HomeMy WebLinkAbout0077 PEACOCK DRIVE - Health 77 Peacock Drive .,
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TITLE 5 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A CERTIFICATION
Property Address: 77 Peacock Drive, West Hyannisport, MA
Owner's Name: Brian Badrigian
RECEIVE
Owner's Address: 11 Loring Street, Newton,,MA 02459
Date of Inspection: May 30, 2003 JUN 0 4 200:3
Name of Inspector: Paul M.cDowell TOWN OF BARNSI .SLE
HEALTH DEPT
Company Name, Address & Telephone Number: The Building Inspector.Of America
2 Brookside Circle -A
_ Wilbraham, Massachuse P109
'-1'800-626-4408 PARCEL ,CERTIFICATION STATEMENT LOT ;
I certify that I have personally inspected the sewage disposal system at this address and that the information
reported below is true, accurate and complete as of the time of the inspection. The inspection was performed {
based on my training and experience in.the proper function and maintenance of on site sewage disposal
systems. I am a DEP approved system inspector pursuant to Section 15.340 of the Title 5 (310 CMR
15,000). The system:
® Passes
❑ Conditionally Passes
❑ Needs Further Evaluation By The Local Approving Authority
❑ Fails
Inspector's Signature: Date: 5/30/03 .
Paul McDowell MM/km
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or
DEP within 30 days of completing this inspection. If the system is a shared system or has a design flow of -i
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:
Original To: ,' Copy To:
Brian Badrigian Town of Barnstable
11 Loring Street Board of Health
Newton, MA 02459 PO Box 534
!.
Hyannis MA 02601 `
(Copy Provided For Buyer) Certified Mail# 7001 0320 001 4601 1457
This report only'describes conditions at the time of inspection and under the conditions of use at F.
that time. This inspection does not address how the system will perform in the future under the same or
different conditions of use.
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TNIe 5 Inspection Form Revised 6I15/2000 - -
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INSPECTION SUMMARY: Check A, B, C, or E. Always complete all of Section D
A.) SYSTEM PASSES:
have not found any information which indicates that any of the failure criteria
described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not
evaluated are indicated below.
Comments:
t
B.) SYSTEM CONDTIONALLY PASSES: N/A
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) for the following statements. i
if"Not Determined" please explain: l
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 ex-filtration, 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:
Observation of sewage backup or break out or high static water level in the distribution, box
due to broken or obstructed pipes) or due to a broken, settled or uneven distribution box,
System will pass inspection if(with approval of Board of Health):
❑ broken pipes) are replaced
❑ obstruction is removed
Ej distribution box is leveled or replaced
ND explain:
The system required pumping more than 4 times a year due to broken or obstructed is
es
The system will pass inspection if (with approval of the Board of Health): p p )
❑ broken pipe(s) are.replaced
El obstruction is removed ,
ND explain:
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N/A = non-applicable
- Tdle 5 Inspection Form Revised 6I15I2000 -
(2)
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C.) FURTHER EVALUATION IS REQUIRED BY THE BOARD•OF HEALTH: N/A
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.
E ,A
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: R
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.,
The system has a septic tank and soil.absorption system (SAS) and the SAS is
within100 feet of a:surface water.supply or tributary to a surface water supply.
,
The system has' a septic tank and SAS and the SAS is within a Zone 1 of a
public water supply,
Y
The system has a septic tank and SAS and the SAS is within 50 feet of a
private water supply well.
The system has a septic tank and SAS.and the SAS is less than 100 feet but
50 feet or,more.from;a private water supply well". A ,°
Method used to determine distance:--.-.,
uT.
"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 noother failure criteria are triggered. 'A copy of the analysis must
be attached to this form.
3. Other.
N/A = non-applicable:-"
Idle 5 Inspection Foos Revised 6/152000
(3) :
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D.) SYSTEM FAILURE (Criteria Applicable To,All Systems)
You must indicate "yes" or"no" to each of the following for all inspections:
YES NO N/A
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❑ ® ❑ Back up of sewage into facility or system component due to overloaded
or clogged..SAS or cesspool f
®_ ® ❑ 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'inches below invert or available
volume is less than% day flow.
❑ ® ❑ Required pumping more thann4 times in the last year NOT due to I
clogged or obstructed pipe(s). Number of times pumped
❑ ® ❑° Any portion of the SAS„cesspool, or privy is,below high groundwater
elevation.
