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Home My WebLink About0321 PITCHER'S WAY - Health 321 PITCHER'S WAY, HYANNIS A= 290 006 i 1 10 aye v d SUBSURFACE SEWAGE DISPOSAL BYBTEM XNBPECTION .FORK Address- of property ` Owner's name '��' � �'�T�'e�r� 4c,��A-� �i�.rvltrl•.�• �+t�A� • Date of Inspection '' N 01 PART A CHECKLIST ' Check if the following have been done: ' Pumping information was requested of the owner, occupant, and Board of Health. None of the system com onents have been p um ed 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 t 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 facilit or dwelling was inspected for signs of sewage back-up.'. Y 9 P g 9 The site was inspected for signs of breakout. All system components, excluding the SAS, have been located on the . site. The � P se tic tank manholes were uncovered opened, and the interior';of p the septic tank was inspected for condition of baffles or. tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. rr// V The size and location of the SAS on the site has been determined based on existing information or approximated by_non-intrusive methods. The facility owner (and occupants, if different from owner) Were, 4Ff;. provided with information on the proper maintenance -of SSDS. : t $� r t,, • yt`. • z SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART H SYSTEM INFORMATION FLOW CONDITIONS If residential number of bedrooms number of current residents garbage grinder, yes or no' laundry connected to system, yes or no _ seasonal use, yes or no .If .nonresidential, calculated flow: ' Water meter readings, if available: +c?I 16Ct-�T Last date of occupancy GENERAL INFORMATION , Pumping records and source of information: System pumped as part of inspection, yes or no if yes, volume pumped Reason for pumping: Type of system Septic tank/distribution box/soil absorption system Single cesspool overflow cesspool 'd Privy Y Shared system (yes or no) (if yes, attach previous inspectionx ' records, if any) other (explain) , Approximate age o'f all components. Date installed, if known.. Source 'ofJ� information: }, dot Sewage odors detected when arriving at the site, yes or no SUBBUUACE BEWAGE DIBPOSAL 8YSTEM INBPECTION PORK PART 8 8Y8TZX INFORMATION continued - SOIL ABSORPTION SYSTEM (SAS) : (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: Type• leaching pits and number f leaching chambers and number leaching galleries and number leaching trenches, number, length leaching fields, number, dimensions overflow cesspool, number <; Comments; (note condition of soil, signs of hydraulic failure, level of ponding;° - condition of vegetation, recommendations for maintenance or repairs,etc.) CESSPOOLS (locate on site plan) : x _ number and configuration depth-top of liquid to inlet invert depth of solids layer depth.,of scum layer dimensions of cesspool materials of construction indication of groundwater inflow (cesspool, must be pumped as `part of, inspection) =.Comments: K (note condition of soil, signs of hydraulic failure., level of ponding , condition of vegetation, recommendations for maintenance or repairs,etc.)` PRIVY; - { aid (locate on site plan) i s materials of construction . :dimensions depth of .solids Comments: w, r :(note condition of soil, signs of hydraulic failure, lever of pondinq y ' condition of vegetation,• re�ommendations. for maintenance-or repairs,etc:) R SUBSURFACE SEWAGE DISPOSAL 8YSTEM INSPECTION FORM PART B • SYSTEM INFORMATION aoatinuea SEPTIC TANK: (locate on si a 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, recommendations for repairs, etc. ) DISTRIBUTION BOX: (locate on site pan) depth of liquid level above outlet invert � Comments: .(note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, recommendation for. repairs, etc.) `p ,PUMP CHAMBER: ;(locate on site lan) ' } ., .. 'k'..Sb 5 5 a .'jTr p•S: pumps in working order, yes or no � } l Comments:• ; -n'-V ;(note condition of pump chamber, condition of pumps and a ppurtenancii" es, s; 1 �rrecommendations for maintenance or repairs,etc.) R. � z ' • q SUBSURFACE MAGE DISPOSAL SYBTEM •INSPECTION .FORM PART B SYSTEM INFORMATION continued SKETCH OF SEWAGE L:SPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 1001 Cc, DEPTH • . f. • f F : DEPTH TO GROUNDWATER 1• depth to groundwater • t method of determination or approximation: F • SUBSURFACE BEWAGE DISPOSAL SYSTEM XN8PECTION FORM PART C FAILURE CRITERIA Indicate yes, no, or not determined (Y, N, or ND) . Describe basis of determination in all instances. If "not determined", explain why not) Backup_ of sewage into facility? -4Discharge or ponding of effluent to the surface. of the ground or 7 surface waters? Static liquid level in the distribution box above outlet invert? . Liquid, depth in cesspo91 <6" below invert or available volume< 1/2' day flow? Required"pumping 4 times or more in the last year? number of times pumped Septic tank is metal? cracked? structurally unsound? substantial infiltration? substantial exfiltration? tank failure imminent? Is any portion of the SAS, cesspool or privy: k .