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HomeMy WebLinkAbout0362 SCUDDER AVENUE - Health .'36'2 S'cud4 AV nUe # Hyannis 28 R ' 0,4500111 B ' f i a 9 jt P 4 9 t COl'U"1O-,\,AVE_A-L:'1'H OF-AL - SE-TTS 1911 E-KECi TI`vE OFFICE OF E- V1R.O-\;YE-N, �T_L� �'� ^��'C :AEI-' T1V1ENT OF E'-N-vTR0-1T�NT_=1L PROTECTIO oyS oo/ t I ' iITI_E 5 OFFICIAL INSPECTION NOT FOR VOLUINTARY ASSESS •IE•IiTS SUBSURFACE -SE.-VN'AGE DISPOSAL SYSTEAlIFOR_1- 1 PA ZT A CERTIFICATION Ix JJ / Property Address: — a v , �0_ 6 0 �� / I Oner's\aris 1/ t�rr'Ie: fln T Owner-s Add r.ess: ( e--0olis �4 oaLo/ Date of Inspection: /� p Hama of Inspector: se print Rs�y/ /'o lea Company Name: ElVkl o 7—EGI-� i Mailing Address: p Telephone Number ,Ly -_2 — V 441 Uj CMTIFIC TIOi ST 4:TE_NIENT -0 I cel v that I h ye personaliv inspected fhe se«-age disuosal syste�!2 at th s address z.nd teat the irsorn aeon rewo— tbelo �s true, a Irate and complete as of the time of the ilspection. The inspection vt as performed based on mv� u airy and exp rience ir.the proper i mc1ion and maintenance of on site swage disposal systems. I am a DEP 11 .ccapprf--ed syste inspector pursuant to Sectio Ia.3r0 of Title 5(310 CI•II215.000). Tile sestery: Passes _ Conditionally Passes ds 1 urt_'1er Evaluation by the Local ApprO,-ing �L't.Or t;• hi t ells luspector's Signature: � Bate: The system inspector shall submit a copy of thus inspection report to the Annroy:n6 Au.horit�• Board of�ealt^or DEP)within 30 days of completing this inspection,if the system is a shared s sicm or has a desi_mn ov,.-o= r 00i gpd Or o7eater, the IriSpeCtOr and the S,'sten_wvner shall subn'1t the report to the app---or.-at re,_?onal of- reo - DEP. The original should be sent to the system owner and copies sent to the buyer, ii anp icabhe, and t'le aut'lorlty. Notes and Comriaent= ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Title d Inspection F _�_ Form 6:'1�,2fl00 pa°e 1 r 1AI Page 2 of 11 OFFICIAL nCSPECTiON a OP.iA-NOT FOP."VOLUNT_-kR ASSESSAJ E_TS SUBSURFACE SE.W4,GE DISPOS_�UL. SYSTEIVI INSPECTION FOI2_ZI l'_'-P,I' CERTIFICATION(continued) Property Address: 3b �C�, �t✓�, /_�l/Q, Owner: Lute of Inspection: a pq Inspection Summary: Check A.B.C,D or E/A_IA-kYS complete aII of Section I3 gasses: I have not found any information which indicates that any of the failure criteria described in 310 C\NIR 15303 or in 310 C.�,:,R 15.304 exist. any failure criteria not.evaluated are indicated belo- t` Comments: B. System Condition..ails-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, «ill pass. answer yes,no or not determwined(Y,N,NND)in the far the follovinz stateT e.nts. if"not detelrnir?ed"please #' explain. The septic tans:iS metal and Over 2,0 vears old"or the septic tank(whether metal Or nOT) iS stria.—a ail . unsound, exhibits substantial infiltration or enfiltration or tark failure is nnnunent. System tviu pass inspectton it the existing tank is replaced with a complying septic tank as approved by the Board of Health. p "A metal septic tank will pass inspection if it is structurally sound,not leakinc and if a CerT.ificate of Compiiance indicating that the tank is less than 20 years old is available. , \D explain: Obsenration of se:gage baGlUp Or DTCcIC Out OI hl?h static water Ie -el in file CIS !bUCIOI bOx dUi O IIOheii Or obstructed pipe(s) or due to a broken. settled or unee eT!dist:-ibuiion box. sier._Sv - will ,pas_ inspection approval of Board of Health): broken pipe(s) are replaced Obstruc-lion