The URL can be used to link to this page

Home My WebLink About1057 PHINNEY'S LANE - Health 1057 PHINNEY'S LANE, HYANNIS A= 273016 , I 6 0 TOWN OF BARNSTABLE LOC;A"3710:' los I rS tiASt— SEWAGE # VILLAGE ESSOR'S MAP & LOT INSTALLER'S NAME.&PHONE NO. SEPTIC TANK CAPACITY 1�2. Cal Pt 1— LEACHING FACILITY: (type) d hh 6 (size) NO.OF BEDROOMS nn,, BUILDER OR OWNER O Val( M PERMTTDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by a oc I �_ TOWN OF BAMSTABLE LOCATION 6oO5�-] SEWAGE # VILLAGE NniS ASSESSOR'S MAP & L3,1�+" INSTALLER'S NAME&PHONE LO. SEPTIC TANK CAPACITY 1 + 6cff, oalwoo� LEACHING FACILITY: (type)�! A ddIsize) 1-A0` vh NO.OF BEDROOMS 25 BUILDER OR OWNER PERMTTDATE: 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 wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by V►QC � o 0 o _ n r � Z7 .ter COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS John Grad DEPARTMENT OF ENVIRONMENTAL PROTECTION DEP Title V Septic Inspector ONE WINTER STREET BOSTON MA 02108(617)292-3500 P.O.Box 2119 TeaTickel,Ma. (508)564-6813 - TRUDY COXE Secretary ARGEO PAUL CELLUCCI DAVID B.STRUHS Govemor Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: 1057 PHINNY'S LANE HYANNIS Name of Owner BERRYMAN lb� Address of Owner: SAME e Date of Inspection: 6/29/99 R01 VE0 Name of Inspector:(Please Print)JOHN GRACI rD J V L im I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000) 9 1999 Moo Company Name: n/a ISAR Mailing Address: n/a ,` Telephone Number: n/a A CERTIFICATION STATEMENT 1 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 The inpectlon Is based on criteria defined in Title V Conditionally Passes code 310 CMR 15.303.My findings are of how the system Is _ Needs Further Evaluation By the Local Approving Authority performing at the time of the Inspection.My Inspection does Fails not Imply any warranty or guarantee of the longgevlty of the septic system and any of Its components useful life. Inspector's Signature: kubmit Date:6/30199 The System Inspector shall copy of this inspection report to the Approving Authority(Board of Health or DEP)within thirty(30)days of completing this Inspection.if the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. NOTES AND COMMENTS THE SYSTEM PASSES TITLE V INSPECTION.RECOMMEND PUMPING THE SYSTEM NOW AND THEN MAINTAINED EVERY YEAR. revised 9/2190 Page 1 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 1067 PHINNY'S LANE HYANNIS Owner: BERRYMAN Date of Inspection:6129/99 INSPECTION SUMMARY: Check A, B, C, or D: A. SYSTEM PASSES: I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist.Any failure criteria not evaluated are indicated below. COMMENTS: System passes Title V inspection B. SYSTEM CONDITIONALLY 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. Indicate yes,no,or not determined(Y,N,or ND).Describe basis of determination in all instances.If"not determined",explain why not. nta The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection;or the septic tank,whether or not metal,is cracked,structurally unsound,shows substantial infiltration or exhItration,or tank failure is Imminent.The system will pass inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. nla Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken,settled or uneven distribution box.The system will pass inspection if(with approval of the Board of Health). _ broken pipe(s)are replaced _ obstruction is removed distribution box is levelled or replaced nla The system required pumping more than four limes a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): _ broken pipe(s)are replaced obstruction is removed revised 9/2190 Page 2 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 1057 PHINNY'S LANE HYANNIS Owner: BERRYMAN Date of Inspection:6/29/99 C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health,safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 16.303(1)(b)THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT ThE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of surface water _ Cesspool or privy Is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER.IF ANY)DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. _ The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well, The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well,unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,Method used to determine distance n/a-(approximation not valid). 