUSETTS
1
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: 19 Norris Street
Hyannis,Mass.
Owner's Name: Moira McAul i ffP
Owner's Address: 1 00n Nnrt-h IT g Highway One
kv
sty-ito--102 Jupiter Florida 33477
Date of Inspection: �_f 1 o�(11
Name of Inspector: (please print) J.P. Macomber Jr.
Company Name:Joseph P. Macomber &, Son Inc
Mailing Address: P.O. Box 66
rpntPrui l l A Ma 02632
Telephone Number: 508-775-3338
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 pursuantt to Section 15.340 of Title 5 (310 CMR 15,000). The system:
Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
F iZ91o4V111f1_1
Inspector's Signature: Date:.�'�
The system inspector shal bmit 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 I
Page 2 of 1 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 19 Norris Street
Hyannis,Mass.
Owner: Moira McAuliffe
Date of Inspection: 12 10 01
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A Sys�te—m—P-a—sses:
�y have not found any information hich indicates that any of the failure criteria described in 310 CMR
15.30J or to 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below.
Comments:
The septic system is in proper working order at
the present time.
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.
Answer yes,no or not determined (Y,N,ND) in the for the following statements'. If"not determined"please
explain.
lfb The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally
unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the
existing tank is replaced with a complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
Ale) Observation of sewage backup or break out or high static water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with
approval of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will
pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain:
2
Page 3 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 19 Norris Street
Hyannis,Mass .
Owner: Moira McAuliffe
Date of Inspection: 12 10 01
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 public health, safety or 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 public health,safety and the environment:
1Z 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,safety and environment:
443 The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of
surface water supply or tributary to a surface water supply.
Ad 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-l00 feet but 50 feet or more from a
private water supply well''. Method used to determine distance 5z2
"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.
3. Other:
3
Page 4 of 1 1
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 19 Norris Street.
Hyannis,mass.
Owoer:Moira Mc u i e
Date of Inspection: 0
D. System Failure Criteria applicable to all systems:
You must indicate "yes" or"no" to each of the following for all inspections:
Yes No
ackup of sewage into faciliry 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 .C_J4
LR
_f1 iquid depth in ceesge is less than 6" below invert or available volume is less than '4 day flow
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number
f times pumped 6.
y 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.
//Arty portion of a cesspool or privy is within a Zone 1 of a public well.
�y 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:
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000
gpd•
You must indicate either"yes" or"no" to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
yes no/ r
JV e system is within 400 feet of a surface drinking water supply
— _ tht system is within 200 feet of a tributary to a surface drinking water supply
— he
system is located in a nitrogen sensitive area (interim Wellhead Protection Area—IWPA)or a mapped
Zone 11 of a public water supply well
If you have answered "yes"to any question in Section E the system is considered a significant threat,or answered
"yes" in Section D above the large system has failed. The owner or operator of any large system considered a
significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
15.304. The system owner should contact the appropriate regional office of the Department.
4
Page 5 of I 1 _
J( OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 19 Norris Street
Hyannis,Mass .
Owner:Moira McAuliffe
Date of Inspection: 12/10/01
Check if the following have been done.You must indicate"yes"or"no"as to each of the following:
Yes NVp"Mpmo
information was provided by the owner, occupant, or Board of Health
Were any of the system components pumped out in the previous two weeks
Has the system received normal flows in the previous two week period?
�ave large volumes of water been introduced to the system recently or as part of this inspection?
Were as built plans of the system obtained and examined?(If they were not available note as N/A)
Was the facility or dwelling inspected for signs of sewage back up
!•� Was the site inspected for signs of break out ?
Were all system components,4luding the SAS, located on site?
z_ 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
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Page 6 of 1 1
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address:19 Norris Street
yannis, ass.