is removed d' iburon box is Ieveied or replaced N explain: The system required pumping more than 4 times.a year due to broken or obstructed r)-'t(s?. T e .:":e,, ;; i pass inspection if(-,with approz:al of the Board of Health;: _ broken pipes)are replaced obstruction is re!noved t \D explain: '? Pare 3 of 12 OFFICIAL ! SPECTION FOR-A/1- NOT FOR VOLLTIN`T-ARX ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SXSTEINI ENSPECTION, FORAT PART A. # / l CERTIFICATION(continued)3'roperty Address: (Oo� .Sec �d�✓ v1✓1r Oa60/ Owner: - Date of Inspection: i t C. Further Evaluation is Required by the Board of health: /V Conditions exist which r - - - -i _ require further evaluation by the Board o�Heald?it-?cider is failing to protect public health, safety or the ens ironment. 1. System will pass unless Board of health determines in accordance with 310 CNIl215.3030)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: Cesspool or privy is within:50 feet of a.surface water Cesspool or pr`v-,is within 50 feet ofa border n_vegetated%retland or a salt:arch ?. System will fail unless the Board of health(and Public Water Suppiier, if any)determines that the system is functioning in a manner that protects the public health.safety, and environment: The system has a septic tank and soil absorption system(SAS)and the SAS is t 7 druin 1 00 feet of a surface water supply or tributary to a surface warer supply. f The system has a septic tar_k and SAS and the SAS is within a Zone 1 ofa public water sung' The system has a septic tank and SAS and the SAS is s itr n Su feet cf a pci�ate t glen supply -ell. _ The system has a septic tank and SAS and the SAS is less Chan 100 feet but 50 feet or more $om a private water supply.veil**. Method used to detetr_Lne distance "`This system passes if the well water analysis,per=ortred at a DEP cer f ed laborarorv. for co"fo-r? bacteria and Volatile organic con2pounds lndicat_s ttiat the v;;ell is f ee Lom pollllT.icn Cronn that a:l its'and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 pprr r-ovided chat-no other failure criteria are tri6Qered.A copy ofthe analy is-must be attached to tzis form 1 3. Other: Page 4 of 11 OFFICIAL INSPECTION FOR11—SOT FOR VOLUNTARY ASSESS-= ENTS SUBSURFACE SEWAGE DISPOSAL SYTSTE�I E\SPE.CTION- FORM _ _kRT CERTIFICATION(Co tinued) Property Address: (o2 G ✓41r 0/ . Owner: Lf vh Date of inspection: oa pLf D. System Failure Criteria applicable to all systems: You must indicate "yes"or"no"to each of the following for all insoections: Yes \'o _ V,,Baclalp of sewagc into facili-r or system comper-ent due to overloaded or cloa?ed S AS c) Discharge or poridmg of effluent to the Surface of the ground or surface waters dLe to an over-, Or 4,.OaTic asedSAS or cesspoolV liquid level in the disi7 button box a ove outlet invert due to an overloadee or cloa_�ed S or (a cesspool 1 i quid depth in cesspool is less than 6"below invert or mailable yo.uzze is less than is oar. i'cw _ Required pumping more than 4 times in the last year NOT due to clog-6ea or Ocs-ucted pi et�'l:\s,;,e, 1 times pumped _. } portion of the SAS; cesspool or prig-y is below high ground water elevation, p r/ A-ni-portion of cesspool or prit-;%li with'in 100 feet of a surface wager SUppiy or tnbutar< i0 a SilrtaCe gate-suti lv. j .ny portion_of a cesspool or z)--;y is within a Zone 1 of a public«-ell. - 1 y portion of a cesspool or priory•is-w-,thin 50 feet of a privatevlater supoIv Any-oortion of a cesspool or pri,y is less than 100 feet but greater than d0 feet tom a rrivate water supply well with no acceptable water quality analysis. This system passes if the well Rater alial-,sis. perfor.