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Home My WebLink About0025 PINE VALLEY ROAD - Health 25 PINE VALLEY RD., HYANNIS A= a I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 0 25 Pine Valley Road Property Address Richard Garvey Owner Owner's Name ~ information is 37 required for Hyannis MA 02601 9/16/2016 z every page. City/Town State Zip Code Date of Inspection qp L71 Inspection results must be submitted on this form. Inspection forms may not be altered in any OD way. Please see completeness checklist at the end of the form. Important:When filling out A. General Information S/ forms on the computer,use 1. Inspector: only the tab key to move your Ronald Burlingame cursor-do not Name of Inspector use the return key. Company Name 58 Oak Street Company Address West Barnstable MA 02601 City/Town State Zip Code 508-776-8544 S14124 Telephone Number License Number B. Certification 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 Title 5(310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 09/17/2016 Inspector's Signature Date 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 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. ****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. t51ns.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 t 't Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 25 Pine Valley Road Property Address Richard Garvey Owner Owner's Name information is required for Hyannis MA 02601 9/16/2016 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I 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: 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. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. 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. ❑ Y ❑ N ❑ ND(Explain below): t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 25 Pine Valley Road Property Address Richard Garvey Owner Owner's Name information is required for Hyannis MA 02601 9/16/2016 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ 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 ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ 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 ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 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, i 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 t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 25 Pine Valley Road Property Address Richard Garvey Owner Owner's Name information is required for Hyannis MA 02601 9/16/2016 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 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 within 100 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. ❑ 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". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent 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: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ❑ Backup of sewage into facility 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 ❑ ❑ Liquid depth in cesspool is less than 6" below invert or available volume is less than '/2 day flow t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ^M 25 Pine Valley Road Property Address Richard Garvey Owner Owner's Name information is required for Hyannis MA 02601 9/16/2016 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® 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 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. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent 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 and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® 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. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. 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 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. t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 25 Pine Valley Road Property Address Richard Garvey Owner Owner's Name information is required for Hyannis MA 02601 9/16/2016 every page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No ® ❑ Pumping 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? ❑ ® 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) ® ❑ 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, 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: ® ❑ 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(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 S t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 I Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 25 Pine Valley Road Property Address Richard Garvey Owner Owner's Name information is required for Hyannis MA 02601 9/16/2016 every page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ® Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): Detail: 2014 -60,000 gallons /2015-63,000 gallons : Hyannis Water Dept Sump pump? ❑ Yes ® No Last date of occupancy: 9/16/2016 Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CM 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 25 Pine Valley Road Property Address Richard Garvey Owner Owner's Name information is required for Hyannis MA 02601 9/16/2016 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Current Date Other(describe below): General Information Pumping Records: Source of information: Homeowner-CapeWide 2014-Ford Spetic 2011 Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ❑ Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator.under contract ❑ Tight tank. Attach a copy of the DEP approval. ® Other(describe): 2 block cesspools with leachpit w/stone t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments CGM , 25 Pine Valley Road Property Address Richard Garvey Owner Owner's Name information is required for Hyannis MA 02601 9/16/2016 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: Cesspools 35 years old - Leachpit 25 years old Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: feet Material of construction: ❑ cast iron ❑ 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: Sludge depth: i t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 25 Pine Valley Road Property Address Richard Garvey Owner Owner's Name information is required for Hyannis MA 02601 9/16/2016 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) 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 How were dimensions determined? Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Both cesspools are in great shape&has plastic tees going to leachpit Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle x. Date of last pumping: Date t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 25 Pine Valley Road Property Address Richard Garvey Owner Owner's Name information is required for Hyannis MA 02601 9/16/2016 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan): M Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 25 Pine Valley Road Property Address Richard Garvey Owner Owner's Name information is required for Hyannis MA 02601 9/16/2016 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 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.): Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No" Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins.doc•rev.6/16 Title 5 official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 25 Pine Valley Road Property Address Richard Garvey Owner Owner's Name information is required for Hyannis MA 02601 9/16/2016 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1 - 1000 gal w/stone ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ® overflow cesspool number: 2- block cesspools ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Cesspools (cesspool must be pumped as part of inspection)(locate on site plan): Number and configuration 2 cesspools block Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer, Dimensions of cesspool 8'deep 5'wide Materials of construction 6 x 8 block cement Indication of groundwater inflow ❑ Yes ® No t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 25 Pine Valley Road Property Address Richard Garvey Owner Owner's Name information is required for Hyannis MA 02601 9/16/2016 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 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.): t5ins.doc•rev.'6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments �M 25 Pine Valley Road Property Address Richard Garvey Owner Owner's Name information is required for Hyannis MA 02601 9/16/2016 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view 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. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 25 Pine Valley Road Property Address Richard Garvey Owner Owner's Name information is required for Hyannis MA 02601 9/16/2016 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view 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. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately A Ptao►r &f GAeAG-E n 7 • 3 Pa-Leach w/ s-bNe. A +o I z3 t 40 f� 40 3 C 3 I `i t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 25 Pine Valley Road Property Address Richard Garvey Owner Owner's Name information is required for Hyannis MA 02601 9/16/2016 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: 12+ feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: 1991 Date ❑ 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 ground water elevation: Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 25 Pine Valley Road Property Address Richard Garvey Owner Owner's Name information is required for H annis MA 02601 9/16/2016 Y every page. CitylTown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D(System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 COMMONWEALTH OF MASSACHUSETTS �e EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS \ J�. DEPARTMENT OF ENVIRONMENTAL PROTECTION -RECEIVED JAN 1 7 2001 TOWN OF BARNSTABLE TITLES HEALTH DEPT. OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 25 Pine Valley Road Hyannis, MA Owner's Name: Diane Beuke Owner's Address: same Date of Inspection: Name of Inspector: (please print) Wi 1 1 i am E_ •Robinson Sr. Company Name: William E. Robinson Septic Service Mailing Address: P O Box 1089 Centerville, MA Telephone Number: (5 0 8) 7 7 5—8 7 7 6 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 pursuantZS7on 15.340 of Title 5(310 CMR 15.000). The system: f. es Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails I Inspector's Signature j,i� ��' Date: ._,S—® J The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health cr 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 1 Page 2 of I 1 ' f OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 25 Pine Valley Rd_ Hyannig Owner• R e tlk_P Date of Inspection: /3 Inspection Summary: Check #CD or E/ALWAYS complete all of Section D A. Syst Passes: 1 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: B. ystem Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repair .The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answe yes,no or not determined(Y,N,ND)in the for the following statements.If"not determined"please explain e septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsoun ,exhibits substantial infiltration or exfiltration or tank failure is imminent.System will pass inspection if the existin tank is replaced with a complying septic tank as approved by the.Board of Health. *A me I septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indica g that the tank is less than 20 years old is available. ND a plain: 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 explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will ass inspection if(with approval of the Board of Health): i broken pipe(s)are replaced n obstruction is removed ND explain: Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 25 Pine Valley Rd. Hyannis Owner: Beuke Date of Inspection: 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 fail' g to protect public health,safety or the environment. 1. ystem will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the stem is not functioning in a manner which will protect public health,safety and the environment: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the sys em 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 within 100 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. _ 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".Method used to determine distance "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. Other: 3 Page 4 of.11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 25 Pine Valley Rd. Hyannis Owner: Beuke Date of Inspection: —3-a7 D. System Failure Criteria applicable to all systems:. Yo must indicate"yes"or"no to each of the following for all inspections: Yes No Backup of sewage into facility 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 Liquid depth in cesspool is less than 6"below invert or available volume is less than''/z 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 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. Any portion of a cesspool or privy is within a Zone 1 of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [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.] t. (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 a considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gp . . Yoi i must indicate either"yes"or"no"to each of the following: ( following criteria apply to large systems in addition to the criteria above) ye 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 . If y u have answered"yes"to any question in Sec�E the system is considered a significant threat,or answered "ye "in Section D above the large system has failed.The owner or operator of any large system considered a Sig ificant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15. 