❑ ❑ ® Any portion of cesspool'or privy is within 100 feet of a surface water
supply or tributary to a surface water supply. _
❑ ❑ ® Any portion;of a cesspool or privy is within a Zone 1 of a public well
❑ ❑ ® Any portionof a cesspool or privy is within.50 feet of a private water
supply well:
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❑ ❑ ® Any portion of a cesspool oryprivy 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 ?:
nit rogenjs 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.).Y
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NO (YES or 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 f'
of Health to determine what'will be necessary to correct the failure. il'
.
, .N/A = non-applicable
Title 5 Inspection Form Revised 6/15/2000
d.a ' (4) fi
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E.) LARGE SYSTEMS: N/A
To be considered a large system, the system must serve a facility with a design flow of 10,00o
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.)
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YES NO N/A
❑ ❑ ❑ The system is within 400 feet of a surface drinking water supply.
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❑ ❑ ❑ The system is within 200 feet of a tributary to a surface drinking water i
supply.
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❑ ❑ ❑ The system is located in a nitrogen sensitive area
(Interim Wellhead Protection Area— IWPA) or a mapped Zone II of a
public water supply well.
If you have answered "yes" to any question in Section E, the system is considered ;I
y s dered a significant threat, ,
or answered "yes" in Section D that 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 Jf'
regional office of the Department.
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E.
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N/A = non-applicable
We 5Inspection Fonn Revised 6/15/2000 -
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TITLE 5 OFFICAL INSPECTION FORM
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B CHECKLIST
Check if the following have been done. You must indicate "yes" or"no" as to each of the following:
YES NO N/A
❑ ® ❑ Pumping information was'provided by the owner, occupant, or
Board of Health. R
❑ ® ❑ 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?
El M ❑ Have large volumes of water been Introduced to the system recently or
as part of this inspection?
® ❑ ❑ Were as built plans of the system obtained and examined?
(If they were not available, note as N/A) f
® ❑ ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ ❑ Was the site-inspected for"signs of break out? =-
® ❑ ❑ Were all system components; excluding the SAS, located on site?
® ❑ ❑ Were the septic tank manholes uncovered, opened, and the interior of
the tank inspected for the condition of the baffles or tees, material of
construction,l dimensions, depth of liquid, depth of sludge, and depth
scum?
® ❑ ❑ Was the facility owner (and occupants if'different from owner) provided
with information on the proper maintenance of subsurface sewage
disposal systems?
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The size and location of the Soil:Absorption System (SAS) on the site has been determined
based on: f
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YES NO N/A -
® ❑ ❑ 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)) c
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N/A = non-applicable
Title 5 Inspection Form Reised 6/15/2000 - -
(6)" i.
TITLE 5 OFFICAL INSPECTION FORM
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C SYSTEM INFORMATION
FLOW DONDTION
RESIDENTIAL
Number of bedrooms (design): 3 Number of bedrooms'(actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 1)0 gpd x#of bedrooms): 330
Number of current residents: 2 .
Does residence have a garbage grinder (Yes or No): NO
Is laundry on a separate sewage system (Yes or No): NO (If yes, separate inspection required)
Laundry system inspected (Yes or No): N/A
Seasonal use (Yes or No): NO
Water meter readings, if available (last two years usage (gpd): Called water department no return
call
Sump pump (Yes or No): NO
Last Date of occupancy: Currently occupied
GENERAL INFORMATION
PUMPING RECORDS w.
Source of information: Unknown per owner and BOH
Was system pumped as part of the inspection? (Yes or'No): NO
If yes, volume pumped: gallons !
How was quantity p q y pumped determined?
Reason for pumping?
TYPE OF SYSTEM p
Septic tank, distribution box, soil absorption system
❑ Single cesspool I
❑ Overflow cesspool
❑ Privy l
El Shared system (Yes or No) (If yes; attach previous.:inspection records, if any)
ElInnovative/Alternative technology. Attach a copy of the current operation and maintenance
contract (to be obtained from system owner)
Tight Tank Attach a.copy of the DEP approval E
❑ Other(describe): i
APPROXIMATE'AGE of all components, date installed (if known) and source of information:
Septic system is eighteen years old, based on materials used and their condition. Three infiltrators i
were added in 1992 based on BOH records.
Were sewage odors detected when arriving at the site (Yes or No): NO
N/A = non-applicable
Title 5 Inspection Foon Revised 6115/2000
(7)
PART C SYSTEM INFORMATION (Continued)
BUILDING SEWER: ✓_(Locate`on site plan)
Depth below grade: 24"
Material of construction: ❑cast iron ® 40 PVC ❑ Other (explain):
Distance from private water supply,well or suction°line: 28'
Comments: (on condition of joints, venting, evidence'of leakage, etc.):
Building sewer exits rear foundation wall. There was no evidence of leakage at time of inspection. .
SEPTIC TANK: ✓ (Locate on site plan)
Depth below grade: 1.8" i
Material of construction: ®concrete ❑ metal ❑ fiberglass ❑polyethylene ❑ other (explain)
If tank is metal, list age: , Is age confirmed by Certificate of Compliance (Yes or No):
(Attach a copy of the Certificate of:Compliance.)
Dimensions: 81 x 5'W x 5'D, approximately.1000 -gallons `
Sludge depth: 6"
Distance from top of sludge to bottom of outlet tee or baffle: 23' '
Scum thickness: 6"
Distance from top of scum to top of outlet tee.or baffle: 6"
f
Distance from bottom of scum to bottom of outlet tee or baffle: 14"
How were dimensions determined?: With a tape measure and pole
Comments: (on pumping recommendations, inlet and outlet tee or baffle condition, structural
integrity, liquid levels as related to,outlet invert, evidence of leakage, etc.):
Fluid level is correct, that is, equal to outlet invert. Observed minimal concrete deterioration above
fluid level of septic tank. Recommend pumping of,septic tank at this time due to scum and sludge f
levels. Recommend installing risers to within 6 inohes below grade on ell three covers of septic tank.
Pumping of septic tank is recommended every three years. }
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N/A = non-applicable
Title 5 Inspection Form Revised 6/15/2000
(8) �,
PART C. SYSTEM INFORMATION (Continued)
DISTRIBUTION BOX: ✓ (If present, it must be opened) (Locate on site plan)
Depth of liquid level above outlet invert: 0
Comments: (Note if box is level, and distribution to outlets equal, any evidence of solids carryover,
and/or any evidence of leakage into or out of distribution box, etc.):
Fluid level was correct, that is, equal with outlet invert(1). There was no evidence of solids carryover.
Distribution box cover was found cracked and was replaced at time of inspection. Some concrete
deterioration was observed on side walls of distribution box,
SOIL ABSORPTION SYSTEM (SAS): ✓ (Locate on site•plan, excavation not required)
If SAS is not located, explain why:
® Leaching pits, number: 1
® Leaching chambers, number: _1 at approximately 24 feet
❑ Leaching galleries, number:
❑ Leaching trenches, number, length:
❑ Leaching fields, number, dimensions.
❑ Overflow cesspool, number:
❑ Innovative/alternative system =Type/name of technology: .
Comments; (Note condition of foil, signs of hydraulic failure, level of ponding, damp soil, and/or
condition of vegetation, etc.):
There was no evidence of hydraulic failure. Vegetation was normal. In 199Z three infiltrators were
installed in a single row as an overflow for the leaching pit.
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N/A = non-applicable l
Title 5 InspwionFom Revised&15/2WO k•
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PART C SYSTEM INFORMATION (Continued)
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 with 100 feet. Locate where public water supply enters
the building.
(Sketch not to scale) R
A= inlet cover on septic tank XA= 39" YA= 23'
B= main cover on septic tank k XB= 41'6" YB= 25'
C= outlet cover on,septic tank XC= 43' YC= 27'6"
D= distribution box XD= 46'6' YD= 363"
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Peacock Drive' i.
Ttlle 5 Inspection Foos Revised 611512OW `.
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PART S SYTEM INFORMATION (Continued)
SITE EXAM
® Slope
❑ Surface Water
® Check Cellar
❑ Shallow Wells
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Estimated depth to groundwater 6+ feet inches. '
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Please indicate (check) all methods used to determine the high groundwater elevation:
❑ Obtained from system design to plan on record.
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(If checked, date of design plan reviewed): a
® Observed site (abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health —explain;
❑ Checked with local excavators, installers'— (attach documentation)
❑ Accessed USGS database- explain:
You must describe how you established the high groundwater elevation:
Basement concrete slab floor is approximately 6 feet below grade. There is no evidence of
efflorescence on foundation walls. Basement does not have a sump pump or pit.
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TRIe 5 InspWion Form Revised 6/15/20W
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TOWN OFo BARNSTABLE
LOCATION" ���bG`� di 1Q SEWAGE iv,ll
VILLAGE.Vj 44'V li ® � .ASSESSOR'S MAP-& LOT ` ( �
INSTALLER'S NAME & PHONE NO PA,bouj 41a955 b
SEPTIC TANK CAPACITY
LEACHING FACILITYAtype) (size)
�4,
NO. OF BEDROOMS PR1VA'TE WELL OR PUBLI WATER
BUILDER OR OWNER 1
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED: ��
VARIANCE GRANTED: Yes No ��
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No.. Fxs..3-e......I——
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
TOWN OF BARNSTABLE
ApplirFatilan for Uiipn, l Mirkii Tnnitrat.rtiun rantit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
�7 Locatio, -Address or Lot No.
1.�..... l.�i �./ •.............................•--•-••••-•-'^- --- ls=-- !%[DO. '�........................................................
W Owner / �jddryss p� /
Installer Address
;. YVPDleof Building Size Lot............................Sq. feet
U
�-[ Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
Other—T e of Building No. of persons............................ Showers
a Other—Type g ---------------------------• P ( )--- Cafeteria ( )
Otherfixtures ---------------------------•--------------------------.•-•••--•-----••••-•--•---•--•------------•---...----------•-. ......---•
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 ( )
14 Percolation Test Results Performed by........................................................................... Date----------------------••-•------------
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................
914 Test Pit No. 2................minutes per inch Depth of Test Pit---:................ Depth to ground water........................
a ...•.........................................................................................................................................................
0 Description of Soil............................................................................... ---------------------------------------•-------------------............................--------------------------------------------------------------------------------------------------------------
UNature of Repairs or Alterations—Answer when applicable.... > �7-------------------------------------------
----------------------------------------------------------------------------------------------------•--------••_....----•-•••----••--•-----•--•-•-...--•-•••-•------•••------ ..........................
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 Compliant has been issued by the board of health.
Signed4 . ....... ...................
C, to
Application Approved By ....:...... ---� - ---/^-9.�-------
.......... ................................................................................... — Dale
Application Disapproved for the following reasons• --------------------------------------- -- -------------- - - ------------ - -------------------------------------
--- - --------------------------------------- -- --- --- -- -- ----------------- -------------------------------------------------------------------- a ..... ....................................
Date
PermitNo. �d -4`r......................... Issued ------------------------Dte------. --.......-----------.--------
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Appliratiun for Disposal Works Tunutrurtiun Frrmi#
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
� /
...... Lam. ----------------
troae-A F ss�,
.....:� /-S_�5�� -----------•------------------------------ Lot..N.
..
, nn'' or
ss
a Zype'
-----------------------------•-------- ; 1!=r� ar1nstaller Address
of Building Size Lot----------------------------Sq. feet
�U Dwelling No. of Bedrooms................. ...._Ex anion Attic
�— ---------------------- p ( ) Garbage Grinder ( )
p l Other—Type of Building ------•--------------------- No. of persons............................ Showers ( ) — Cafeteria ( )
PI Other fixtures
WW 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....................
f� Test Pit No. 2................minutes per inch Depth of.Test Pit-----.._-------•-__. Depth to ground water........................
----------------------------------•------------------------•-------•--------....------------------------------...._......_...---................
------------
Descriptionof Soil...............................................................................----------------•-----------------•-----•-----------------------------------------------
W
V ------------------------------
•---------•------------------------
---------------------------------------------------------------------------------------
•-----------------------------------------------
W
------------ - --- ------ --- - - --
x ��;----R------------------•------------------------
U Nature of Repairs or Alterations—Answer when applicable.____--A' __,..__•___----__.-�/�..........................................
......
•--------------------------------------
•------------------------------------------------------------------------------------------
---------------------
----------------
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 �as been issued by board of health.
Sign C .. - '�--------- ���Signed ,
Application Approved By -------------
� �- �^�--\------------------------------------------------------------------ Date
Application Disapproved for the following reasons: ----------)--------------------------------------------------------------------- ------------------------------------------------------
- - - ------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------- ----------------- -------------=-=-
-.............
Dare
PermitNo. .......... 4 y------------------------- Issued ----------------------------------------
Dare
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
(9erliftxtt#e of ( antylianre
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired
be - /� ���-------------- ---------------------------------------- ------------------------------------------......------------------------------------=--
Y __..........fi ( ✓e.a..^f z.°•E a Installer
at -----------------7-? �� i-. = Y a----------------------------------------------------------------
--------------
-
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-------------------------�-- ��=-------------------------------- Inspector ------------------------=:�_. ...................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
No.....
�( :- '�!� TOWN OF BARNSTABLE
Disposal f or u Tunu#rnr#iun Prrmit
Permission is hereby granted. �------------------ i�a`J4 ._..
to Construct ( or Repair ( an In ividu al Sewag Disposal System
atNo................. •--7 - ----- ----------------------------------------------------
Street �----q------•-------
as shown on the application for Disposal Works Construction Permit No-A_-__T�_'_ Dated..........................................
(�
DATE. G _ ! v ��.................................. �BOaid of Health
FORM 3850E HOBBS R WARREN.INC..PUBLISHERS