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HomeMy WebLinkAbout0038 PRAM ROAD - Health 38 Pram Road Hyannis P 268 047 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF 9NVIRONMENTAL AFFAIRS r DEPARTMENT OF ENVIRONMENTAL PROTECTION MAP `�G,$ RECEIVED PARCEL O �C 4 Yµ`� AUG 0 9 2004 TOWN OF BARNSTABLE TITLE 5 HEALTHDEPT. OMCIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSE ' - n ' SURFACE SEWAGE DISPOSAL,SYSTEM FOB MENTS PART A _ a T. CERTIFICATIONf, Property Address: 3 or� -'' 49 Owner's Name; Sc v ' cile, Owner'sAd rn va Date of Name of for: Company Name- ease prat) R✓ /'o ✓v� 'o -� T'EC. Mailing"dd o Zj Telephone Number. So4 (I ak G CERTIFICATION STATEMENT I cer"fy that I have personally inspected the sewage disposal below.is tom,accurate and complete as of the ' system at this address and that the information reported training,and experience in the Proper function and of the of on nspectio,,The won was performed bad on my approved system inspector punt.to Section 15.340 of Title 5 3 it C wage d►sp�� 'I am a DEP MR 15.000� The system: Conditionally Passes Needs Finer Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: /i p The system inspector shall submit a co -- _ DEP)within 30 of this inspection report to the Approving Authority Board of Health or gpd or days of completing this inspection, If the system is a shared greater,the.inspector and the system owner shall submit there report to them or has a design DEP. The original should be sent to the po flow of 1Qonal office of the a��ty system owner and copies sent to the buyer,ifate and the approving Notes and Comments is report only describes conditions at the time of inspection and under the conditions time.This inspection does not address how the system will perform in the future under the same seat that conditions of use. different Page 2 of 11 ., 1 OFMCIAL INSPECTION FORM_NOT FO SUBSURFACE SEWAGE DISPOSAL SYSVOLUNTARY ASSESSMENTS M INSPECTION FORM PART A CERTIFICATION(continued) h*Py Address: E Owner. Comes Dmeof c e/ ' �4 � O bsPechon Sun"Iry: Check AAC,D or E/AL_W_VS coin l A. Syste Pete all of Section D I have not found any formation which indicates 15:303 or in 310 CMR 15.304 exist Any failure criteria of evaluated of the failure criteria described in 314 CI�IIt Consents: uated are indicated below. B- $yst-em—.Con di ly p assew ZOne or more system components o as described in the"Conditional Pass" Von completion of the in or won need to be repair,as approved by the Board of H laced or Answer yes,no or not determined Health,will pass. explain, (Z',N,ND)in the for the following statements.If"not determined"please The septic tank is metal and over 20 unsounA exhibits Years old or the.septic tank(whether metal or not)infiltration qr exflhntion or )is structuraii existing is tanreplaced.with a complying Septic�as a�failure is imminent.System y Indic tank lass inspection if it is approved by the Board of Health. will inspection if the Ong that the tank is less than 20 years old i�aurae mod'not leaking and if a Certificate of Compliance iL ND explain:. Observation of ° swat).or due_t sewage b backup or break out or high static water level in the distribution.box alovai of Board of Health): n,settled or uneven distribution boz S _ _. . __ .__._._ due to broken or- - will Pass inspection if(with broken pipes)are replaced fiction is removed distribution box is leveled or.repla ND explain ced The system Pass inspection if(wlred Pumping more than 4 times a year due to broken or obstructed th approval of the Board of Health): cted pipe(s)- The system will broken pipes)are replaced obstruction is removed ND explain: 0 Page 3 of 1 I i OFFICIAL,INSPECTION FORM- NOT SUBSURFACE SEWAGE DISPOSAL, OR VOLUNTARY ASSESSMENTS PART A SYSTEM INSPECTION FORM CERTIFICATION(continued) Perty Address: CERTIFICATION (", / Owner: 1411 Y G S s c Date of Inspection. 