04.The system owner should contact the appropriate regional office of the Department. /v 4 Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 25 Pine Valley Rd. Hyannis Owner: Beuke Date of Inspection: J•-3—0-1 Check if the following have been done.You must indicate`yes"or"no"as to each of the following: Yes /No Pumping 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? E/ 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) 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? I> _ 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 — 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 Page 6 of l l OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 25 Pine Valley Rd. Hyannis Owner: Beuke Date of Inspection: i `3 / FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):,3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): J— 0 Number of current residents:_ Does residence have a garbage grinder(yes or no): A,-O Is laundry on a separate sewage system(yes or no):A,.6 [if yes separate inspection required] Laundry system inspected(yes or no): 4-z Seasonal use: (yes or no): &,t) Water meter readings, if available(last 2 years usage(gpd)): 1 9 9-0 0 105, 750 gal. Sump pump(yes or no):A, a 1998-99 108,000 gal. Last date of occupancy: ro l COMME ' IAL/INDUSTRIAL Type of es ta lishment: Design flow based on 310 CMR 15.203): and Basis of de! flow(seats/persons/sqft,etc.): Grease trap resent(yes or no): Industrial w ste holding tank present(yes or no): Non-sani waste discharged to the Title 5 system(yes or no):_ Water met readings,if available: Last date f occupancy/use: OTHE (describe): GENERAL INFORMATION Pumping Records Source of information: 9 6' Was system pumped as part of the inspection(yes or no):,y-s If yes,volume pumped:2c,s,-o allons--How was quantity pumped determined? o� ,e ,e- Reason for pumping: �r m TYPE OF SYSTEM _Septic tank,distribution box,soil absorption system _Sibigle cesspool _ verflow cesspool _Privy _Shared system(yes or no)(if yes,attach previous inspection records, if any) _Innovative/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 _Other(describe): Approximate age of all components,date installed(if known)and source of information: .� .� 2 ✓B c ,2 S c7 �- Were sewage odors detected when arriving at the site(yes or no).A 6 6 Page 7 of I l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 25 Pine Valley Rd. Hyannis Owner: Beuke Date of Inspection: /-3—a G B ' LDING SEWER(locate on site plan) Depth elow grade: Materia of construction:_cast iron _40 PVC_other(explain): Distance om private water supply well or suction line: Comments on condition of joints,venting,evidence of leakage,etc.): SEPTIC T K:_(locate on site plan) Depth below ade: Material of co struction:_concrete_metal_fiberglass polyethylene _other(expla ) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions: Sludge depth: Distance fro top of sludge to bottom of outlet tee or baffle: Scum thickn ss: Distance fro top of scum to top of outlet tee or baffle: Distance fr in bottom of scum to bottom of outlet tee or baffle: How were dimensions determined: Commen (on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity,liquid levels as related t outlet invert,evidence of.leakage,etc.): GREASE RAP:_(locate on site plan) Depth be w grade:_ Materia of construction:_concrete_metal_fiberglass polyethylene_other (explairt� Dimensi s: Scum thic ess: Distance om top of scum to top of outlet tee or baffle: Distance fr in bottom of scum to bottom of outlet tee or baffle: Date of las pumping: Comments on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity,liquid'levels as related t outlet invert,evidence of leakage,etc.): 441 Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 25 Pine Valley Rd. Hyannis Owner: Beule Date of Inspection:.)-3--ea i TI T or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Dept below grade: Mater a]of construction: concrete metal fiberglass_polyethylene other(explain): Dimen ions: Capaci : gallons Design Flow: gallons/day Alarm resent(yes or no): Alarm evel: Alarm in working order(yes or no): Date o last pumping: Co nts(condition of alarm and float switches,etc.): DI TRIBUTION BOX: (if present must be opened)(locate on site plan) epth of liquid level above outlet invert: omments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of le kage into or out of box,etc.): P MP CHAMBER: (locate on site plan) P ps in working order(yes or no): A�atms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): 8 Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 25 Pine Valley Rd. Hyannis Owner: Beuke Date of Inspection: 1-3-6 2 / SOIL ABSORPTION SYSTEM(SAS): y (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number: leaching chambers,number: leaching galleries,number: leaching trenches,number, length: leaching fields,number,dimensions: overflow cesspool,number:s7 innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): we CESSPOOLS: or�/(cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: 2 G c4 9- 13/o z l0�o I Pet,z G ` L ap s- Depth—top of liquid to inlet invert: Depth of solids layer: 7 Depth of scum layer: Dimensions of cesspool: Materials of construction: IC,S L y;1- k 3 - A G 4 3� Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PR (locate on site plan) Materia s of construction: Dimens ons: Depth f solids: Co nts(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): f 9 Page 10 of 11 «� OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 25 Pine Valley Rd. Hyannis Owner: Beuke Date of Inspection: n,-&l SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at leist two permanent reference landmarks or benchmarks.Locate all wells within 100 feet.Locate where public�w1ater supply enters the building. � bI s � din 10 10 =° Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 2 5 Pi n a Val 1 e . Rd. Hyannis Owner: BPu k P Date of Inspection: I ✓�—�—� SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water of O feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) -Checked with local Board of Health-explain: 6 l 0 S Checked with local excavators,installers-(attach documentation] Accessed USGS database-explain: You must describe,how you established the high ground water elevation: /u� 11 k * Q Fss.....3...b......... b THE COMMONWEALTH OF MASSACHUSEfts BOARD OF HEALTH TOWN OF BARNSTABLE Appliratiun for Disposal Works Tonuirudiun Prrmit Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal System at: 25 Pine Valley Rd Hyannis MA: 02601 -7---. ---.----. .............Locatio ---Address ........................... ..........................................