Owner: Moira McAuiiffe
Date of Inspection: 1 2 1 0 01
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): -1 Number of bedrooms(actual):
DESIGN flow based on 310 CMR 15.203 (for example: 1 10 gpd x # of bedrooms): -
Number of current residents:
Does residence have a garbage grinder(yes or no):
Is laundry on a separate sewage system (yes or no):tiJC) [if yes separate inspection required)
Laundry system inspected(yes or no):
Seasonal use: (yes or no):V2)
Water meter readings, if avai)able(last 2 years usage(gpd)): 7y
�Sump pump(yes or no): / L, ;4
Last date of occupancy: I'�� �c ,--�'j —6y^ '?�'C) '� 9J" �� ,
COMM ERCIALMtDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): ' f4- gpd
Basis of design flow(seau/persons/sgft,etc.): it
Grease trap present(yes or no): 4)A1
Industrial waste holding tank present(yes or no):A�4
Non-sanitary waste discharged to the Title 5 system (yes or no):
Water meter readings, if available: 41
Last date of occupancy/use: 1
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information: 't�wd
Was system pumped as part of the inspection (yes or no):
If yes, volume pumped: C� gallons -- How was quantity pumped determined?
Reason for pumping: �1,4
TYPE OF SYSTEM
Septic tank,distribution box, soil absorption system
Single cesspool
�D Overflow cesspool
Privy
4V Shared system (yes or no) (if yes, attach previous inspection records, if any)
N( Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be
obtained from system owner)
/tom!)Tight tank Attach a copy of the DEP approval
Other(describe):
Appro imat ge of all components, date installed (if known) and source of information:
Were sewage odors detected when arriving at the site (yes or no):
„ 6
p
g
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Page 7 of I
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OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 19 Norris Street
Hyannis,Mass.
Owner:Moira McAuliffe
Date of Inspection: 12/1 0/01
BUILDING SEWER (locate on site plan)
Depth below grade: L
Materials of construction: /cast iron 40 PVC Vdother(explain):
Distance from private water supply well or suction line: J67'7—
Comments(on condition of joints, venting, evidence of leakage, etc.):
Joints a1ppear tight No evidence of leakage.The system is
vented through the house vents.
l/
SEPTIC TANK: (locate on site plan) Aevo
Depth below Bade: /�X
Material of construction: concrete/0-0meml.e),?CiberglassrJ , olyethylene
Ndother(explain) 111W
If tank is metal list as/ge:, Is age confirmed by a,Certificate of Compliance (yes or no):�(attach a copy of
Dimensions: ��''Wn//A 244)& �7/�!>l
Sludge depth., .-
gistanee from top1sludge to bosom of outlet tee or baffle:/,L;�
Scum thickness:
Distance from top of scum to too of outlet tee or baffle:
Distance from bonom of scum to 'bottom of outlet to or baffle: .�
Now were dimensions determined: ti�'d
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert, evidence of leakage, etc.):
Pump the septic tank every 2-3 years _ Inlet & outlet tees
are in place.The tank is structurally sound and shows no
evidence of leakage.
GREASE TRAPAb/,/alocate on site plan)
Depth below grade:40
Material of construction: (//QconcreteYQmetaliLberglass,�/.+�polyethyleneother
(explain): 114
Dimensions:
Scum thickness: /Jl/
Distance from top of scum to top of outlet tee or baffle:
Distance from bosom of scum to bottom of outlet tee or baffle:
Date of last pumping: _zl)ee
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structwal integrity, liquid levels
as related to outlet invert, evidence of leakage, etc.):
Grease trap is not present
' I
7
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Page 8 of 1 1
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OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 19 Norris Street
yannis,Mass .
Owner: Moira McAuliffe
Date of Inspection:12/10/01
TIGHT or HOLDING TANK&t/t' (tank- must be pumped at time of inspection)(locate on site plan)
Depth below grade: WA
Material of construction: ✓4 concrete metal X//Ifiberglass ti�olyethylenes other(explain):
A)4
Dimensions: AA
Capacity: 40 aallons
Design Flow: /t) gallons/day
Alarm present(yes or no): 4U
Alarm level: A,�4 Alarm in working order(yes or no):`/�4
Date of last pumping: V/111
Comments(condition of alarm and float switches, etc.):
Tight or holding tanks are not present.