0 r Evaluation is Required by the Board of Health: Conditions exist which req.re f-0,��,is failing.to protect public nth,safety or theon o nit the Board of Health in order to de termine if the system I• System will Pan unless Board of Health determines system is not functioning in a manner which in accordance with 31,0 CMR i5.303 1 Will Prefect public health,saf (xb)that the _ Cesspool or ety and the environment.. Privy is within 50 feet of a surface water ` _ Cesspool or privy is within 50 feet of z a bog vegetated wetland or a Alt marsh 2. System win fail unless the Board of Health system is functioning in a manner that (and Public Water Supplier,if protects the public health,safety and environmenrt: that the The system has a septic tank and soil abso sur ace water supply or tributary to a surface waterosupply m(SAS)and the SAS is within 100 feet of a _ The system has a septic tank and SAS and the SAS is within a Zone 1 of a i public water _ The sYstenl has a septic.tank and SAS_ The system has a septic tank and and the SAS is wit hin 50 feet of a private water supply well. SAS and the SAS is leis Private-water supply well Method to than 100 feet but 50 feet or more from a ** determine.distance This system,passes.if the well water analysis,bacteria and volatile or�c com lx=rformed at a DEP certified laboratory,for coliform the presence of pads indicates that the-well is free.from poiluWa from ammonia nitrogen and nitrate nitrogen is equal to or less than 5 that facility and failure criteria are triggers A copy of the analysis must be attached to this form.'provided that no other 3. Other: L Page 4 of 11 J ' OFRCIAI.INSPECTION FORM— NOT SUBSURFACE SEWAGE DISPOSAL SYSTEM VOLUNTARY ASSESSMENTS PART A INSPECTION FORM CERTIFICATION(continued) Property Address. 3 /" �qq Owner: Date of Inspection: D. System Failure Criteria applicable to aU systems: You must indicate `yes"or"no"to each of the following for an motions: Yes — N� p of sewage into facility or e or ponding of effluent to them component due to overloaded or clogged S clogged SAS or cesspool of the ground or surface wad AS or cesspool — _ c liquid level in the distribution box ue to an overloaded or cesspool above outlet invert overloaded or clogged t� -"quid depth m cesspool is less than 6»below iIIvert or to an oven gged SAS or ti l Pumping more than 4 times in the Iasi year NOm'mlable volume is less than%day flow ° °�limped_ . due to clogged or obstructed Pipe(s).Number g — Portion of the SAS,cesspool or privy is below hi wwater soon of cesspool or privy is within 100 feet of gh ground water elevatio . � Pp1Y• a surface water supply or tribe — .portion of a cesspool or tart'to a surface Y portion of a cesspoolPrivy is a Zone 1 of a public well. or privy is within 50 feet of a private water supply�Y portion of a cesspool or privy is less than 100 f pp Y well. supply well with no acceptable water feet but greater than 50 feet from a Performed at a DEP ��'analysis. [This system private water certified laboratory,for co analysis. [ b Passes if the well water anal indicates that the well is free from pollution from that facr7r'na and volatile o analysis, nitrogen and nitrate nitrog ty and the rganic compounds y are triggered.A ra en is equal to or less than 5 Presence of ammonia copy of the analysis m PPmq Provided that no other failure criteria Y must be attached to this form.) (YesJNo)The system fails.I have described in 310 C Ve determined Mat one or more of the above failure Grit MR 15.303,therefore the system fails.The criteria exist as Health to determine what will bt necessary,to co system owner should con correct the failure. tact the Board of E. Large Systems: To be considered a large system the system must serve a facility with a gpd� i design You must indicate either-yes- now of 10,000 gpd to 159000 (The folio - criteria Yes or ,no,,to each of the following: g teria apply to large systems in addition to the criteria above) no system is within 400 feet of a surface drinlang water supply the system is within 200 feet of a tribut ary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area- e Zon II of a public water supply well rWPA)or a mapper If you have . swered"yes"to airy question in S "yes"in Section D above the large Section E the system is considered a si significant threat under g system has failed The owner or operator of gmficant threat, or answered 15.304. 'The won E or failed under Section D shall u any large system considered a system owner should contact the appropriate regional office oth s system in accordance ce with 310 CMIt /�� partment. Page 5 of 11 OFFICIAL,INSPECTION FORM—NOT FOP`r OLT'ARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CRECICLIST PftWriy Address; 3;6' lol Qd e Date of)ink; Check if the q have been ow.You rmrst indicate es"or"no"as to each of the fo�lowin Yes/1�To dd oon was Provided by the owlOccuPwtcmr-Bcard of Health —/— were any of tl+e spste= d twt in&epxvjOMtwo weeks LC Has thesysfsm zeceivednowaa Rows ja- P ions two Wak per od i 0 bWvdhmM of w,ater been luftdkwed in the. Mm recently or as pvt of Were as builtp�of the ��Pe<'tion Was the ined and Mmuied? �tbey were naMv Mft as N/A) lY of sewage back up Was the site=PeMd:h)r SOS off out Were all system co 'Mho the SAS,located on site Were the septic tank n�anhol ofthe es of ed,6 ofle' tam. �or ;rn�erial� M � of liquid, of sludge mqxMd fer the condition _ — Was.���'owner(ark depth of scum penance of Subs��sewage differe�rt.f ows3rstemsner) with won on the propel n�The size and location of the Soil Absorption System(SA j on the site has been bused on: xisting information.For esan'Oe,a plan at the Board of Health is un pile 3��in the field(if any of the faihae criteria related to Part C is at issue appr )[ CZ1�R IS'302(3Xb)] on ofdistance Wage 6 of 11 OFNCIAL INSPECTION FOR M:--NOT FOR VOLUNTARY SUBSURFACE SEWAGE DISPOSAL SYSTEM ASSFSS�NTS INSPECTION FORM PART C SYSTEM INFORMATION Property Addnm- >e AM ati led Date ofb oa: RFSOXNITAL FLOW CONDMONS Number m �w�ooms(design)- Number of N ° C1 15203(for 1�(�#) D�reddeame have a garbage i' 1© bedrooms). Is lady on a separate (Yes no):-� LaundiX system.. ���'��):�P/� [if spec tion usez(Yes Sump metP(yes ar no �/O if (last 2 years nsaW ): ° y . COCLAIMBUSTRIAL Type of establ Design Qdw(based on 310 CN R 35203): Basis of desi Grease trap prevent(yes or no): )' NdL�waste holding tank p��(yes or il°); Watereter waste dieadhiA�to the Title 5 system(yes or mo): Last date of le: _ iw OTMR(describe): Records GENERAI,MORMATION Source of information:Was system PunTed If yes, t n vh� °f motio .(yes ormpedL no : � Reason for _agallons—How was quantity Pumped dft=wmjxL? F SYSTEM Septic —Single box,soil absorp system Overflow cesspool _.__ivy —Shared system(yes or no)(if Yes,attach InnovativdAlt=adW technology. p1vioas inspection record ifany) °��S7'�m owner) h a�of the ant operation and .,contract —Atfta a copy of the DBp,aPProval to be Offiff(describe): Approximate age of all Components,date itstall (' and source of tlon: Were sewage oW�detected When �'� hen arriving at the site(yes or no):/L� i l I gage 7 of l l OFFS INSPECTION FORM—NOT FOR.VO SIIRFACE SEWAGE DISPOSAL SYSTEM SPEC ASSES PART C "I ION.FORM SYSTEM FORMATION(ems PruMqAddrem- O-J;�� Owner.- �I,1c. Daft of r o RulQ WG SEwXR 00C31C Oft she plan) DEpth oMatefials f -�_ _ r/ iron 4oPve DWanm from private watm stay weR m suction —° (ems): Comments(oII araditioIIofjintss venting evidence of h x etc)• SEP17C TANK=(locate an site plan) Delith below grade:Material of,construcioIx —rr � leaiu) _metal.— ass_ ethylene g If i tankis , AQp- l g �r certificate) Ceafficaof ce(yes or no}: _(attach s copy of Sludge depdr bottom Of outlet a Sca�m'tbic�,£' tee.or ba�ffie:.. .