3) OTHER Wit revised 9/2/98 Page 3 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 1067 PHINNY'S LANE HYANNIS Owner: BERRYMAN Date of Inspection:6/29/99 D. SYSTEM FAILS: You must indicate either"Yes"or"No"to each of the following: I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303.The basis for this determination is identified below.The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No X Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. X Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow, X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped u(a. X Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. X Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone I of a public well. X Any portion of a cesspool or privy Is within 50 feet of a private water supply well, X Any portion of a cesspool or privy Is less-than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis.If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic ompounds, ammonia nitrogen and nitrate nitrogen. X The liquid level in the SAS is over the invert pipe,is in Hydraulic Failure. E. LARGE SYSTEM FAILS: 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: 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 X the system is within 400 feet of a surface drinking water supply X the system is within 200 feet of a tributary to a surface drinking water supply X the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone II of a public water supply well) The owner or operator of any such system shall upgrade the system in accordance with 31.0 CMR 15.30412).Please consult the local regional office of the Department for further information. revised 9/2198 Page 4 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 1057 PHINNY'S LANE HYANNIS Owner: BERRYMAN Date of Inspection:6/29/99 Check if the following have been done:You must indicate either`Yes"or"No"as to each of the following: Yes No X Pumping information was provided by the owner,occupant,or Board of Health. X None of the system components have been pumped for at least two weeks and-the system has been receiving normal flow rates during 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.baflies or tees,material of construction,dimensions,depth of liquid,depth of sludge,depth of scum.The size and location of the Soil Absorption System on the site has been determined based on: X Existing Information,For example,Plan at B4O,H, X Determined in the field(if any of the failure criteria related to Part C is at Issue,approximation of distance is unacceptable) (1 5.302(3)(b)J X The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of SubSurface Disposal Systems. revised 9/2/98 Page 5 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 1057 PHINNY'S LANE HYANNIS Owner: BERRYMAN Date of Inspection:6/29/99 FLOW CONDITIONS RESIDENTIAL: Design flow:-M g.p.d./bedroom Number of bedrooms(design): 5 Number of bedrooms(actual):5 Total DESIGN flow: H& Number of current residents:2 Garbage grinder(yes or no):NQ Laundry(separate system)(yes or no): NO If yes,separate inspection required Laundry system inspected(yes or no):M Seasonal use(yes or no):M Water meter readings,if available(last two year's usage(gpd): Wa Sump Pump(yes or no): NQ Last date of occupancy: n1a COMMERCIAL/INDUSTRIAL Type of establishment: nta Design flow: nta gpd(Based on 15.203) Basis of design flow: nla Grease trap present:(yes or no):._pLQ Industrial Waste Holding Tank present:(yes or no): NII Non-sanitary waste discharged to the Title 5 system:(yes or no):MQ Water meter readings.if available:n& Last dale of occupancy: n1a OTHER: (Describe) nta Last date of occupancy: n1a GENERAL INFORMATION PUMPING RECORDS and source of information: THE SYSTEM WAS LAST PUMPED 1N JUNE 98 BY CANCO System pumped as part of inspection:(yes or no):NQ If yes,volume pumped nta- gallons Reason for pumping: n& TYPE OF SYSTEM X Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no)(if yes.attach previous inspection records,if any) I/A Technology etc.Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other: nta APPROXIMATE AGE of all components,date Installed(if known)and source of information: THE SYSTEM IS 25 YEARS OLD. Sewage odors detected when arriving at the site:(yes or no). N12 revised 9/2/98 Page 6 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1067 PHINNY'S LANE HYANNIS Owner: BERRYMAN Date of Inspection:6/29/99 BUILDING SEWER: (Locate on site plan) Depth below grade: 2 Material of construction:_ cast iron _40 PVC X other(explain) Distance from private water supply well or suction line: TOWN Diameter: nLa Comments: (condition of joints,venting,evidence of leakage,etc.) nla SEPTIC TANK: X (locate on site plan) Depth below grade: V Material of construction:X concrete_ metal_ Fiberglass _ Polyethylene _ other(explain) nLa If tank is metal,list age Is age confirmed by Certificate of Compliance(Yes/No): No nta Dimensions: 6'X6'BLOCK CESSPOOL Sludge depth: 4" Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: Distance from lop of scum to top of outlet tee or baffle: 4_ Distance from bottom of scum to bottom of outlet tee or baffle: ME How dimensions were determined: MEASURED Comments: (recommendation for pumping,condition of inlet and outlet lees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage, etc.) MAIN CESSPOOL AND ALL COMPONENTS ARE STRUCTURALLY SOUND_RECOMMEND PUMPING SYSTEM EVERY ONE YEAR, GREASE TRAP: (locate on site plan) Depth below grade: Material of construction:_concrete_ metal_ Fiberglass _ Polyethylene_other(explain) n& Dimensions: nla Scum thickness: nLa Distance from top of scum to top of outlet