-ned at a DEP certified laboratory,for cofiform bacteria and volatile oQar is compounds indicates that the well is free from pollution from that facility-and the presence of ammonia nitrogen and nitrate nitres, _s equal to or less than 5- ,provided that no other failure criteria are triggered.A copy-of the ar_alysis must be attached to this form.j (Yes/\o) The s3,stem fails.I have determined that one or more of the above failure cri-,—r'a exist as described in 310 C1N`R 15.303.therefore the s'ysrern fails.Tlie system oy iier should contact fne Board of 1 Health to determine what;will be necessa,yro co-ect the failure. E. Large Svstems: To be considered a large system the system must serve a facility with a design flow of 10.000 gpd to 15.000 5 gpd !; You must indicate either"ves" or"no"to each ofthe fol?ou ins: �l (The following criteria apply to llarge systems in addition to the Criteria above) Xthe the system is within400 feet of a surface driii;,in`water supple die sysierri is within 200 feet of a tributar; rin-to a surface dkir_C.;%ater suppl: s"y%stern is located in a nit'ioger,sensitive area(liltedil Wellhead Pro-ectior_Area—I':�np - Zone II of a public water supply Ifyou have answered"yes"to any cuesron in Section E the S%sL=M is co_^.sidered a i, 'yes"in Section D abo�.e the large systems r - - Vrl h iailed. The o;,:per or operater ofart: ;ar�.e s ter,--o_S d. - significant threat under Section E or failed under Sec-ion D shall'upgrade the sL'Sr'M in a`` r - `15.304. The system 0-rier should contact th o '` �e approprzte reg?onal office of the Depa, 7,-nr. - r k i µ,. Pa-e 5 of 11 f' OFFICIAL INSPECTION F+OI61+I-!'OAT FOR`%OLIO T_RY ASSESS:�IENTS SUBSURFACE SEWAGE DISPOSAL SYSTE,l4I E SPECTION FOR-NI FART B CHECKLIST Property Address: bC- D�6 0/ Owner: vz✓701 Date of Inspection: a ID Check if the following have beer.done. You must indicate "yes"cr"no"as to each ofthe foio,vinc: I Yes No Pumping information�,-as provided by ilie owner, occupant, or Board o-i Health Were any of the system components pumped out in the previous to-o«-eekc Has the system received normal:lo's in the previous Mo«-eel:period? :ave lane volumes of:rater been introduced to the system recently or as;.art oft?is inspection ' � .%ere as built laps of t,'le syste_ tt ? -, - -a - -p _ .� obtai�za and exarmnzo. (if_i:ey u�erz r_o: _valablz nose as Was the facility or d,velling inspected for signs of sev.-aQe back up? Was the site inspected for signs of break out Were all system components,excluding the SAS, located on site ? Were the septic tank m-anholes uncovered; open-d; and the irienor of the tank inspected_or the con iron of the/baffles or tees,material of constn c"or_;dimensions depth of liquid,depth of sludze ar_'depta}i of scum'' v Was the facility o«•�ner and occupants if different ftom o�-ner)provided iz� r,pt— — ( p 'th information on t.i�;_oiler I maintenance of subsurface sewage disposal systems 1 Thesize and location of the Soil Absorption System(SAS)on the sire has beer,determined based or.: Yes no / existing information.or exat_ule, a plan at me Board of Health. Determined in the field(if ar_y of the failure criteria related to Part Cis at issue apnro_inat on cfd.'srance is unacceptable) 1310 CM LR 1 5.302(3)(b)] } r I` s F: I Pare 6 of I i OFFICIAL INSPECTION FOR�kl—NOT FOR VOI,LTN-, TT ASSESSAFEITS S1f"RSURE_,CE S.EE-W7AC-E DISPOSAL SYSTEM U SPECTION F-0R:%1 PART C S 'STEM][FOR`IATIO Property Address: ti c'�✓P,� t v� Os`ner: �cn v hoN Date of inspection: FLO V CONDiTIONS RESIDEN TLAL Nu-nber of bedrooms desi`n : ( ) o�- luirber of bedrooms(actuaI): DESIGN flow based on 310 C--.