{ I below the high groundwater elevation? within .50 feet of a surface water? within 100 feet of a surface water supply or tributary to a surface's water supply? within a Zone I of a public well? within 50 feet of a bordering vegetated wetland or salt marsh. (cesspools and privies only, II the SAS)? j tom . n r within 50 feet of a private water supply well? rra, 1 rt s less than 100 feet but greater than 50 feet from a private waterr," { supply well with no acceptable water quality analysis? . If the well"" ' • has been .analyzed to be acceptable, attach copy of well water analy. � • for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. SUSSURFACE SEWAGE DISPOSAL SYSTEM 1NGPECTION FORM PART D CERTIFICATION Name of Inspector, lao--C�- J , Company Name G ► �- �s� Company Address caw. A J CertificAtipn Statgment Vcert,ify that I have personally inspected the sewage disposal system at this address and that the information reported is.• true, accurate and complete as of the time of inspection. The inspection was performed and. any recommendations regarding upgrade, maintenance and repair are consistent with my training and. experience in the proper function and pahitenance of on-site sewage disposal , systems. Chec one: I have not found any information which indicates that the system fails to adequately protect public health or the environment as defined in 310 CMR 15.303. Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form. I have determined that the system' fails to protect public health and the- environment as. defined in 310 CMR 15.303. The basis 'for this determination is provided in the FAILURE CRITERIA section of this i form. ..Inspector's Signature Date �y C� r Original to system owner Copies to �w .. 1 Buyer (if applicable) Approving authority r } TOWN OF BARNSTABLE LOCATION �.� ��/��il��'S Lc. � SEWAGE # VILLAGE l�_ V a ASSESSOR'S MAP& LOT INSTALLER' NAME AME&PHONE NO. SEPTIC TANK CAPACITY ff-e 5i�2 LEACHING FACILITY: (type) p d 7— (size) (O NO.OF BEDROOMS BUILDER OR OWNER ✓� �5 0 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 l 6 f --S> _ �. r _ ; �, Lot f: A ' ION 5EW' C: GE PERM Htt0 VILLAGE f— i ASSESSORS MAP NO: INS r A LLER'S NAME ADDRESS Ll U I L D E R DA 0WHE,,R .:- 1) ATE 1; ERIAIT ISSDED �_ DATE COMPLIANCE ISSUtD l )' 1I a G Z + \ v vV q� v^TiY _1 9 t7, n Ki J v S �6 -3 Board of Health Fizig Town of Bar�n�ap�MONWEALTH OF MASSACHUSETTS j hlyannis, Mass P.o. B®x534 �I� PsdQF HEALTH ��p / ..................:........................0 F.......................................................................................... Allp iratinn for Biipuial Works Tonstrnrtinn "Prod# Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: ....:......aal..---.•.........fit^:: ...................`.r-------------- -------------------• .......................................... Location-Address or Lot No. ......... _ .�F—: Y+��sr� -------------------------- . •--•--------------- ..:1 �. --.......................................... . "� Ow res s { / Installer Address Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms_._...................................Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building No. of persons............................ Showers Cafeteria WOther fixtu ------------------------------------• -----------I••--•---•••••••••-••••••-••-•-••--•-•-••----•-•.......•--•••---•-•-•-•--............_........_. Design Flow........15... ...........................gallons per person per day. Total daily flow.......... _. .. ......._._....gallons. . W. Septic Tank—Liquid capacity............gallons Length................ Width______.-___- _ - Diameter---------------- Depth................ Disposal Trench—No. .................... Width.................... Total Length_._._.............._ Total leaching area....................sq. ft. " Seepage Pit No--------/--------- Diameter....../p1 ..... Depth below inlet........ '.t.._.. Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.................... ..................................................... Date........................................ aTest Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ P4 -••--•......--•••••••••••--•••-••-••••---•-••••....••....................................................................................................... 0 Description of Soil........................................................................................................................................................................ x W -•••••••---•-------------------••••-••••••-••-••••-•---•------•...••••••••••••••••--•-•••-••-••••••-•--••---••-•••-•-•--------•---••--•--•-•--••-•••-•-•••••----•-••-•--•-•••---••-•......--........... UNature of Repairs or Alterations—Answer when applicable.......40V....___�, &-._.::14".,e_e .�i�___CI✓/ fr �'? =-------=>�..... 7.....�:- 5 �ff '------------------------------------------------------ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System.in accordance with the provisions of iITL% 5 of the State Sanitary Code—.The undersigned further agrees not to place the system in operation until a Certificate of Compliance h b the board of t . Signed..... _... •--••--•-------------- ----- --- --• .................. �( Date Application Approved B -....