tee or baffle:_n& Distance from bottom of scum to bottom of outlet tee or baffle n& Dale of last pumping: nLa 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.) n& revised 9/2198 Page 7 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1067 PHINNY'S LANE HYANNIS Owner: BERRYMAN Date of Inspection:6129/99 TIGHT OR HOLDING TANK: NO (Tank must be pumped prior to,or at time of,inspection) (locate on site plan) Depth below grade: nta Material of construction:_ concrete_ metal_ Fiberglass _Polyethylene_ other(explain) nLa Dimensions: nLa Capacity: nLa gallons Design flow: nta gallons/day Alarm present: NQ Alarm level:ilia_ Alarm in working order:Yes_No_: NQ Date of previous pumping: nLa Comments: (condition of inlet tee,condition of alarm and float switches,etc.) nLa DISTRIBUTION BOX: _ (locale on site plan) Depth of liquid level above outlet invert:n1a Comments: (note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.) nta PUMP CHAMBER: NO (locate on site plan) Pumps in working order:(Yes or No): NQ Alarms in working order(Yes or No): NQ Comments: (note condition of pump chamber,condition of pumps and appurtenances.etc.) nLa ` revised 9/2/98 Page 8 of 11 l SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1067 PHINNY'S LANE HYANNIS Owner: BERRYMAN Date of Inspection:6/29199 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,if possible;excavation not required,location may be approximated by non-intrusive methods) If not located,explain: nta Type: leaching pits,number: 1000 GALLON LEACH PIT leaching chambers,number: -n(a leaching galleries,number: jiLa leaching trenches,number,length: nla leaching fields,number,dimensions: n& overflow cesspool,number: 6'X6'BLOCK CESSPOOL Alternative system: nLa Name of Technology: jVa Comments: (note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.) THE OVERFLOWS ARE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY THE H10 PIT WAS 112 FULL AT THE TIME OF THE INSPECTION_ CESSPOOLS: _ (locale on site plan) Number and configuration: Wa Depth-top of liquid to inlet invert: WA Depth of solids layer: n& Depth of scum layer. n& Dimensions of cesspool: nla Materials of construction: n& Indication of groundwater: nta inflow(cesspool must be pumped as part of inspection)Wa Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) Wa PRIVY: _ (locate on site plan) Materials of construction:nLa Dimensions:n& Depth of solids: nta Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) nta revised 9/2/98 Page 9 of t t SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1057 PHINNY'S LANE HYANNIS Owner: BERRYMAN Date of Inspection:6129/99 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100'(Locate where public water supply comes into house) n/a RrVt A4 41 �n 15 revised 9/2/98 Page 10 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1067 PHINNY'S LANE HYANNIS Owner: BERRYMAN Date of Inspection:6/29199 NRCS Report name: Wit Soil Type: Wa Typical depth to groundwater: nla USGS Date website visited: nla Observation Wells checked: NQ Groundwater depth:Shallow _ Moderate _ Deep _ SITE EXAM _ Slope _ Surface water _ Check Cellar Shallow wells Estimated Depth to Groundwater 12 Feet Please indicate all the methods used to determine High Groundwater Elevation: _ Obtained from Design Plans on record Observed Site(Abutting property,observation hole,basement sump etc.) _ Determined from local conditions Checked with local Board of health Checked FEMA Maps Checked pumping records _ Checked local excavators,installers X Used USGS Data Describe how you established the High Groundwater Elevation.(Must be completed) USGS MAPS AND CHARTS AND VISUAL revised 9/2198 Page 11 of 11 Commonwealth of Massachusetts. 114:7 _ - ExecLftive Office of Environmental Affairs John Grad D.E.P. Title V Septic Inspector De artment of -P.O. Box 2119 _ Environmental Protection Teaticket, MA 02536 _ (508) 564-6813 11MIBIam mo F.Weld Ciorwr Trudy t,oxe - EOEA David B.Struhs Comrninioner-- SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM- - PART A - - CERTIFICATION Property Address: 05 ntnn�y �' A ress of Owner: - Date of Inspection: -(If different) Name of Inspector: - Company Name, Address and Telephone Number: �d CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information rep ed a�true, accuu to and complete as of the time of inspection. The inspection was performed based on my training and ex�erienciiiLt{ie p , ctionc�, maintenance of on-site sewage disposal systems. The system: 4p 11g asses s7 �90 _ Conditionally Passes ' _ Needs further Ev luation By the local Approving Authority ` ✓ 1 Fails ', ' Inspector's Signature: ail Date: The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (30) days of completing this inspection. If the system is a shared system or has a design, flog+ of i0,000 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 originai should be sent to t'ne sy stem o�+ner anu copje� se.'