DISTRIBUTION BOX: (f present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: 116110
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.):
Distribution box has one lateral .No evidence of solids carry
over.No evidence of leakage into or out o the ox.
PUMP CHAMBEMZ,4,7d-(locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no):
Comments(note condition of pump chamber, condition of pumps and appurtenances,etc.):
Piimn rh;:imher is not present- _
8
Page 9 of 1 I
OFFICIAL INSPECTION FORM —NOT FOR TOM IN ASSESSMEN N FORM TS
SUBSURFACE SEWAGE DISPOSAL SYS
PART C
SYSTEM INFORMATION(continued)
Property Address: 19 Norris St -ept-
Hyanni G,Mass
OwnerM-a ra Mc- ul i ffA
Date of Inspection:1 9 i 1 n /n 1
SOIL ABSORPTION SYSTEM (SAS): 2(locate on site plan, excavation not required)
1 -1000 cialLon
If SAS not located explain why:
Located; See page in
Typ —leaching pits, number: Z
leaching chambers, number:Q
4)1)leaching galleries, number: 1
leaching trenches, number, length: C
/1J0 leaching fields, number, dimensions:
�D overflow cesspool, number:C)
innovative/altemative system Type/name of technology damp
damp soil,condition of vegetation,
-
Coments(note condition of soil, signs of hydraulic failure, level of ponding,
m
etc.):
Loam sand to .me
ai ure or ondin S Vegetation
is e ow the invert pipe.
CESSPOOL )e (cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration:
Depth—top of liquid to inlet invert: 2�
Depth of solids Layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction: 4
Indication of groundwater inflow(yes or no):
Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
Ces
PRIVY L(locate on site plan)
Materials of construction:
Dimensions:
Depth of solids: /r:
Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
Privy is oot prosent.
9
I Page 10 of 1 I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 19 Norris Street
Hyannis,Mass .
Owner:Moira McAuliffe
Date of Inspection: 1 2/1 0/01
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.
9 /1/arrrs St-. H ah.�is
21 '
A �
A l-<< 961 12-
10
ti Page 11 of l I M
l�
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OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 19 Norris Street
Hyannis,Mass.
Owner: Moira McAuliffe
Date of Inspection: 1 2 1 0/01
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
1
Estimated depth to ground water :))e feet
Please indicate(check)all methods used to determine the high ground water elevation:
NO Obtained om s ste desi Tans on record - If checked, date of design plan reviewed: }
bserved site(abutting prope bservation 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:
Used; Gahrety & Miller Model - 12/16/94 Grnndwater ahnvP SPa T.PVP1
Tspd.;TTSGS nhseryati on Wet 1 nat� jiine 1 c1A2
iTcPr�� TTS(-,S P1 at-P #2 (-,rr)xtcl T,7atPr 1Pve1 92-000-1
Top of r un
Leaching
Pit
Groundwater Feet Below Bottom of Pit High Groundwater Adjustment 1.8 ft per Frimpter Method
�)
Thercfore, the vertical separation distance between the bottor��
of the Icaching pit and the adjusted groundwater table is
feet.
I1
•wrnrwrn.r►r-r-.— rnrmrnmr►-..r.rm.mn::�.+-+-v.r�+rmrm rrm-u*.v'irrsrt.a-n .. •�'
.ram-�rT-.tee-nr—......r•
.1.OWN OF Barnstable (WARD OF HEALTH
Sl1I1SH FACT 9FWAGE DISPOSAL SYSTEM INSPECTION FORM - PART D •- CERTIFICATION
•••re•t-r••.-•.:rr..n.-..:m..+r.,n•nrm r�..r.as-rr rtrT.rr..—.�.-�mrn armnr�"n+n'awrrrr-u+*m.aa►w•'rn's r n oil ..+.rrr•r-�. —.
