HomeMy WebLinkAbout0005 PIRATES WAY - Health 5 PIRATES WAY,HYANNIS
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# TOWN OF BARNSTABLE
LOCATION iA-411_s-` W e SEWAGE#
VELLAGE Wo_1'P #-VA4�0s p-6A-1- ASSESSOR'S MAP&LOT
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) C49s'.;4voL-S (size) Jogo C.iL
NO.OF BEDROOMS
BUILDER OR OWNER &Za Le SCO A ►J 491
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
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COMMONWEALTH OF MASSACHUSETTS
fD EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
s DEPARTMENT OF ENVIRONMENTAL PROTECTI09
ONE (WINTER STREET. BOSTON, MA 02108 617-292-5500
V
SV•y
WILLIAM F.WELD E R r
Governor {I Secretary
ARGEO PAUL CELLUCCI DAVID B.STRUHS.
Lt.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Commissioner
a p PART A
I CERTIFICATION
i 5 Pirates Way W.Hyanni .,port
Property Address: Address of Owner: HAROLD Sloan
Date of Inspection: (If different) P.O . BOX 129
Name of Inspector: Wm E Robinson Sr
I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000)
Company Name: Wm E Robinson Septic Service
Mailing Address: PO Box 1089 , Centervi 1 1 r-r MA 02632
Telephone Numberry 5 0 8 77 c,_A 77 A
CERTIFICATION STATEMENT.
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate
and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems. The system:
Passes
_ Conditionally Passes
Needs Further Evaluation By the Local Approving Authority
_ Fails
Inspector's Signature: 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 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.
INSPECTION SUMMARY: Check A, B, C, or D:
A] SYSTE ASSES:
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.
COMMENTS:
B] CW
STEM 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.
Indica yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain why not.
The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of
Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection; or
the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank
failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank
as approved by the Board of Health.
(revised 04/25/97) Page 1 of 10
DEP on the World Wide Web: http:ltwww.magnet.state.ma.us/dep
e'J Printed on Recycled Paper
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
P Pirates Way W- Hyannis port
, roperty Address:
+o ner: Harold. Sloan
Date of'Inspection:
1 ty B] SY 'EM CONDITIONALLY PASSES (continued)
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). Describe observations:
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
Cl F THER 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) YSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER
HICH 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) S STEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT
T E SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE
VIRONMENT:
_ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet to 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 (approximation not valid).
3) O HER
(revised 04/25/97) Page 2 of 10
i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 5 Pirates Way W. Hyannisport
Owner: Harold. Sloan
Date of Inspection: /,;— `/—jar
D] SYSTEM FAILS:
Yo must indicate eir,er "Yes" or "No" as to each of the following:
I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis
for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct
the failure.
Yes � No
_ Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool.
1
_ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or
i cesspool.
I _ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
I
I _ 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 1.00 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.
E] LA GE SYSTEM FAILS:
You ust indicate either "Yes" or "No" as to each of the following:
The following criteria apply to large systems in addition to the criteria above:
The system serves a facility with a design flow of 10,000 gpd or greater (Large System) and the system is a significant threat to
public health and safety and the environment because one or more of the following conditions exist:
Yes No
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area- IWPA)or a mapped Zone II of a
public water supply well)
The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program
req irements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.
(revised 04/25/97) Page 3 of 30
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 5 Pirates Way W. Hyannisport
Owner: Harold, Sloan
Date of Inspection:
Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following:
Yes No
_ Pumping information was provided by the owner, occupant, or Board of Health.
_✓ _ None of the system components have been pumped for at least two weeks and the system has been receiving normal
flow rates during that period. Large volumes of water have not been introduced into the system recently or
as part of this inspection.
_ As built plans have been obtained and examined. Note if they are not available with N/A.
_ The facility or dwelling was inspected for signs of sewage back-up.
_ The system does not receive non-sanitary or industrial waste flow.
_ The site was inspected for signs of breakout.
_ All system components, excluding the Soil Absorption System, have been located on the site.
The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of
baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum.
—The size and location of the Soil Absorption System on the site has been determined based on:
The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of
Sub-Surface Disposal System.
Existing information. Ex. Plan at B.O.H.
t✓ _ Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is
unacceptable) [15.302(3)(b)]
(zavinad 04/25/97) Page 4 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 5 Pirates Way W. Hyanni ,port
Owner:
Harold. Sloan
Date of Inspection:
FLOW CONDITIONS
RESIDENTIAL:
Design flow: _g.p.d./bedroorn for S.A.S.
Number of bedrooms:
Number of current residents:-2--
Garbage grinder (yes or no):Z--O
Laundry connected to system (yes or no):VC1
Seasonal use (yes or no):e() 10-7-98 thru 10-4�-96
Water meter readings, if available (last two (2)year usage (gpd):
Sump Pump (yes or no)-.,A.- C> r
250 gals
Last date of occupancy:
COMMER C IAUINDUSTRIAL•
Type of est lishment:
Design flow allons/day
Grease trap resent: (yes or no)_
Industrial W ste Holding Tank present: (yes or no)_
Non-sanitary waste discharged to the Title 5 system: (yes or no)_
Water mete readings, if available: 10-7-98
Last date o occupancy:
OTHER: Describe)
Last da f occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
System pumped as part of inspection: (yes or no)4 3
If yes, volume pumped: � gallons
Reason for pumping: a
TYPE OF SYSTEM
�S ptic tank/distribution box/soil absorption system
ngle cesspool
�,/ Overflow cesspool
Privy
Shared system (yes or no) (if yes, attach previous inspection records, if any)
I/A Technology etc. Copy of up to date contract?