.; tv tiie buyer, if app:icable and the appro,Ing a '`orit . INSPECTION S,"MMARY: ChecNl � C, or D: Aj SYSTEM PASS S: I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. B] SYSTEM CONDITIONALLY PASSES: One or Sore system 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, cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 8/15/95) One VAnter Street a Boston,Massachusetts 02108 a FAX(617)S6 ID49 a TW"*A a(617)M-UM qD Printed on Recyded Pgwr SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM - _ PART A _ CERTIFICATION (continued) Property Address: Owner: Date of Inspection: - B] SYSTEM CONDITIONALLY PASSES (continued) _- Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe pp s) or due to a broken, settled or uneven distribution box. The system will-pass-inspection if(with-approval of the Board of Health): . _ - broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than.four times a year due to broken or obstructed pipe(s). The system will pass - inspection if(with approval of the Board of Health): . broken pipe(s) are replaced obstruction is removed C] FURTHER EVALUATION 15 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: Imp >\Stem nd>-a >ewi( ianK anu Suit du�-orpoon sysit'n, dri(i ii 'w iill iuv icci iG d Su�u�c �..aiC; S;;pp! 3, i;,,�,,;ta-, i surface water supply. The s\s!Prr ha, a septic tank and soil absorption system and is within a Zone I of a public water supply well. _. ,The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. The systen, has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammo ppm. nia nitrogen and nitrate nitrogen is equal to or less than 5 D] SYSTEM FAILS: 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. Backup of sewage into facility or system component due to an overloaded or dogged 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. (revised 8/15/95) 2 && 0m, r: F+H f Big K. SUBSURFACE SEWAGE DISPOSAL SYSTEM_INSPECTION FORM PART A - - CERTIFICATION (continued) Property Address: -- Owner: Date of Inspection: DI SYSTEM FAILS (continued): -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). Number of times pumped Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. El LARGE SYSTEM FAILS: The following criteria apply to large systems in addition to the criteria above: The design flog, of system is 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area (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 8/15/95) 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION_ FORM - - PART B CHECKLIST Propert ress: Owner: �Gs rc�o Date of Inspection: Check if the following have been done: ping information was requested of the owner, occupant, and Board of Health. - _L,b4vrte of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. C�&(Afbuilt plans have been obtained and examined. Note if they are not available with N/A. L 5e facility or dwelling was inspected for signs of sewage back-up. _r�he system does not receive non-sanitary or industrial waste flow L=The site was inspected for signs of breakout. vAll system components, excluding the Soil Absorption System, have been located on the site. '_ fhe 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. _L--The size and location of the Soil Absorption System on the site has been determined based on existing information or approximated b} non-intrusive methods _ i;r1IfiPrPn irn• , o%tine-', were provided v ith information on the proper maintenance of Sub- Surface Disposal System. I (revised 8/15/95) 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION. FORM ` PART C - SYSTEM INFORMATION Property Address: Owner: Do- Date of Inspection: �a\C-�\(A - FLOW CONDITIONS - — - RESIDENTIAL: -- Design flow: stallons Number of bedrooms: Number of current residents: -- Garbage grinder (yes or no):_)L�� Laundry connected to system (yes or no):�-APj Seasonal use.(yes or no):nb Water meter readings,_if available: - . Last date of occupancy: COMMERCIAUINDUSTRIAL: Type of establishment: Design flow:_gallons/day Grease trap present: (yes or no)_ Industrial Waste Holding Tank present: (yes or no)_ Non-sanitary waste discharged to the Title 5 system: (yes or no)_ Water meter readings, if available: Last date of occupancy: OTHER: (Describe) Last date of occupancy: GENERAL INFORMATION PUMPING R RDS and source of information: System pumped as part of inspection: (yes or no)_ If yes, vo+eMe pumped eall qnc .