--r.Lo-.Ko........................................... ' Location-Address or Lot No. D. Beuke ......................_--........................................................................ -----------_------------------------••-------------.---------.-----•--•---------------------------- W Wm. E. RobinsonoYeptic Service P.O. Box 1089 aKferville MA Installer Address d Type of Building °" Size Lot----------------------------Sq. feet U Dwelling—No. of Bedrooms.......3....................... .Expansion Attic ( ) Garbage Grinder ( ) 9k Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Q' Other fixtures -•-----------------••---------•. . W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. W Septic 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 ( ) Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit-------------------- Depth to ground water........................ rX4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ P ----......................................................................................................................................................... 0 Description of SOU.........sand and gavel....................................................... w U N ture off Re airs or Alterations—Answer when applicable_____1.040---ga-l_---ston-epacked---------------------------- �.eacoUrt ..----------•---------------•---•--••--••--•-----•-•-------•-------------------------...................---------------------------------------------.................................................. 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 be . sued by ��dofheal& Signed ----_iC/ -----/ .....�..._ Dace Application Approved BY ------------- � .t r-�..--.? -t,u, r .-----...............................-------------------------- ..... � Application Disapproved for the following reasons- ----------- --------- ---------------------------------------------=----------- -------- .-.... ----- ----------------------------------------------------------------- ------------------------------------------------------------- --- ----------------- ---=.................................. -------------------------------- Permit No. ------- ------ .-Via------------------ Issued ...................... ---------........---......�.e...--- Dace Ficz THE'COMMONWEALTH OF MASSACHUSETTS x y BOARD OF HEALTH TOWN OF BARNSTABLE Appliration for Disposal Works Tonotrnrtiun rnmit Application is hereby made for a Permit to Construct ( ) or Repair` ( /an Individual Sewage Disposal System at: I 25 Pine!Valley Rd Hyannis MA 02601 -•.............__.....-- ......... - .......................... _.....------•-----------------------------------------•-•-----•--......................----•-•---- Location-Address or Lot No. D. Beuke . ...........................•-----............-----•--------•--------------------------------•. --------•---•--••-•--•-----••-•--------•---------•----....._..---------•-•----••--._.._._...---_.. W Wm. E. jobinsono'K'eptic Service P.O. Box 1089 e4dAVerville MA W ------ -... ....._... Installer Address Type of Building Size Lot............................Sq. feet V Dwelling—No. of Bedrooms........ ______............................Expansion Attic ( ) Garbage Grinder (' ) a Other—Type of Building No.•of persons____________________________ Showers — Cafeteria P I 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------------------------ 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 1:4 _---• ----- ------------• ---------------------------•---•--•------....-•-•._...--•-••-•----------------------._....----.....---•--•------- 0 Description of Soil.........sand---and gravel - - v ......_..-•-•-•---------•--•-----------•-••---------------------------------------------•----...-------._._...---•----------•-----------------------•----•-----------......._....__...-------•-••---•---. W x ---------------------------------------------------------------------------------------------------•-------------------------------------------•-------•-----••---._._..._.._•------------•-------- U Nature ofpei)aairs or Alterations—Answer when applicable-____1_0.94._.J _1__;___L L_ Q ----------------------------•------••-----•------•------•--•------------•-...--••------•-------------------•---•-------------------....--_..._..------------------------------------------------------. 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 hag bee b e b and of health. Signed �� C —'3-�� -------- -------------------------------------------------------------------------------G....... .. ...-.-.----------..--------------.. . Date Application Approved By................... --� AVM- "r?� ----... ..r..-3..� f Date Application Disapproved for the following reasons- ------------------------------------------......................................................................... --.------- --------------------------------------------------- -------- ------- ----------------------------------------------------------------------------------------------------------------------- -- .................--a-te------------------ Permit No. .........Cd, Issued ........................................................D ------ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH -TOWN OF BARNSTABLE (gertifirate of (11IImpliattre THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( X ) by....... Wm. E. Robinson Septic Service ------------------- ------------------------- ..------...- :------------------------------------------------------------------------------------------------------------ ---........ ' f' - Installer at ----25--Pi-ne--Va11ey --Rd.--- Hyannis---.MA-------------......................................---------------------------------------------------------------- ----- 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......... une---.3 ---.1 9 91 . . --------------------.................................. Inspector ............................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH . - ••- TOWN OF BARNSTABLE No.----- FEE. _a' Disposal Worksdun ri i�an Prsni# Permission is hereby granted.............................................................................................................................................. to Construct ( ) or Repair ( y) an Individual Sewage Disposal System atNo...25---1'i.a.. *!r_,......_...---- --------------------------•-------_.............._.•-------------------_...._._......... Street -d as shown on the application for Disposal Works Construction Permit No_,., :_ Dated............................... .................................... .• ...TI-----------......_.__....._•-----••....---•---. Board o�- DATE................. - ealth "c, _•-----•-------------•----_----- •••----- FORM 36508 HOBBS 6 WARREN.INC.,PUBLISHERS 5