-TYPL OR PRINT CLEARLY-
PROPERTY INSPECTED
STREET ADDRESS19 Norris Street Hyannis,Mass. '
ASSESSORS MAP , DLOCK AND PARCEL # ��y70
OWNER' s NAMEMoira McAuliffe
PART U - C1;RTIFICATI0N
NAME OF INSPECTOR Joseph P. Macomber Jr.
COMPANY NAME
Joseph P. Macomber & San Inc
COMPANY ADDRESS P.O. Box 66 Centerville Ma 02632 .
Stravt Town or City State LIP
COMPANY TELEPHONE (508 ) 775 - 3338 FAX ( 508 ) 790 _ 1578
m
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at
this address and that the information reported is true , accurate , and
omplete as of the time of :inspection . The inspection was performed and any
recommendations regarding upgrade , maintenance , and repair are consistent
with my training and experience in the proper function and maintenance of on-
site sewage disposal systems ,
11 ill:,li
C
heck one :
one :
PASSED
The inspection which I have conducted has not found any information
which indicates that the system fails to adequately protect public.
health or the environment as defined in . 310 CMR 15 - 303 , Any failure
criteria not evaluated are as stated in the FAILURE CRITERIA section of
this form .
System FAILi?D
The inspection which I have con 'acted has found that the system fails to
protect the j-)ublic health and the environment in accordance with Title
5 , 110 CMR 15 - 303 , and as specifically noted on PART C - FAILURE
CRITERIA of this inspection form .
4 1 ,
Inspector Signature Date
ecopy of this certification must be provided to the OWNER, the BUYER
On
where applicable ) and the 130ARD OF IIEALI'JI.
* 'Zf the inspection FAILED , th'e owner or""operator shall upgrade ' the system
within o"ne year oP the date of the inspection , unless allowed or required
otherwise as provided in 3.10 CHR 16 . 305 .
a
partd .doc
Commonwealth of Massachusetts
Executive Office of Environmental Affairs
Dept. of Environmental Protection
One winter Street,Boston,Ma. 02108 JohnS pti
D.C.P. Title V Septic Inspector
kv P.O. Box 2119
Teaticket, MA 02536
WILLIAM F.WELD (508)564-6813
Governor
ARGEO PAUL CELLUCCI
Lt.Governor
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
Property Address: 19 Norris St.Hyannis Map 306 Lot 14 Address of Owner:
Date of Inspection: 8/12/98 (If different)
Name of Inspector: John Graci Kenneth Rubino:95 Brookside Dr.Bridgewater Ma.02324
1 am a DEP approved system inspector pursuant to Section 15.340 of Title%(310 CMR 15.000)
Company Name, Address and Telephone Number:
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:
X Passes This Inspection Is based on criteria dented In Title V
Conditional) Passes code 310CMR16303.Mytindings are of how the system Is
Y performing at the time of the Inspection.My Inspection does
_ Needs Further Evaluation By the Local Approving Authority not Imply any warrantyor guarantee of the longevity ofthe
F its septic system and any of Its components useful life.
Inspector's Signature: Date: 8121198
The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this
inspections. 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.
r &
INSPECTION SUMMARY: - REcivLO 'r+`d
Check A, B, C,or D: AUG� � � 1990
A] SYSTEM PASSES: 0
TOWN OF BAR%TABLE
x I have not found any information which indicates that the system violates any of the failure criteria -A HEALTHDEPT.
defined as in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. �9
COMMENTS:
rF-71>e
B] SYSTEM CONDITIONALLY PASSES:
One or more systein components need to be replaced or repaired. The system,upon completion
of the replacement or repair,passes inspection.
• 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 lank,whether or not nietal, is cracked, structurally unsound, shows substantial infilllatlon of exfilttation, of tank
failure is imminent.The system will pass inspection if the existing septic tank is replaced with a conforming septic tank
as approved by the Board of Health.
(revised WNW)
One Winter Street a Boston,Massachusetts 0210E Is FAX(617)556-1049 is Telephone(617)292-5500
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 19 Norris St.Hyannis Map 306 Lot 14
Owner: Kenneth Rubino:95 Brookside Dr.Bridgewater Ma.02324
Date of Inspection:8i12f98
_ Sewage backup or.breakout or hioli.static water level observed.in.the distribution box is due to a broken.
or obstructed pipe(s)or due to broken,settled or uneven distribution box.The system will pass inspection if,
(with approval of the Board of Health). Describe observations:
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled 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
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 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 APPROPRIATE)DETERMINES
THAT THE SYSTEM IS FUNCTIONING IN A MANNER 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 of water supply or tributary to a surface water supply.
The system has a septic tank and soil absorption system and is within a Zone 1 of a public watersupply 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 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 presense of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppin. Method usedto determine distance (approximation not valid)
3)Other
D] SYSTEM FAILS:
You must indicate either"Yes"or"No"as to each of the following:
_ I have determined that the system violates one or more of the following failure criteria as defined 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 in 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
cesspool.
SAS is in hydraulic failure.
(revised 04127)97)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 19 Norris St.Hyannis Map 306 Lot 14
Owner: Kenneth Rubino:95 Brookside Dr.Bridgewater Ma.02324
Date of Inspection:8112199
D]SYSTEM FAILS(continued)
Yes No
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 1/2 day flow.
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Numbers 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
p q y analysis. If the well has been analyzed to be acceptable,attach copy of well water analysis for
colifonn 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:
The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to
public health and safety and the environment because one or more of the following conditions exist:
Yes No
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area(IWPA)or a mapped Zone II of a
public water supply well)
The owner or operator of any such system shall bring the system and facility into full compliance 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.
(revised 04/27/97)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECLIST
Property Address: 19 Norris St.Hyannis Map 306 Lot 14
Owner: Kenneth Rubino:95 Brookside Dr.Bridgewater Ma.02324
Date of Inspection:8112198
Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following:
_c_ — 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 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.
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 septic tank was inspected
for condition of baffles or tees, material of construction, dimensions,depth of liquid,depth of sludge,depth of scum.
x The size and location of the Soil Absorption System on the site has been determined based on
— — The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of
Sub-Surface Disposal Systens.
x Existing information. Ex. Plan at B.O.H.
x Determined in the field(if any failure criteria related to Part C is at issue, approximation of distance is
unacceptable)[15.302(3)(b)]
(revised 04127)97)
i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 19 Norris St.Hyannis Map 306 Lot 14
Owner: Kenneth Rubino:95 Brookside Dr.Bridgewater Ma.02324
Date of Inspection:8112198
FLOW CONDITIONS
RESIDENTIAL:
Design flow: 3m g•p•d./bedroom for S.A.S.
Number of bedrooms: 2
Number of current residents: 0
Garbage grinder(yes or no): No
Laundry connected to system(yes or no): No
Seasonal use(yes or no): Yes
Water meter readings, if available:(last two(2)year usage(gpd).
n/a
Sump Pump(yes or no): No
Last date of occupancy: n1a
COMMERCIAL/INDUSTRIAL:
Type of establishment: nia
Design flow:0 gallons/day
Grease trap present: (yes or no) No
Industrial Waste Holding Tank present:(yes or no) No
Non-sanitary waste discharged to the Title 5 system:(yes or no) No
Water meter readings,if available: rda
Last date of occupancy: n1a
OTHER:(Describe) n1a
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
n1a
System pumped as part of inspection: (yes or no)Nc
If yes,volume pumped:0 gallons
Reason for pumping: n1a
TYPE OF SYSTEM
x Septic tank/distribution box/soil absorptions system
Single cesspool
Overflow cesspool
Privy
Shared system(yes or no) ( if yes, attach previous inspection records,if any)
I/A Technology etc.Copy of up to date contract?
Other:
APPROXIMATE AGE of all components, date installed(If known)and source Information:
1990
Sewage odors detected when arriving at the site: (yes or no) No
(revised04127197)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 19 Norris St.Hyannis Map 306 Lot 14
Owner: Kenneth Rubino:95 Brookside Dr.Bridgewater Ma.02324
Date of Inspection:8112198
SEPTIC TANK: x
(locate on site plan)
Depth below grade: 2'
Material of construction:x concreate metal FRP Polyethylene_other(explain)
If tank is metal, list age n1a . Is age confirmed by Certificate of Compliance No (Yes/No)
Dimensions: 1.6'6"H5-r•w4.10"
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle: 33"
Scum thickness:o
Distance from top of scum to top of outlet tee or baffle:6"
Distance form bottom of scum to bottom of outlet tee or baffle:o
How dimensions were determined: Measured
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.)
Septic tank and all components are structurally sound and functloning properly.Recommend pumping every two years for maintenance.
GREASE TRAP:
(locate on site plan)
Depth below grade: rda
Material of construction: concrete metal FRP Polyethylene_other(explain)
Dimensions: n1a
Scum thickness:rda
Distance from top of scum to top of outlet tee or baffle:rda
Distance from bottom of scum to bottom of outlet tee or baffle:nla
Date of last pumpingril�
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.)
rda
BUILDING SEWER:
(Locate on site plan)
Depth below grade: 2'6"
Material of construction:_cast iron x 40 PVC_other(explain)
Distance from private water supply well or suction line3o—
Diameter. nla_
rw,lmments: (conditions of joints, venting, evidence of leakage,etc.)
(revleed 04127197) _
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 19 Norris St.Hyannis Map 306 Lot 14
Owner: Kenneth Rubino:95 Brookside Dr.Bridgewater Ma.02324
Date of Inspection:9112198
TIGHT OR HOLDING TANK:
(locate on site plan)
Depth below grade: nfa
Material of construction:_concrete_metal_FRP_Polyethylene—other(explain)
Dimensions: n!a
Capacity: rda gallons
Design flow: nfa gallons/day
Alarm level:_nfa Alarm in working order?_Yes_No
Date of previous pumping:
Comments:
(condition of inlet tee, condition of alarrn and float switches,etc.)
nfa
DISTRIBUTION BOX: x
(locate on site plan)
Depth of liquid level above outlet invert: nra
Comments:
(note if level and distribution is equal, evidence of solids carryover,evidence of leakage into or out of box etc.)
nfa
PUMP CHAMBER:
(locate on site plan)
Pumps in working order:(yes or no)No
Alarms in working order(yes or no)_ves
Comments:
(note condition of pump chamber, condition of pumps and appurtenances,etc.)
nfa
(revlaed 040197)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 19 Norris St.Hyannis Map 306 Lot 14
Owner: Kenneth Rubino:95 Brookside Dr.Bridgewater Ma.02324
Date of Inspection:8112198
SOIL ABSORPTION SYSTEM (SAS):x
(locate on site plan, if possible;excavation not required, but may be approximated by non-intrusive methods)
If not determined to be present,explain:
n/a
Type:
leaching pits,number: 1000 gallon leach pit with 7ofstone
leaching chambers, number:rda
leaching galleries, number: rda
leaching trenches, number,length: rda
leaching fields,number, dimensions:rda
overflow cesspool, number:nla
Alternate system: nia Name of Technology._nra
Comments: (note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.)
The leach pit is structurally sound and Is functioning property.The pit was empty at the time of the Inspection.
CESSPOOLS:_
(locate on site plan)
Number and configuration: rJa
Depth-top of liquid to inlet invert: rva
Depth of solids layer: rda
Depth of scum layer: nla
Dimensions of cesspool: rda
Materials of construction: nla
Indication of groundwater: nla
inflow(cesspool must be pumped as part of inspection)
nla
Comments: (note condition of soil, signs of hydraulic failure,level of ponding,condition of vegetation, etc.)
rda
PRIVY:_
(locate on site plan)
Materials of construction: nla Dimensions: rda
Depth of solids: rda
Comments: (note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.)
rda
(revised 04127/97)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
19 Norris St.Hyannis Map 306 Lot 14
Kenneth Rubino:95 Brookside Dr.Bridgewater Ma.02324
8112198
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references, landmarks or benchmarks
locate all wells within 100'(Locate where public water supply comes into house)
0)
e-
P j I'i
I-
l�
I
(revised MUM) Page 0 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
19 Norris St Hyannis Map 306 Lot 14
Kenneth Rubino:95 Brookside Dr.Bridgewater Ma.02324
8f12f98
Depth of groundwater 12
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from design plans on record.
Observation of Site(Abutting property, observation hole, basement sump etc.)
Determine it from local conditions
Check with local Board of Health
Check FEMA Maps
Check pumping records
Check local excavators, installers
x Use USGS Data
Describe in your own words how you established the High Groundwater Elevation.(MUST be completed)
USGS Maps and Charts
(revised04127197) page 10 of It
1
No.---...§`......... Fps. ... e.00...........
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
T own Barnstable
1 ......... ..... ..................OF......... .. ............-------
AppltrtttilaBt for Uhipwia1 No rk 6 To ustrurttun rrmtt
4
Application is hereby made for a Permit to Construct ( ) or Repair (X ) an Individual Sewage Disposal
System at:
Norris St. .. Hyannis,_MA .02601
. .............__-- --•--•..................... ---•..._._..._..__...--••.........---.....---•••-••••••-••--••----..........................-•-•--
Location-Address or Lot No.
Phillip Gallerani 27 Main St., W:Springfield=__MA...;01089
Owner Address
A & B Cesspool Service 128 BishopsTerraee, Hyannis: MA 02601
Installer Address
a of Building r. Size Lot....
d Type g _.....-•---._.......Sq. feet
Dwelling—No. of Bedrooms................._......._..__...___........Expansion Attic ( ) Garbage Grinder ( )
04 Other—Type of Building ............................ No. of persons---------------------------- Showers ( ) — Cafeteria ( )
C4 Other fixtures ----------------------------------------------
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity............gallons Length---------------- Width................ Diameter---------------- Depth................
x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by.......................................................................... Date........................................
,.� Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................
Test Pit No. 2...........:....minutes per inch Depth .of Test Pit.................... Depth to ground water........................
-- -------------------------------•---••--•------------..............--•-----••---•---------•------..._--•--•-----•------......
ODescription of Soil......SaJ2d....---•------------------------•---------------•--------------••....•-•----••••••-----------------••--------------•----------•--•---•----------•-----
x
w
-----------•-----------•-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
U Nature of Repairs or Alterations—Answer when applicable-installatian--0
st one..�paeked_-leach._Pit__-(overflow..............................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TLITA IE 5 of the State Sanitary Code—The undersign further agrees not to place the system in
operation until a Certificate of Compliance h en ' s by the?boao t .Signe -•------.•-•----•---•--------------------- ........................................ . ....12/11,F81-------•-
Date
Application Approved By.....
Date
Application-Disapproved for the following reasons-----------------------------•-------------------------------------------------------------...---•-----••••----
------------------------------------------------------------------------------------•--•------------------------------•--•-•••-•----•---•---•---------•12 11 81------------•----•--------
Date
PermitNo........._81 -------------------------- --- Issued.............----1----�-----•......•---.....••----
Date
No.......R7-._..----- ' FE $..... ...........
.a THE COMMONWEALTH OF MASSACHUSETTS
` BOARD OF HEALTH
I ..............T.own.........---....OF....................Ba=stal)l�-
ApplirFation for Diopoottl Works Tonotrnrtion ermit
Application is hereby made for a Permit to Construct ( ) or Repair (X ) an Individual Sewage Disposal
System at: ;
.....026DI..........................
.....••-•-•.................. ......-•----......•----••..............--
Location-Address or Lot No.
?h ..Q%2 exam...... ..............................::. ........... -Z73..Main-.S.t_,.,-.�. - r M9fi.skit_.MA.....01000......
Owner Address
aA,&......Cesspool.Sg v ---...•...................................... 12 .. i,ghczpsT.erxace,..Hyau�nis._.MA.....0?.�i01......
'`;Installer Address
Type of Building Size Lot............................Sq. feet
a1 Dwelling—No. of Bedrooms............... ............................Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building ............................. No. of persons...............2.__--.--.- Showers ( ) — Cafeteria ( )
dOther fixtures ...............-n....................................................................................................................................
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
9 Septic Tank—Liquid*capacity............gallons Length................ Width................ Diameter................ Depth................
Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No............... ... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date........................................
aTest Pit No. 1................minutes per inch Depth of Test Pit------.............. Depth to ground water......--................
G14 Test Pit No. 2................minutes per inch Depth of Test Pit---................. Depth to ground water......--................
94 •-•-•-•--•---•-•-•-------•••----••-...•--•-••--••••••--•.....---•-•-•.......-•-••-•-••..........--•................•--..........-•••-•-----••.......••...•--
O Description of Soil.....S&nd-•••••--••••-••-•••--..
U
W -•••------------------------•--•--------•-••----••••--•-•-----•------••-•••-••••--•-------•••••-••••----•••••----•---•-----•-•---•-••-••-•----•-•-•••-------••-•-••-••••......--••--
------------
U Nature of Repairs or Alterations—Answer when applicablei.nstaUati,on---of- .1TIIOQ-g8.11AtL,---fie:=fit,
st.Qne•--packecl.leach..pit---(cverfl ow)................•------------.....------------------------------------------------•-----------------•----•----=-..........
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance'with
the provisions of TTT I:;,:. 5 of the State Sanitary Code—The undersign fu- per agrees not to place the system in
operation until a Certificate of Compliance has i ued y the boar ,heatt
Signed. . .............. ----=.........................
...... ........
Dat
Application Approved BY r !' ! a -` -' ......................... ...........12/1V81.........
Date
Application Disapproved for the following reasons------------------------•-•------------------------------------•----------------------------•......•--•........•.
..............................••--•••---•--••-•••-••••-•----•--•---•••-••••••-•--••--•---......-----••---
Date
Permit No........8it....................----•----••----••--- Issued...------....W11/01.......................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
......................TSM.........oF...............Barnstable...........................................
(9rdifiratr of ToutpliFatta
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (X )
byA &._B._ �elpool._lse !�ce ---------------------------------------------------------------•----------...........---------------------------•------------
Installer
at Nods_St. HyAnr
isGAll, 7CI11---------------------------------•-•-------------•--....-•---------•-•-------•-----------
has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No...... ln-------�-�.a.......... dated............32/11/81..:.............
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISF CTORY.
DATE................................................... .�����....---.. Inspector................ �/ ..j...............................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH /
'�'.. ............. ............... rnstable.........------------.........
No...�l.-.....�.�.G .........I..... QM . 0 F Ba . ..-----
.... FEE.-$•-.rj_IItl1.---
Uiopooatl Vorkv 10.1,11notr ion rrntt
Permission is hereby granted.....A-A..B----G.esjg20Q1.,Ser.vic.H---------------------••------------.........-•--•-------.......I........:.........
to Construct ( ) or Repair (X ) an Individual Sewage Disposal System
at No......... orris_•St.,---•-Hy_ann s......................=m....-----......Pbi.11ip--Qallerani.---------•---------------------------:-...........
Street as shown on the application for Disposal Works Construction Permit Nal.........._.� Dated......12/u/81•1............
......................................................
Board of Health
DATE , -----•---•-•----•-
FORM 1255 HOBBS & WARREN. INC., PUBLISHERS''
1