`� �10x)c(—') Reason for pumping: TYPE OF SYSTEM Septic tank/distr-ibakic�oil absorption system Single cesspool Overflow cesspool Privy Shared system (yes or no) (if yes, attach previous inspection records, if any) Other (explain) APPROXIMATE AGE of all components, date installed (if known) and source of information: �5�t C i Sewage odors detected when arriving at the site: (yes or no) (revised 8/15/95) 5 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART C _ f!11 SYSTEM INFORMATION (continued) Property dress: 1 V��klm-Ik� LS - — - L . Owner: J Date of Inspection: - - CGS SEPTIC TAN-K:-.C\I - - - (locate on-site plan) - - Depth below grade: - Material of construction: _concrete _metal__FRP =other(explain) Dimensions: Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: - - Scum thickness: Distance from top of scum to top of outlet-tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: 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.) GREASE TRAP:(\(4- (locate on site plan) Depth below grade: Material of construction: _concrete _metal _FRP _other(explain) Dimensions: Scum thickne». Distance from top of scum to top of outlet tee or baffle: n:sta,ire fro.rr hotto— n' «ti - hottom of outlet tee or battle: 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.) c i` (revised 8;!5/95) 6 t.,r.' R. 7 y9 r- . f: SUBSURFACE SEWAGE DISPOSAL SYSTEM-INSPECTION FORM - PART C - .. r� SYSTEM INFORMATION (continued) - Property Address: 1�1�15� xn(��15 -- Owner:�� cz'�MQ - Date of InspectQn: TIGHT OR HOLDING TANK:LN-4- (locate on site plan) Depth below grade: Material of construction:_ _concrete _metal _FRP —Other(explain) - Dimensions: Capacity: gallons Design flow: gallons/day Alarm level: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX:C)N(Z`1- (locate on site plan) Depth of liquid level above outlet invert: Comments: mote if ievei and distribuuu;, ryuei, e"drnce of so;,ii_ ca;r)o,cr, e\,uence of leakage into or out of box, etc.? PUMP CHAMBER:�\(-�— (locate on site plan) Pumps-in working order.(yes or no) Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) (revised 8/15/95) 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM _ PART C SYSTEM INFORMATION (continued) _ Property s:. ' Owner: OU M O — Date of Inspection: SOIL ABSORPTION SYSTEM (SAS): - - (locate on site plan, if possible; excavation not required, but may be approximaFed by non-intrusive methods) If not-.determined to be present, explain: - — - leaching pits, number.` .i leaching chambers, number:= leaching galleries, number. _ - - leaching trenches, number,length: leaching fields, number, dimensions: overflow cesspool, number. Comment ..(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,etc.) S S t S c� e c l�- CESSPOOLS: L/ (locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Q �' Depth of solids layer: �t Depth of scum layer: 4 t� Dimensions of cesspool: 1 Materials of construction: Indication of grou„d.'.a:e- inflow (cesspool must be pumped as part of inspection) nts: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) 4 r I SAC tr 2U�� `c• -PC, C PRIVY: (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) (revised 8/15/95) 8 I SUBSURFACE SEWAGE DISPOSAL_SYSTEM INSPECTION FORM - PART.-C SYSTEM INFORMATION (continued) Property .Owner: c) C-am� - - Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: - - include ties to at least two permanent references landmarks or benchmarks -locate all wells within 100' R lou DEPTH TO GROUNDWATER Depth to groundwater: ,ate feet method of determination or approximation: (revised 8/15/95) 9 TOWN OF BARNSTABLE LOCATION SEWAGE # VILLAGE.0 nIF2 ASSESSOR'S MAP & LOT INSTALLER'S NAME 6z PHONE NO. I SEPTIC TANK CAPACITY 1 LEACHING FACILITY:(type) S (size) ),® 6 NO. OF BEDROOMS PRIVATE WELL O UBLIC WA� BUILDER OR OWNER DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No r � r r _ t,9 0 o i ,� a _ TOWN OF BARNSTABLE LOCATION IDS.`? `i?1iJNltcw$ 6N. SEWAGE # T. VILLAGE ASSESSOR'S MAP & LOT INSTALLER'S NAME & PHONE NO. e&A %1' 7) 1 `(1 OL lb SEPTIC TANK CAPACITY LEACHING FACILITYAtype) i T e (size) NO. OF BEDROOMS ' PRIVATE WELL O PUBLIC WATER BUILDER OR OWNER S\\h Q. DATE PERMIT ISSUED: .1 DATE COMPLIANCE ISSUED_ VARIANCE GRANTED: Yes 4? i 3. ��77 a� 3 No... ..... /1 Fim &.0.... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ....'��UW . .....................OF... - ....................... . Appliration for Uiipuuai Works Towitrnrttnn 1hrmit Application is hereby made for a Permit to Construct ( ) or Repair ( an Individual Sewage Disposal System at: Q(,I1.000 (�-----------------••--- l at on-Address o t No.�S . _ (..... ...•-•.....-•••-•--•.._..---•------------------ ..........--...................................................................................... Owner Address a ` o1'. 9. - Installer Address dType of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms________________________________ -Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( ) a' Other fixtures .......................................... W Design Flow____________________________________________gallons per person per day. Total daily flow............................................gallons. P4 Septic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................ Disposal Trench—No_____________________ Width.................... Total Length.................... Total leaching area....................sq. ft. 3 Seepage Pit No..................... Diameter....-............... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1----------------minutes per inch Depth of Test Pit.................... Depth to ground water------------------------ Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water------------------------ -----------------------------------------------------------------------------------------------------•------- O Description of Soil-------- ' ___C - _ &,j 5,,� 2 - (? / e a/tw x U ..............................................