�� . Distalme. p of- Dist�ftmbottm Haw were iom 9onoII tee or 6 e: § COIIImenL4(OII De 1: o C Aej ! leg recommendations;inlet �� as to outlet my ate tee Or 10 N evzd of leakag�etc�. conditiojo, actural i1te9r1Y,liquid levels ✓!o t- e J" C 4 �Lj,�. . CAH '- SASE TRAP: (locate on site plan) Depth belowgrjde; al.of consti„cb;os:—COS_metat fiberglass_p�,ly�,yl� � )' +other Visions: Scum thiclme Distaum from top scum to top of outlet tee or bate: Dastance fiom bottom of scum to bottom — Date of la( � outlet tee or bail on as related to outlet g mcommend� ,inlet and outlet tee or baffle condition, �urt evidence of leakage,etc.) egrity,liquid levels i i Alm 8of11 OFRSC[A�.SUIATSPEC TION FORM--NOT FOR VOLUNT RANTS RFACE SEWAGE DISPOSAL SyS ARY ASSESS TEM INSPECTION F PART C FORM SYSTEM INFORMATION IONProperty Ads: Date of f" 0 O'HOLDING TA X- AHM be DePth below Bade: time.of inspedonvocaft oa site pbn) dal° won conarete metal l; --Polyethylene other(epLain): ChpWaty- d l�gnl�tOw Aft p�Ig! ,Or no);_ �Y Alarm in WWkin ------------ g � �mments(concim of�and switches,etc.): Y D'STRURMON BOA present must be • 0Xned)(1ocate on site plan) Depth of&quid level above leakagQmmnlee (note d"x is level'and to outlets equal;any evidence of into or out Of box,etc.): so>ids YOVe1,any evidence of 4 A/ PUMP CHAMBFJL- o site plan) a Pumps in working�(ems or Atarms is wog order(yes or no} COts(note co - ndUoa of pump chamhea,condition of pumps and 0 Page 9 of 11 0 IML INSPECTION FORM_NOT FOR VOLIEM SUBSURFACE SEWAGE DPQSAE SYSTEM INSPECTION� � PART C FORM SYSTEM INFORI"TION Pr)perty Address: 1 lGt li�j �c� Owner: ti Date of Inspeetion; l G SOIL,ABSORPTION SYSTEM(SAS). Rate on site plan,excavation not requred) IfSAS nt located why: Type 'eac g Pam,number: ( v leg chambers,member tA/ leaching galleries,number. / 'leachingc ,number,length: leg number,dimensions: °�'erfton'cesspool,number innovativetalternative system Comments(note condition of so' Type/name of technology: etc.): il,signs of hydraulic failure,level ofponding,dam h 00 C"- G /�� e L P soil,condition of vegetation, 49 time. CESSPOOLS:!c!'(cesspool must be pumped as part Of mspectionxlocate on site plan) Number and configuration: p ) Depth—top of liquid to inlet invert: Depth of solids layer. Depth of scum layer; Dimensions of cesspool: Mauls of construction: Indication of groundwater inflow(yes or no): 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 ve etatio g n,etc.): Page to of l l OFnCIAL INSPECMjq FORM-NOT IVOR VOLUNTARY TARY ASSESS ` SUBSURFACE SEWAGE DISPOS,4L SYSTEM INSPEIMON FORM TS PART C SYSTEM M E 'ORMATION(ooatim�d} Property AQdmemss: Wj �a w� t DL9POS,4L SVSTEN provide a skctbh of the�.I orate a sewage system �fetence wells withia 3p0 few ties to h two re pubfic Tangy or water supply enters the bu mmg h/ 4jo J t Page 11 of 11 OCIAL INSPECTION FORM_NOT FOR VOLUNTARY A SUBSURFACE SSESS SEWAGE DISPOSAL SYSTEM INSPECTION FOR PART C SYSTEM INFORMATION(continued) Property Addn+ess; �j� �✓�,� � / e GHvtr o/ d//�rt� Owner. ��c Date of Inspectim- 0 S]TE EXAM slope Surface,water Check cellar Shallow wells to ground water 22 feet Please mchcate(check)all mmtho&used to determine the high groom water elevation: Obtained from system design plans On record-1f checkmt date of d---m �.t �'ed �` g y/observation Im1e within 150 feet of SAS} Checked with local.Board of Health-explain: V'7 Al2 j Checked with local ammatorx,kstailers-(attach Accessed USGS database-explain: �OII) You must descn-be w Y establis 0the high V7¢water elevation: r e Gr�a v8 3G o07 �. L� C cz� 9 r( G>r/G. 4(0 v1 �-�✓ 4d - d 44,N , 000 I COMMONWEALTH OF MASACHUSETTS `� EXECUTIVE OFFICE OF ENVIRONMENTAI AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET BOSTON MA 02108(617)292-3500 TRUDY COXE Secretary ARGEO PAUL CELLUCCI DAVID B.STRUHS Governor Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: 38 PRAM RD WEST HYANNISPORT, MA 02672 '?,kO'6 Name of Owner SYLVIA RUGO Address of Owner: 38 PRAM RD WEST HYANNISPORT,MA 02672 Date of Inspection: 8/22/00 Name of Inspector: JOHN GMCI I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000) Company Name: SEPTIC INSPECTIONS Mailing Address: P.O.BOX 2119 TEATICKET,MA.02636 Telephone Number: 608-664-6813 FAX 608-664-7270 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: X Passes _ Conditionally Passes _ Needs Further Evaluation By the Local Approving Authority _ Fails Inspector's Signature: �� Date:8/22/00 The System Inspector shall su it a 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 inspection is based on criteria defined in Title V code 310 CMR 15.303.My findings are of how the system is performing at the time of inspection.My inspection does not imply any warranty or guarantee of the longevity of the septic system and any of its component's useful life" THE SYSTEM PASSES TITLE V INSPECTION.RECOMMEND PUMPING NOW AND EVERY TWO YEARS. r: revised 9/2198 Page 1 of 11 "SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A a, CERTIFICATION(continued) Property Address: 38 PRAM RD WEST HYANNISPORT, MA 02672 Name of Owner SYLVIA RUGO Date of Inspection: 8/22/00 INSPECTION SUMMARY: Check A, B, C, or D: A. SYSTEM PASSES: X 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. 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. 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,isl 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 complying septic tank as approved by the Board of Health. ilia 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 ilia 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 revised 9/2/98 Page 2 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 38 PRAM RD WEST HYANNISPORT, MA 02672 Name of Owner SYLVIA RUGO Date of Inspection: 8/22/00 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, ir. 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 ". n/a revised 9/2/98 Page 3 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 38 PRAM RD WEST HYANNISPORT, MA 02672 Name of Owner SYLVIA RUGO Date of Inspection: 8122/00 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 4. - 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 compounds, ammonia nitrogen and nitrate nitrogen. 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 310 CMR 15.30412).Please consult the local regional office of the Department for further information. revised 9/2/98 Page 4 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART 8 CHECKLIST Property Address: 38 PRAM RD WEST HYANNISPORT, MA 02672 Name of Owner: SYLVIA RUGO Date of Inspection: 8/22/00 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. s 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 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: 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)t 5.302(3)(b)] X - The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of SubSurface Disposal Systems. „ cif e ' revised 9/2/98 Page 5 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 38 PRAM RD WEST HYANNISPORT, MA 02672 Name of Owner: SYLVIA RUGO Date of Inspection: 8/22/00 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 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: 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)t 5.302(3)(b)] 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: 38 PRAM RD WEST HYANNISPORT, MA 02672 Name of Owner SYLVIA RUGO Date of Inspection: 8/22/00 FLOW CONDITIONS RESIDENTIAL: Design flow: 110 g.p.d./bedroom Number of bedrooms(design): 3 Number of bedrooms(actual):n/a Total DESIGN flow: 330 gpd Number of current residents:0 Garbage grinder(yes or no):NO Laundry(separate system)(yes or no): NO If yes,separate inspection required Laundry system inspected(yes or no): NO Seasonal use(yes or no): YES Water meter readings,if available(last two year's usage): n/a gpd Sump Pump(yes or no): NO Last date of occupancy: 6/1/00 COMMERCIALIINDUSTRIAL Type of establishment: n/a Design flow: n/a gpd(Based on 15.203) Basis of design flow:n/a Grease trap present:(yes or no): NO Industrial Waste Holding Tank present:(yes or no): NO Non-sanitary waste discharged to the Title 5 system:(yes or no):NO Water meter readings.if available: n/a Last date of occupancy:n/a OTHER: (Describe) n/a GENERAL INFORMATION PUMPING RECORDS and source of information: n/a System pumped as part of inspection:(yes or no):NO If