Other
APPROXIMATE AGE of all components, date installed (if known) and source of information: A j
Sewage odors detected when arriving at the site: (yes or no)
(revised 04/25/97) Page 5 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 5 Pirates Way W. �Hyanni port
Owner: Harold. Sloan
Date of Inspection:
BUIt
ING SEWER:
(Local on site plan)
Depth low grade:
Materi I of construction: _cast iron _40 PVC_other (explain)
Dista ce from private water supply well or suction line
Dia eter
Co ments: (condition'of joints, venting, evidence-of-leakage, etc.)
SE' IC TAN :_
(local on siteK plan)
Depth elow grade:
Material of construction: _concrete _metal _Fiberglass _Polyethylene _other(explain)
If tank is metal, list age _ Is age confirmed by Certificate of Compliance _(Yes/No)
Dimensi ns:
Sludge d pth:
Distance from top of sludge to bottom of outlet tee or baffle:
Scum thickness:
Distanc from top of scum to top of outlet tee or baffle:
Distan from bottom of scum to bottom of outlet tee or baffle:
How imensions were determined:
Co ents:
(reco mendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
integri , evidence of leakage, etc.)
GRE SE TRAP:
(locat on site plan)
Depth slow grade:
Material of construction: _concrete _metal _Fiberglass _Polyethylene —other(explain)
Dimensi s:
Scum thi kness:
Distance rom top of scum to top of outlet tee or baffle:
Distance rom bottom of scum to bottom of outlet tee or baffle:
Date of st pumping:
Com nts:
(reco mendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
inte ty, evidence of leakage, etc.)
(revised 04/25/97) Page 6 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
•Property Address: 5 Pirates Way W.Hyannis port
Owner: Har"old. Sloan
Date of Inspection:
TIG T OR HOLDING TANK: (Tank must be pumped prior to, or at time, of inspection)
(looat on site plan)
Depth low grade:
Material f construction: _concrete _metal _Fiberglass _Polyethylene _other(explain)
Dimension;:
Capacity: gallons
Design flo gallons/day
Alarm leve : Alarm in working order_ Yes; _ No
Date of pr vious pumping:
Comment
(conditio of inlet tee, condition of alarm and float switches, etc.)
DISTRIBU ION BOX:_
(locate on ite plan)
Depth of squid level above outlet invert:
Comore ts:
(note if evel and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.)
PUMP C AMBER:
(locate on site plan)
Pumps in working order: (Yes or No)
Alarms i working order dyes or No)
Comore ts:
(note c ndition of pump chamber, condition of pumps and appurtenances, etc.)
(revised 04/25/97) Page 7 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: .5 //Qa T« /"J'�
Owner: /0
Date of Inspection:
SOIL ABSORPTION SYSTEM(SAS):
(locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods)
If n determined to be present, explain:
Type:
leaching pits, number:_
leaching chambers, number:_
leaching galleries, number:
leaching trenches, number,length:
leaching fields, number, dimensions:
overflow cesspool, number:
Alternative system:
Name of Technology:
Comm nts:
(note ondition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
CESSPOOLS: _
(locate on site plan)
Number and configuration: �� u$
Depth-top of liquid to inlet invert:
Depth of solids layer: _t.3 '
Depth of scum layer: s
Dimensions of cesspool: 6 l
Materials of construction: /6 cK 3
Indication of groundwater: /L0
inflow (cesspool must be pumped as part of inspection)
Comments:
(note condition of soil,signs of by aulic failure, level of po,,r ding, condition of v etation, etc.)
/J 1Vr� ye, 1
PRI
(locat on site plan)
Mate ials of construction: Dimensions:
Dep h of solids
Co ments:
(n a condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
(reviled 04/25/97) Page 8 of 10
.SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 5 Pirates Way W. Hyannisport
Owner: Harold. Sloan
Date of Inspection:
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100' (Locate where public water supply comes into house)
J�
(revised 04/25 97
/ ) Page 9 of 10
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 5 Pirates Way W. Hyanni port
Harold. Sloan
Owner:
Date of Inspection:
Depth to Groundwater Feet
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from Design Plans on record
Observation of Site (Abutting property, observation hole, basement sump etc.)
Determine it from local conditions
Check with local Board of health
Check FEMA Maps
Check pumping records
F
Check local excavators, installers
Use USGS Data
Describe in your own�``orrds how you established the High Groundwater Elevation. (Must be completed)
(revised 04/25/97) Page 10 of 10
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TOWN OF BARNSTABLE
LOCATION .S P Ah'tky w V SEWAGE #
VILLAGE 1..1�.n" V,g �►� s pa.E�-r- ASSESSOR'S MAP & LOT
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) _ C. S.5 hcyt s- (size) /s000 C.IL
NO.OF BEDROOMS
BUILDER OR OWNER N die•Ld SCO
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
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