--•------•---•------•----•-•-------•----------------------------•-•••••-----•••-•---•-•----•---------••••••••--•----..................................... W ------------------------------- --------------•----------•-•--------•---•-•-----•-•---•----•--•----•----•-•--••--------......--------•-•--•-------•---------••---•--------•-•---•-••-----•------------•- U Nature of Repairs or Alterations—An wer when applicable--_.-: ..... Agreement: The undersigned agrees to in tall the aforedescribed Individual Sewage Disposal System in accordance with the provisions of A.- ` p 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance ha been is�hehealth. Signed.._.... ts' -•-------------- ... Date Application Approved By.................. Date Application Disapproved for the following reasons--------------------------------------------------•------------•------------------------..-...--------...._...._ ..................•_..._......_._..-•----...----....-------------------------------------•---- c� Date PermitNo..........u-%.-.7VZ....................... Issued....................................................... 1� No.-A--I V1 Fiza...s2.. ......_ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH - I ----------------_-OF... '.....-..........bi........ .A fir #ion for Uh4 os al Worko Tonarnrtion Vrrmff Application is hereby made for a Permit to Construct ( ) or Repair (tool an Individual Sewage Disposal System at: .....t OJ\ W".T okk!5.....(-!A...._.... ..................... Locat'on2 •Address or Lot No. h! �►�� - -S A� ------------------------------- --------------------------------------•------------.............................................. Owner Address Installer Address Type of Building Size Lot............................Sq. feet V Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) a Other fixtures -----------------------------------------••--- 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........................................ 04 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.-_---__________•--____. �+ ---••-------•.............•------•-•-•-------•---••-----•••---•------------....-•-•---•••••------....... O Description of Soil....... _ ----------------------------•-•-- v ---•---••••---•-•-•--•-----------•----•--•-•-•-•-••--•------•---•-••----•----•--••-•.......... w U Nature of Repairs or Alterations—An wer when applicable._-•_-__C1'-'_ '�1.�________--=G?!!�?Z--_,__.�� _ `�__--••••--•--. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of'T'IE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance ha been issued,b, -�h�e board�o�f health. k Signed....... Vic. V ,sa ......... 1...... ------. Date Application Approved By............... J` -�- -----SD-'ter ---------------------------------------- Date Application Disapproved for the following reasons:----•----------•-----•-•----•--•----•----------------------------------------------------------•-•-••-........-- ..........................•---•-•-----•---•--------•---•-•-•-...-•••--.....-----•---------...------•-----•-••-•--------•---•-------------•--------•-••••••-•---•-•-•------------••--------•••--•----•-.. Date PermitNo---------- ------7 /------------------------ Issued-....................................................... D i THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Z�w ...................oF.: . w.s`� q`........................................... vEnfif i atr of TompliFanrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired---------------- ( (,� Installer at.... I O-5(. .,. .rr` V, C `4 VJ:,- fL�l\ L L ----- has been installed in accordance with the provisions of T I T IE 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No.......... ........... dated................................................ THE ISSUANCE OF THIS CERTIFICATE SMALL NOT BE CONSTRUED. AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE..............�..� -ti�.. .`.g. ............................... Inspector.............. = 1 .................................................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ................. NO.._ . ! FEE._. -C� BioiooFal lVorkii Tuonptrwfion panfit Permission is hereby granted......... :k J\4..._-x- KC-x -L..............................: to Construct ( ) or Repair ( �n Individual Sewage Disposal System at No---------1•-Q-57-!-----------2.&t !,/rye, ---•---- ..................0!_k_r-_/_ 1.`�-- .--•--•---------•----------------•-•----------- Srreet rA` as shown on the application for Disposal Works Construction Permit No _ .: . . __.._.. Dated.......................................... ................................ `--��•- ............................. Board of Health DATE--------------�--�-'-�-�........... --� FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS i