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0028 SAUNA ROAD - Health
l 28 &,,tuna Road Hyannis P A = 269 132003 i 444 i i 4 - TOWN OF.BARNSTABLE LOCATION 5,6w-4 8011-14 SEWAGE # VILLAQE ASSESSOR'S MAP & LOT I@IST4d=L-ER'S NAME&PHONE NO. G'vr� SEPTIC TANK CAPACITY 100a 41.9-1 LEACHING FACILITY: (type) ��o4-9 (size) /ems& NO. OF BEDROOMS BUILDER O<:OiNE$)— PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leachine Facility 7 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 w� �" ,: V.i _ � e 1. -� a2 - �` a�� ' 3�� j< �' 1 .y 'LOCA,TION !���Gv�t.�.. SEWAGE # =VILLA E— o, ASSESSOR'S MAP & LCTA*3- INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACTY LEACHING FACIL=: (type) ��� (size) C.X6 NO.OF BEDROOMS BLUDER OR O DYNE?? PERMITDATE:':7 COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table _ F: Private Water Supply Well and Leaching Facility (If any we!ls exist on site or within 200 feet of leaching facility) F* Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) F_ Furnished byC��� r �1 os UP dP cA -11 � r _ r rs 1 . TOWN 6,, -:,ARNSTABLE LOCATION l SEWAGE # �'� VILLAGE /�y/� r✓n✓�� ASSESSOR'S MAP & LOT /3 a 3 . ,,,INSTALLER'S NAME Si PHONE NO.AP- ely �J / SEPTIC TANK CAPACITY 6, 1 LEACHING FACILITY:(type) /0;>i /' (size) f o- c G .E? NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER/ c CBUI:LDTl�OR OWNER �.�1/ r Zy h- C DATE PERMIT ISSUED: �` ® �- r . DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes L� No o ` 4 \�� ^ �D y„y�' `� a �. �\ .� �, `. . W � p�. v � ,. .... ! r ieSFSSORS P.Ap NO.. No. ` V Y'7 • GEC -�_...�.. THE COMMONWEALTH OF MASSACHUSETTS OARD OF HEALTH �IN.!J.........OF........ .. ( : .......... Apprativaa for Uiapoii al Workii Tuauitrurtivaa Vanfit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System-at ................ ---.....-.....---. .a ...... ...... n .... ------------------------------------------------- r Lot OtT � Y-._... c 'f 5---- � f- .../�li�J(_ov!�✓ No.�.. Owner Address a C1 ..... � fly?10�-------------------- ......�.k,9B...0 Installer Address d Type of Building Size Lot.___'_.0�-.-g©.....Sq. feet U g— ._...Expansion Attic ( ) Garbage Grinder ( }Y� Dwelling No. of Bedrooms_______________________________________ — 4Other—T e of BuildingNo. of persons............................ Showers Cafeteria Q' Other fixtures ____________________________ W Design Flow.................................. ...gallons per person per day. Total daily flow----- ..........................gallons. WSeptic Tank—Liquid capacity,/e_D,l�.gallons Length. _G_-__ Width.. ?a Diameter...... ......... Depth-�� ..... x Disposal Trench-No..................... Width.................... Total Length.................... Total leaching area--------------------sq. ft. Seepage Pit No-----------/-------- Diameter....... ..__.___. Depth below inlet.....6........... Total leaching area----A®l....sq. ft. Z Other Distribution box (✓ , Dosing tank ( ) '-' Percolation Test Results Performed b 4._Cia_ __ !4 !y ..._... Date___ /�-"._dam_—�.._...__. y Ate. a Test Pit No. 14 32.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----/. 1 o__-____ Wj'.""•---•-------------- ----•"..___.._-•--•---------______....•--•-••-•--"-............._..._...._._..._......_............__......_..._..............-- O Description of Soil 1 Via/-_��_ 1� C ' A ' ---------_- U --'----•-----------------•'------ n�S7 SUf'lCrCyr��: -=. . . W rlESiGMtIG Liv�aY�vR_�C;:RTIFY li i \N U Nature of Repairs or Alterations—Answer when applicable------------ "ISTALL�7I I I'"�� LLED IV I ' _._._ .�e��-_1MS-TA- ....................... IVY VAS -.iF S�rJ Y r TI-Y ��_ hle...-• Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of i T'.is p 5 of the State Sanitary Code=The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been /issued b the boar of 10@t . D t - `-� f Application Approved By.......... ------•--- Date Application Disapproved for the following reasons---------------••-•-----------------------------------'•-••••......-• ---------------....................... --------------•------------...---....-'-....----------------•-----------------"••---------•--------•-•-.•-••-------•--------••-'---•-------•-'--••---•--------------------------------------------•---- Date Permit No..---- ..-��. ...... Issued_....................................................... Date No.. ...t_. .. Fxs .........._............... THE COMMONWEALTH OF MASSACHUSETTS _,,---BOARD OF HEALTH ...... blw_ ...........OF..........�.�.�...........U.`�.....'r L.. Applirntinn for Uispunal Works Tomil.rnrtiun Prrnti# Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: E.- p " ovF1 .�1 an r LS - -------•_ •--•. r .............. Location Address or Lot Ivo. •.....................»..........__.._.............._......•--•••.................•..........__. .............................................. Owner Address W Installer Address _ d Type of Building Size Lot__/ _... ..•..._Sq. feet Dwelling—No. of Bedrooms___...�—...:...........................Expansion Attic '( ) Garbage Grinder ( ) aOther—Type of Building ---------------------------- No. of persons............................ Showers ( ) — Cafeteria ( ) Otherfixtures .........--•-•------------------•-•----•-----•--•-••-----••---------------•--•----------------•--•-- ................................................ W Design Flow.....................................�......gallons per person per day. Total daily flow----7-.Z-,::......_.....................gallons. WSeptic Tank—Liquid capacit/?v�..gallons Length.)L! .-_.. Width.:__(a..._ Diameter______ Depthg.............. x Disposal Trench—N'o. .................... Width.................... Total Length.................... Total leaching area________----•___----sq. ft. Seepage Pit No---------- __-______ Diameter......................... Depth below inlet...4 .. Total leaching area...20>------sq. ft. Z Other Distribution box (✓) Dosing tank ( ) '-' Percolation Test Results Performed by-_-_ �L__ - "-'��' : _-f-. ;' fit/ Date..s _'_..............................�- � ,.a Test Pit No. Y-!= _ ,__minutes per inch Depth of Test Pit .. ------- Depth to ground water __-. rxq Test Pit No. 2................minutes per inch Depth of Test Pit---Z,: -.--- Depth to ground water.._!Z ........ ---------------- --------------•------•••-•--• --------.------------------------------------------------------------------------------------------ O Description of Soil.-- ......-•-•r -�<!'�.....-//.......G/ter G '...:.vv j`/ a�G UW ---•----------------------------•----------•-----• ----•-•--------------•-------•-•---••-----------•-••------••------ Nature of Repairs or Alterations—Answer when applicabl -----------------------------I............................................................... ------------------------------------------- Agreement: The undersigned agrees to install the afor edescribed Individual Sewage Disposal System in accordance with the provisions of-'TT., ; of the State Sanitary Code—The undersigned further agrees not to piace the system in operation until a Certificate of Compliance has been issued the boa of ealt . ..- 1 Slghe. A ..._.....�.~`.. ` ./...........D....t.o.............. .Zr,—,APPlication Approved B . �- ...........................•--- f Date Application Disapproved for the following reasons:.......................•---•---•----•---------•--------•--------------------•----------------------------------- ••••-••--•---••--•--•-••••.................••-•-•---•---•-•-----------•••....••----------••--•----------- ------------------ e Date Permit No........ ....... Issued-....................................................... Date - THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH J� Nti��f�k' C Lam. OF...........:................ ........................................................ �prtifiratr of Tuntph atta THIS,I TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( } bY..... �:.-------•--•--•-------------------•----•---•----•--••------------------......................--------•--------------------......----------•-••...-----••--•------ 1 ' Co �o In... nn at _ ---•- has been installed in accordance with the provisions of ice"'"-' of The State Sanitary Cod as described in the application for Disposal Works Construction Permit No._ ._-`-'- __^ _..___. date.i_..._�__1_L.2__ -v�f ----... ---•---•-•-•• THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT rHE SYSTEM WILL FUNCTION SATISFACTORY. e-- - DATE_..... -l..s48...............•---••---•---••-•....... Inspector.--_._�.�..-------------------•-•------------------------••-•-----•••-•---•--. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH r v vJ -� S7i4(mac . FEE............... Disposal Workii �aanstrudi an antic Permission is hereby granted..._.��C=. l........................................•----------•---------.....--------------.......••----..._••--..........---... to Construct ( ) or Repair ( ) an Individual Sewage .xsposal System at No.................1--• . A...... ........ �✓�z. Street as shown on the application for Disposal Works Construction Permit N��_.3 ..... Dated.._._�`/ - - / hol ------------- Board of Health DATE•--_..�- ---- ---•-•-----------•----------------------------------------------- FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS • Dec . 15 , 1987 Town of Barnstable Barnstable Board of Health Main /Street Hyannis , MAss . 02601 RE : Andrew Laska Lot 66 Sauna Road Hyannis , Mass . 02601 The septic system for this lot was installed according to , plan by this company. All Cape En in ering 49 Harbor R ad gyannis , '_'-lass . 02601 Tel . : 778-0058 .`o• , 57 .tot 56 I .Lot SS _ rzc j 17. l-6.1 6 r 6 r pitit /t dtone `j: j =20I a JJ/! �atoraz 100% =1427 cJpd < i � r I 000 31 o ------- .tot 65 10 I 14.4 lbt 67 ai3.3 .cot 6 6 I 000 1 11 2S0.S9 L1 j I !31 I I ii 3 i 11`o te: 'Uatet :to be , ! ; Sauna ad 40 r tU�e //•S 14.r i I j R•Ct Cape (r . _ . J 49 Ra,cboz Y�oad . . t � I /dganv: Ma. 0260! I . Izetch •Lan o and tin !d c�nai� I -S_ t , j '?oa And&ew Paaha ' 1 e v� dot 66 aa.' dwwn on Xand Covert l 1:328 /3 2 £•beuat o" ace bam. d on wateh �oand on .Cot. ' I t Jcte: Ac�ev1, : rze I3ociu�-p -T�Pu;1,�k - t • fit. I I i try?.-6tJS2 ._ _ _.....__� -- -- - - - --- - Ciade 8-15-86 - Wate,t jencouniterred • n 2 ►in p nh I" j I 9n, ,. 9/ 2 , t �to p P.o cvt4e co a"t4e { arul �d honecr y a z�, i 19 ' ___ COMMONWEALTH OF I�LkSSACHLSETTS - _-. EXECUTIVE OFFICE OF E1'VIR0hIAIENTAL FAJ F f d f���iv d DEPARTMENT OF ENVIRONMENTAL PROTE'1, - = �= DEPAR t ONE WINTER STREET. BOSTON �L� 021Ut (fi17) 292•i:iu i ?Mork �AL1HDEpr"�f-_- T Y COXc_ ecrE:an STR ARGEO PALL CELLUCCI D CORIItllSS rdss'H� ::,',E' Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A 6-` CERTIFICATION Wf 3 a�SC1QPw 0-d Name of Owner •\f Property Address: - ��� ��� �c �'��NtlllJ�btd Address of Owner:_ �:��G4�- � , Date of Inspection:. / � I W%�ry\%1JstU yJ 1 Name of Inspector:(Please Pnm)I ! Clr ti C�C �f ELK U 1 am a DEP approved system inspector pursuant to Section 15.340 of Trde 5(310 CMR 15.000) Conwany Name. C4._A*r J0�_k LA J'-Cry s= L + N+CA Mailing Address: -'r,eD /Z,1 -2 �� 15 Telephone Number: / S6- CERTIFICATION STATEMENT 1 certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true. accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: Passes � Conditionally Passes Needs Further Evaluation B the ocal Approving Authority Fails 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 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 then 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 revised 9/2/98 lr>geIof11 wo Printed on Recycled Paper r ! SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (corrtirxwed) 'roperty.Address: Jwner: V C� G , �.� Date of Irupecti � l5 INSPECTION SUMMARY: Check A, B, C, of D: A. SYSTEM'PASSES: 1 have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist. Any failure criteria not evaluated are indicated below. COMMENTS: 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 NO). 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 complying septic tank as approved by the Board of Health. _ 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 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 ea I gelofil . r ` SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Owner: 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 d ermine if the system is failing to protect the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDA E WITH 310 CMR 15.303 (1)(b) THAT.THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC H LTH 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 wetl d or a salt marsh. 21 SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND P BLIC WATER SUPPLIER, IF ANY)DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC EALTH AND SAFETY AND THE ENVIRONMENT: _ The system has a septic tank and soil absorption,system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. % _ The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well. _ The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well,unless a well water analysis for eoliform 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) OTHER i revised 9 2/96 rote 3or11 a SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Owner: \ Date of Inspecti D. SYSTEM FAIL • You must indicate eit er •'Yes" or "No" to each of the following: I have determ ne d that one or more of the following failuridentified below. The Board of Heat rmination s e conditions exist as described in 310 CMR 1 5.303. The basis for this Health should be contacted to determine what will be necessary to correct the failure. r date Yes No Backup o sewage into facility or system component due to an overloaded or clogged SAS or cesspool. _ Discharge or onding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. Static liquid level • the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cessp of is less than 6'" below invert or available volume is less than 112 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipelsl. Number of times pumpe _ Any portion of the Soil Abs\rptlonSystem, cesspool or privy is below the high groundwater elevation. Any portion of a cesspool os within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool os within a Zone I of a public well. Any portion of a cesspool or privywithin 50 feet of a private water supply well. Any portion of a cesspool or privy is than 100 feet but greater than 50 feet from a private water supply well with no Q as been analyzed to be acceptable, attach copy of well water analysis for acceptable water quality analysis. If the well h 'coliform bacteria, volatile organic comp unds, ammonia nitrogen and nitrate nitrogen. E. LARGE SYSTEM FAILS: l You must indicate either "Yes" or "No" to each of the following: The following criteria apply to large sys tems in addition to the criteria above: The system serves a facility with a design flow of 10.0 1 gpd or greater(Large System) and the system is a significant threat to publi 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 surfa c drinking water supply the system Is located in a nitrogen sensitive area(Interim ellhead Protection Area-IWPA) or a mapped Zone 11 of a public water supply well) The owner or operator of any such system shall upgrade the system in accords ce with 310 CMR 15.304(2). Please consult the local regional office of the Department for further information. revised 9/2/98 pdge4orIt SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST ?roperty Address: Owner: Date of Inspection. Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: s 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 NIA. 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. J 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: Existing information. For example, Plan at B.O.H. Determined In the field(if any of the failure criteria related to Part C is et issue, approximation of distance is unacceptable) (15.302(3)Ib)] J( The facility owner (and occupants,if different from owner) were provided with information on the proper maintenanca-of SubSurface Disposal Systems. I revised 9/2/98 Page$of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM. PART C SYSTEM INFORMATION 'roperty Address: � Owner: Date of Inspection: FLOW CONDITIONS RESIDENTIAL: Design flow: 0 g.p.d./bedroom. Number of bedrooms (design): Number of bedrooms (actual): Total DESIGN flow_ Number of current residents: Garbage grinder(yes or no): 1` ' Laundry (separates ystem) ( es or o)',O: If yes, separate inspection required Laundry system inspectedr no) Seasonal use (yes or no): Water meter readings, if av table Ilast two year's usage (gpd): Sump Pump(yes or not: Last date of occupancy: l�5`l COMMERCIALANDUSTRIAL: Type of establishment: Design flow: qpd ( Based on 15.203) Basis of design flow Grease trap present: (yes or no)_ Industrial Waste Holding Tank present: (yes or no)_ Non-sanitary waste discharged to the Title 5 system: (yes or no)_ Water meter readings, if available: Last date of occupancy: OTHER:(Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of inf��a�tion: System pumped as pan of inspection:(yes or no)_ If yes, volume pumped: gallons Reason for pumping: !Y OF SYSTEM --k�`'r- 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) 1/A Technology etc.Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other APPROXIMATE AGE of all components, date Installed Of known)and source of information: � Sewage odors detected when arriving at the site: (yes or no)d1.� revised 9/2/98 P,rgc6af11 e � SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C n p SYSTEM INFORMATION (continued) 'roperty Addr ss: S�V r�^'� ( y Owner: - 1(/e—c-c—k,-A Date of Inspection: 7 lj 1 l e7 BUILDING SEWER: (Locate on site plan) Y Depth below grade:_ Material of construction: _cast iron_40 PVC_ other (explain) Distance from private water supply well or suction line Diameter Comments: (condition of joints, venting, evidence of leakage, etc.( SEPTIC TANK: (locate on site p an) tl Depth below grade: `Z Material of construction: concrete _metal _Fiberglass _Polyethylene_other explain) If tank is metal,list age _ Is age confirmed by Certificate of Compliance—(Yes/No) Dimensions: \C? / iQ - Sludge depth: Ca tf Distance from top of sludgeto bottom of outlet tee or baffle: Scum thickness:_ tt Distance from top of scum to top of outlet tee or baffler tt Distance from bottom of scum to bottom of outlet tee r baffler._ How dimensions were determined: :,omments: (recommendation for pumpin eonditio�af' let and outlet tees or baffles, depth of liquid level in rela ion to outlet' ver structu�integrity. evidence of leakage,etc.) , GREASETRAP:� (locate on site plan) Depth below grade: 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: Date of last pumping: Comments: ffl (recommendation for pumping,condition of Inlet and outlet tees or bees,depth of liquid level in relation to outlet invert,structural integrity, evidence of leakage,etc.) revised 9/2/98 Pac`Iortl SUBSURF ACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) 'roperty Address: 0 _' Owner: Date of Inspection: me of, inspection) q��,\ U P TIGHT OR HOLDING TANK: V' (Tank must be pumped Prior to, or at (locate on site plan) Depth below grade:_ Material of construction: _concrete _metal_Fiberglass _Polyethylene other(explain) Dimensions: Capacity: gallons Design flow: gallons/day Alarm present Alarm level: Alarm in working order: Yes _ No_ Date of previous pumping: Comments: :condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX: g (locate on site plan) Depth of liquid level above outlet invert: 4X 7 Comments: — (n if lev I and distribution a al, vidence of solids carryov�evidence of le age into or out ,5c=x, etc.) ( - PUMP CHAMBERJ/-1Z) (locate on site plan) Pumps in working order:(Yes or No) Alarms in working order(Yes or No) Comments: (note condition of pump chamber,•condition of pumps and appurtenances,etc.) revised 9/2/98 Pagc8or11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (corrbnuedl Yoperty Address: Owner: Date of Inspection: SOIL ABSORPTION SYSTEM (SAS): S (locate on site plan, if possible; exca tion not required, location may be approximated by non •intrusive methods) If not located, explain: Type I x leaching pits, number: �f) �f leaching chambers, number:_ leaching galleries, number:_ leaching trenches, number, length: leaching fields, number, dimensions: overflow cesspool, number:_ Alternative system: Name of Technology: Comments: (note condition of soil, igns of by ulic failure, level of po ding, da soit, c diti of vegetation etc _ u e -r: CESSPOOLS: (locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: 9epth of solids layer: )epth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater: Inflow(cesspool must be pumped as part of inspection) 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.) revised 9/2/98 Paige 9of11 r ,y SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) 'roaerty Address: )wner: Date of Inspection: 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) Z4b 33 'L c revised 9/2/98 page to or it SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) roperty Address: Owner: G _7 iv2c c c L Date of Inspe Dri::71( �� NRCS Report name - --- ----- -- Soil Type_ — -- -------- ------ Typical depth to groundwater__—_ USGS Date website visited U-lt Observation Wells checked Groundwater depth: Shallow Moderate Deep SITE EXAM Slope Gad . Surface watert—"6 Check Cellar t Shallow wells I`6 Estimated Depth to Groundwater l 1 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 Used USGS Data Describe how you established the High Groundwater Elevation. (Must be completed) (S° �cr-jACO JUG' revised 9/2/98 Page 11of11 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTEC L�EIVE® a 0 932- DEC 0 3 2002 M SV e 9 Z I TOWN OF BARNSTABLE HEALTH DEPT. TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 28 Sauna Rd. W.Hyannis Owner's Name:Edward Dolby Owner's Address: Date of Inspection: 10/4/02 Name of Inspector: Timothy Lovell Company Name:Accurate Inspections MAP Mailing Address: 550 Willow Street PARCEL , 3 �O W.Yarmouth,MA. _._ ....... Telephone Number: 508-771-3700 LOT - 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 pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority s Inspector's Signature: Date: 10/4/02 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 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 Leaching pit liquid elevation is 2'below invert if change in usage may put strain on leaching pit ****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. Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 28 Sauna Rd.W.Hyannis Owner: Edward Dolby Date of Inspection: 10/4/02 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: _X_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: _N/A One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined"please explain. _N/A 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 infiltration 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. ND explain: _N/A 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 ND explain: I N/A_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 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: 28 Sauna Rd.W.Hyannis Owner: Edward Dolby Date of Inspection: 10/4/02 C. Further Evaluation is Required by the Board of Health: _N/A 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,safety and the environment: _N/A_Cesspool or privy is within 50 feet of surface water N/A 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,safety and environment: _n/a_ 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. _n/a The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. _n/a_ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _n/a_ 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. 3. Other: Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address:28 Sauna Rd.W.Hyannis Owner: Edward Dolby Date of Inspection: 10/4/02 System Failure Criteria applicable to all systems: You must indicate`yes"or"no"to each of the following for all inspections: Yes No _x_Backup of sewage into facility or system component due to 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 V2 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 _x Any portion of the SAS,cesspool or privy is below high ground water elevation. _x Any portion of 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 1 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. [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.] No (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CM R 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: N/A To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. 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) 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. Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address:28 Sauna Rd.W.Hyannis Owner: Edward Dolby Date of Inspection: 10/4/02 Check if the following have been done.You must indicate`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 Were any of the system components pumped out in the previous two weeks? _x_ _Has the system received normal flows in the previous two-week period? x Have large volumes of water been introduced to the system recently or as part of this inspection? _x _Were as built plans of the system obtained and examined?(If they were not available note as N/A) _x _Was the facility or dwelling inspected for signs of sewage back up? _x _Was the site inspected for signs of break out? _x _Were all system components,excluding the SAS,located on site? _x_ _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? _x_ _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 no _x _Existing information.For example,a plan at the Board of Health. x_ _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)] I - Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address:28 Sauna Rd.W.Hyannis Owner:Edward Dolby Date of Inspection: 10/4/02 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):_330 Number of current residents:_3 Does residence have a garbage grinder(yes or no):_no_ Is laundry on a separate sewage system(yes or no):_no_ [if yes separate inspection required] Laundry system inspected(yes or no):_n/a_ Seasonal use: (yes or no):_no_ Water meter readings,if available(last 2 years usage(gpd): N/A Sump pump(yes or no):_no_ Last date of occupancy:_current COMMERCIALANDUSTRIAL n/a Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgk etc.): Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no):_ Non-sanitary waste discharged to the Title 5 system(yes or no):_ Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: 1999 Was system pumped as part of the inspection(yes or no):_no_ If yes,volume pumped: gallons--How was quantity pumped determined? Reason for pumping: 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) _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: 13 years old Were sewage odors detected when arriving at the site(yes or no): No_ Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 28 Sauna Rd.W.Hyannis Owner: Edward Dolby Date of Inspection: 10/4/02 BUILDING SEWER(locate on site plan) Depth below grade:_3' Materials of construction:_cast iron _x_40 PVC—other(explain): Distance from private water supply well or suction line:_50' Comments(on condition of joints,venting,evidence of leakage,etc.): Ping looks to be in fine shape venting ok no evidence of leakage SEPTIC TANK:_x (locate on site plan) 'Depth below grade:_2' Material of construction:_x_concrete—metal_fiberglass—polyethylene—other (explain) If tank is metal list age:—Is age confirmed by a Certificate of Compliance(yes or no):—(attach a copy of certificate) Dimensions: 1000 Gallon Tank 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:_6" Distance from bottom of scum to bottom of outlet tee or baffle:_16" How were dimensions determined: in the field tape measurements_ Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): Tank cover should be built up the back yard has had material added to it,no evidence of leakage,liquid levels are invert out,tee'are in place GREASE TRAP:_n/a (locate on site plan) Depth below grade:— 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 bale: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 28 Sauna Rd.W.Hyannis Owner: Edward Dolby Date of Inspection: 10/4/02 TIGHT or HOLDING TANK:_n/a (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass_polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX:_x (if present must be opencd)(locate on site plan) Depth of liquid level above outlet invert:_0"_ 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.): Distribution box is in good condition cover is 3'deep no evidence of solid carry over no evidence of leakage PUMP CHAMBER:_n/a (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:28 Sauna Rd.W.Hyannis Owner: Edward Dolby Date of Inspection: 10/4/02 SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why: Type _x_Leaching pits,number:—I— Leaching chambers,number: Leaching galleries,number: Leaching trenches,number,length: Leaching fields,number,dimensions: Overflow cesspool,number: 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.): 1000 gallon leaching pit cover is 3'8"deep liquid level is 2'below invert no evidence of hydraulic failure, vegetation is normal,soil is sandy gravel CESSPOOLS:_n/a (cesspool must be pumped as part of inspection)(locate on site plan) 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(yes or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY:_n/a (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.): Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:28 Sauna Rd.W.Hyannis Owner: Edward Dolby Date of Inspection: 10/4/02 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch 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. Back of Home D ........................................ �v 7' �Ja` Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:28 Sauna Rd.W.Hyannis Owner:Edward Dolby Date of Inspection: 10/4/02 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water_30' 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: Checked with local excavators,installers-(attach documentation) _X Accessed USGS database-explain: - Plate 2 You must describe how you established the high ground water elevation: Information provided by Cape Cod Commission well data index Well#MIW-29 August 2002 reading is at 9.8 ft with an adjustment of 5.5 in zone C bottom of leaching pit is approx 23.3 with a 7' separation