yes,volume pumped n/a gallons Reason for pumping:n/a 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:n/a APPROXIMATE AGE of all components,date installed(if known)and source of information: 1993 §iwide ddori ditictid wheii aitiving at the site:(yes of no): NO revised 9/2/98 Page 6 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 38 PRAM RD WEST HYANNISPORT, MA 02672 Name of Owner SYLVIA RUGO Date of Inspection: 8/22/00 BUILDING SEWER:X (Locate on site plan) Depth below grade: 14" Material of construction: _ cast iron X 40 Pvc _ other(explain) Distance from private water supply well or suction line: n/a Diameter: n/a Comments: (condition of joints,venting,evidence of leakage,etc.) THERE IS TOWN WATER SEPTIC TANK: X ` (locate on site plan) Depth below grade: 8" Material of construction: X concrete_ metal_ Fiberglass_ Polyethylene_ other explain: n/a If tank is metal,list age Is age confirmed by Certificate of Compliance(Yes/No): NO Age: n/a Dimensions: 1000G L 8'6"H 6'7"W 4'10 Sludge depth: 4" Distance from top of sludge to bottom of outlet tee or baffle: 30" Scum thickness: 3" Distance from top of scum to top of outlet tee or baffle: 24" Distance from bottom of scum to bottom of outlet tee or baffle: 0" How dimensions were determined: MEASURED 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.) THE SEPTIC TANK IS STRUCTURALLY SOUND.RECOMMEND PUMPING NOW AND EVERY TWO YEARS. GREASE TRAP: _ (locate on site plan) Depth below grade: n/a Material of construction: _concrete_ metal_ Fiberglass _ Polyethylene_other Explain: n/a Dimensions:n/a Scum thickness: n/a Distance from top of scum to top of outlet tee or baffle: n/a Distance from bottom of scum to bottom of outlet tee or baffle n/a Date of last pumping: n/a 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/a A revised 9/2198 Page 7 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 38 PRAM RD WEST HYANNISPORT, MA 02672 Name of Owner SYLVIA RUGO Date of Inspection: 8122100 TIGHT OR HOLDING TANK: _ (Tank must be pumped prior to,or at time of,inspection) (locate on site plan) Depth below grade: n/a Material of construction: _concrete_ metal_Fiberglass _Polyethylene _other Explain: n/a Dimensions: n/a Capacity: n/a gallons Design flow: n/a gallons/day Alarm present: NO Alarm level:N/A Alarm in working order:NO Date of previous pumping: n/a Comments: (condition of inlet tee,condition of alarm and float switches,etc.) n/a DISTRIBUTION BOX:_ (locate on site plan) Depth of liquid level above outlet invert: n/a Comments: (note.if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.) n/a PUMP CHAMBER: _ (locate on site plan) Pumps in working order:(Yes or No): NO Alarms in working order(Yes or No): NO Comments: (note condition of pump chamber,condition of pumps and appurtenances.etc.) n/a revised 9/2/98 Page 8 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 38 PRAM RD WEST HYANNISPORT, MA 02672 Name of Owner SYLVIA RUGO Date of Inspection: 8/22/00 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: n/a Type: leaching pits,number:(1)1000 GAL 6'X 6 leaching chambers,number: (n/a)n/a leaching galleries,number: (n/a)n/a leaching trenches,number,length: (n/a)n/a leaching fields,number,dimensions: (n/a)n/a overflow cesspool,number: (n/a)n/a Alternative system: nla Name of Technology: n/a Comments: (note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.) THE LEACH PIT IS STRUCTURALLY SOUND AND APPEARS TO BE FUNCTIONING PROPERLY.THE PIT WAS EMPTY AT THE TIME OF THE INSPECTION.SHOW SIGNS OF BEING 3/4 FULL. CESSPOOLS: _ 5p (locate on site plan) Number and configuration: n/a Depth-top of liquid to inlet invert: n/a Depth of solids layer: n/a Depth of scum layer. n/a Dimensions of cesspool: n/a Materials of construction: n/a Indication of groundwater: n/a inflow(cesspool must be pumped as part of inspection)NO Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) n/a PRIVY: (locate on site plan) Materials of construction: n/a Dimensions: n/a" Depth of solids: n/a Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) n/a revised 9/2198 Page 9 of 11 • SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 38 PRAM RD WEST HYANNISPORT, MA 02672 Name of Owner SYLVIA RUGO Date of Inspection: 8/22/00 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) GA O AA 3`6 A6 a� AC a6 V31 S revised 9/2/98 Page 10 of 11 w SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 38 PRAM RD WEST HYANNISPORT, MA 02672 Name of Owner SYLVIA RUGO Date of Inspection: 8/22100 s NRCS Report name: n/a Soil Type: n/a Typical depth to groundwater: n/a USGS Date website visited: n/a Observation Wells checked: NO 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 .. t revised 9098 Page 11 of 11 TOWN OF BARNSTABLE t+ v L��CAT10N� ���-� � SEWAGE # IL ' VILLAGE r /�/ ASSESSOR'S MAP 6z LOTOW-O°( INSTALLER'S NAME PHONE NO.dtg a &y�-) 1" SEPTIC TANK CAPACITY l i LEACHING FACILITYAtype) (size) NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER DATE PERMIT ISSUED: - � u DATE COMPLIANCE ISSUED: i VARIANCE GRANTED: Yes No e/' a Q� QP {�f TO F ARNSTABLE LOCATIONR � SEWAGE # �MLAGE �� ASSESSOR'S MAP t�I� INSTALLER'S NAME&WONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) NO.OF BEDROOMS p ' BUILDER OR OWNER PERMITDATE: 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 TIM- 3 No... A�'pIED Fas.... Barnstabl8 Conservation D@P81'tli OntTHE COMMONWEALTH OF MASSACHUSETTS 2` /f_? _ 72BOARD OF HEALTH Si ed Date TOWN OF BARNSTABLE Appliration for Diripooul Works Tonotrnr#inn Permit Application is hereby made for a Permit to Construct ( ) or Repair ( -an Individual Sewage Disposal S at ... .............. .......... ......... ...------------ --- �.............. --------------- -------------R oc ti n- \ddr Lot N . � -�c'-�. ..... . ..... ................ ................. A&L ---- ----- ----- Installer Addre UType of Building Size Lot............................Sq. feet .� Dwelling— No. of Bedrooms---------------------------------------_.--Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons---------------------------- Showers ( ) — Cafeteria ( ) Q, 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 ( ) '~ Percolation Test Results Performed by.......................................................................... Date........................................ a Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ fZ Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 04 ----------------------------------••---------....---....-•-----••--•------------............•--_............................................................ 0 Description of Soil..................................................................................................................................................................... x --•-------------------•---•---. --------.._............----•-•---...........-------------------------- ..--.... ------.7...�......_ ..........,�..... U Natur f Rep i s, or Alterations—Answer when applicable./� �... �1 .f..1.J.!0 .��.-� /...��f......... t1�----------------------------------------------------------------------------------------------------r..------.-----------------•------.......................---. A rZement: g 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 placethe system in operation until a Certificate of Compliance ha ssue, byssue, by the healt L5 � �" - �......... Sig .... ..................... ...... ................�_e.................. ApplicationApproved By ........ . .. ........................................... ..............................................-- -- ------------------------- ...........-...-. ..................Due Application Disapproved for the following reasons: .............................................................................. .................................. ................. ... --------...... ................................. ------ ................................... ... Dare Permit No. . .............. Issued ......../ . ..... ... . t•• �' �,.�v.-...:-..,,_,f';�-E�'.�".-:..i1�"S;ti�`.-`-^:,.1�.--�.-�'m'-» .. ,, a ice..a�4�^-ti,r�,�'j •F,h, , •. t �;.id„Y-v.�r•il� `!'�""'-`..'�. q3 60� No....I.........._....... Fss.....� / /• THE COMMONWEALTH OF MASSACHUSETTS ly" ,/ _s _ 73BOARD OF HEALTH TOWN OF BARNSTABLE ApVtiratiuit for Di►ipniu1 Wnrk.6 Tomitrnr#iun rprmit Application is hereby made for a Permit to Construct ( ) or Repair (.- an Individual Sewage Disposal System at _t.. �n�? ,►�.L� Location- Address Ir9a, . �r�,��. ..� <�<:C . �� c ._.. c .> t �f�/ Cl>'1/S._ - V ._.. Installer Address Q Type of Building Size Lot............................Sq. feet U Dwelling No. of Bedrooms______________________________ _ _ -Expansion Attic Garbage Grinder aOther—Type of Building ............................ No. of persons---------------------------- Showers ( ) — Cafeteria ( ) Q' Other fixtures .................................. Q 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 ( ) Percolation Test Results Performed by.......................................................................... Date........................................ ,.� Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ (T4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a •--•••••--••-•--------------••--•---••-•---••••--••-----••---•••-•---••-._.._.....-••-----••---•---.....--•--•-----•-••---.._._.......----•--••---.......•••. 0 Description of Soil........................................................................................................................................................................ ...............-............................................................................................................ . _---•- ---_....- b0 -- U Natur of Repairs or Alterations—Answer when applicable. 0 ---- n��.�a..��.��3./:.._� �_7 __._.__... (�.. �...-- - .�/-•-•-•---•-•--------••-----•--------. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has-be ri ssued,by the board of health.,- ............. a Stgned .. . ./..............y t Date ApplicationApproved By ......... -- .... ....__............ .............-.--------------------------------------------�..,. Dare Application Disapproved for the following reasons: ....... ......... .......................................................:........ ................ ..... ............... .... ...... . .. ... ......... ............. Date Permit No. ............... -. L/.-.. ................ Issued ... S THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BAR(.�NSTABLE �ertift�C�Ite of C�aniplialare THIS IS TO-CERTIFY That,the Individual Sewage Disposal System constructed ( ) or Repaired by ................._....- .. f. fir.-:..�G.l (/ �k/)....e(I)t��t-. C '1 - .......... fl ............ at ..................._......... .�-----....... .t'c . '7-----4� Cl.......... _�I:al; ...... ......... has been installed in accordance with the provisions of TIfI I.E�ofThe St to as described in the application for Disposal Works Construction Permit No. ........"'..... .....�vi:onmentalCoNde date ............................._. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT E CONS "R E A GURATEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. '2 /r................................... - ........._._ ......... Inspector ........ - =...`..:::. ............................... DATE............... ..... (� THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH �� TOWN OF BARNSTABLE N .. �.....,, FEs.__.... ,t�1y,{ nr����un�truatn rrmi� " Permission is hereby granted.......'_!U�J 11-1 t _••c fl. ....................................... • -- • wt ge Disposal System to Construct ( )��Repair (�')�an Individual S� , nr^ . C,G atNo...................... `'fE,�� r .......-•-_-..__. -j--- v Strcet ((�� as shown on the a li ation for Disposal, Construction P m�- No.( � Ited._ 11.�. PP P 0•---•...... fJ Board of/Health DATE.....�_!.......... ......• .•... ...................................... FORM 36508 HOBBS&WARREN.INC..PUBLISHERS