`P ... .. . ... . .................... .......... PP PP Y••-----•-••......-----••-•-• � Date Application Disapproved for the following reasons-........................................ ••------•••--•--•---•----•••-•--•••••----•-•-•-•-•.....---•-...---... Date ,4 Permit No.......................................................... Issued.............................. .------------•--••-•----- 0 Date No................_... Fns......................... _ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH T. .. ............ .......OF.............................................-----........................................ Appliratf:on for 11iopolial Works Tonotrnrtion umit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at 14�.. Location Address o Lot No. ew..............................................._..... • Owner �d Installer Address UType of Building Size Lot............................Sq. feet 1.4 Dwelling—No. of Bedrooms..... .................................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Q' Othe,r fi!-.tU=s .: -•----••--•- -------------•-------•--•--.----- d W Design Flow....... %. •.........................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons, Length................ Width................ Diameter........._...... Depth................ x Disposal Trench—N ..................... Width.................... Total Length.............. Total leaching area....................sq. ft. Seepage Pit No........�_._____-- Diameter...../4........ Depth below inlet............... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by-•-•-------•-•-----------••..............••••--•...._............•--•-•.. Date........................................ ,.-I Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ G14 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 1:4 -••-----•-••-•-------•------••••--••-••--------•-•••••...........................................•••......................................................... ODescription of Soil.........................................................•••--...---••--•••---•--•---••--•...--••-----•----•-••--••-•-•---------...•----•-•••--•--••••-•-....-----•--- U -•-------•-••••--••••-----------------------•---•-------•---•••--•-------•....----............-•••---•-•-•--••----••••--......•-•-----••----•-----•-•---•---•----••----•---•---•--•----••-•............_ W •-•-------------------------•-----•••-------••--............-••-•---•••••••••---•-•-•-•-------•-•••-----••••--- - ---- ....._ .. - U Nature of Repairs or 'Alterations—Answer when applicable.._____.. .. �+G..... .:._._.... _... !c........_7--- ----�'t�_r.�� r w�...... savAA�-,� Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System.in accordance with the provisions of TIT1E 5 of the State Sanitary Code The undersigned further a rees not to place the system in operation until a Certificate of Compliance"t-r the boar of ealt Signed.--- .. ._,,...., '` _D Application Approved By........................................ •---•- ---- S Date Application Disapproved for the following reasons:.............................................................................................................. ....................•---...--•-•---•-----•---•--......------...............--------.......--•--..........._.......----...............----•-•-•---•-•---------......--------------------------------•••--- Date PermitNo......................................................... Issued----------------------------------•---•--------•-•--•-- Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH (Inrtif irate of Tontpliatta T1Q&4-S-Z_ CERTI Y, T)aat 1 Se age Disposal System constructed ( ) or Repaired ( ) cat... -tsr_...-••--•--- .... . `" - ... :::... ..._.. n y ...-•--- t / ( Installer� Cc�� }�•� at........................... �-1---- . i �i � V1t'4/4 �✓L!CA-. .. •-----••.#..... 6r .... ... �. -----------•----- ----- -- „' L has been installed in accordance with the provisions of TITLE 5 of Th State Sanitary Code, ass,d_e�, in the application for Disposal Works Construction Permit No........... G_:._'.A ....... dated---------- .. ......................... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE.......................................•--------.............--•------•---•----. Inspector..............................................................................•---- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH _ .t1 4?4- q ~.�.7.70!-: .'.`.'..v........OF........: , 1..�_II.Y`` " �rr. c••',�...................... No....................... FEE........................ �iopr ur o fora Wt rrutit Permission is hereby granted... --a :, ..` `- .---..... _ to Construct ( ) or Repair ( an Individual Sewage Disposal System i/` - at No. �' Cyr`---7w.. -V4-� ----•--- J ` ........................... vc Str et c it 1? as shown on the application for Disposal Works Construction Permit No........... ........ l4ed.......................................... ......................................... ..................................................... cJ_ C . and of Health DATE-------•-•--••--••--••••----• .' > •y FORM 1255 A. M. SULKIN, INC., BOSTON - -- t.