%,P,15203 (for exanmle: 110 a-pd x_of bedrooms): Number of cul-rent residents: 0 Does re=_idence have a garbage gri-nd=r(yes or no): A Is 'laundry on a separate sewage system(yes or no):�� ;=fees separate inspectier rewired) Laundry system inspected(yes or no):� Seasonal use: (yes or a_c):/(/A Water meter readi_irs, if a*,albilelast 2 years usage(cpd)):_ Sump pump(yes or no): Last date of occupancy: CO-AZI-IERC1_'�!I--D STR.iAL Type of establishment: . Design flow(based on 310 CvIR 15.203): — «pd Basis of design flow(seatsipersons/seft,ec.):_ 1: Grease trap present(yes or no):— industriai waste holding tank present(yes or no):_ Non-sanitary waste discharged to the Tlkle 5 system.(yes or no): Water ineter readings; if available:_ Last date OI OCCL'pancy/use:_ OTHER(describe): GE`'ERAL D-FOR-AIATIO Pumping Records / Source or infonrlation: / � /10 G`__ �✓c�,� Was system pumped as part of the inspection(yes or 46):/t'/{9 If yes, volume pumped: gallons was quantity pumped determined? Reason for p mg: TIT OF SY STEM _Septic tans. distribution box. soil absorption system —Single cesspool Overflow cesspool _Privy Shared system(yes or no) (if yes, attach previous inspection records; if ary —irmovattye/Alternarive technology.Attach a copy of th? curiera operation and mal terlanc con` 1 a_ obtained from system o caner) Tight tank Attach a copy of the DEP approve i -Other(describe): Approximate are of all comp onen date)~stalled(i' o"; )and souse of :fe-radon: Were sewage odors detected:;-hen arrivin,at tho site(yes or r_o):, a Page 1, of 11 s �w ` OFFICIAL INSPECTIO FOR-1-I—SOT FOR VOLU1T-A-FR 'ASSESSME�\TS SUBSURFACF SENVAGR.DISPOSAL- SYSTEM INSPECTION Fop-:M PART C SYSTEM INIFOW14ATION(conur_ued) Property address: Owner: P70- Bate of Inspection: BUILDING SENVER(locate on site plan) Depth below grade: Materials of construction: vast iron _1-40 PVC other(e:tplain): Distance from private seater supply v ell or suction line: Comments(on condition of joLrits. enting,evidence oflezaage, etc.): SEPTIC T_ .NK: _i7ocaie or site plan) Depth below grade: 1 Material of construction: —concrete_r.etal fiberglass_polyet�ylene _other(explain) If tank is metal list age: Is age confirined by a Certificate of Cormliance(yes or no): (attach_a cop; of certificate) Dimensions: Sludge depth: _ o li Distance from top o sludge to bottom of outlet tee or baffle: Scum thickness: Distance from top of scum to top of outlet tee or baffle: ,Sc- Distance from bottom of scum to 00-Lt of outlet ee or baffle: AV Ho,,,,.�-ere dimensions determined: Ao-Q G5 C� �<e Comments(on pumping recommendations; inlet outlet tee or baffle condition;stz-scn_r_1 L t�arir., liquid 1: els as elated to outlet invert; evidence of/leakage./etc.): Z—t w �/,/ GREASE TRAP;N {locate on site plan) Depth below grade: Material ofconstructicn:_concrete_metal tibe-mass_IDolyethv lone ot_ner e (ex lain : P ) 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 (on pumping recornmendatlons, .nlet and oUtiet:ee or baffle condition.smuctural. ila as related to outlet invert; evidence of leakage, etc.): y i Pace S of 11 OFFICIAL INSPECTION FORINT— 'OT FOR VOEL T:RY ASSESS_ TENS t SUBSURFACE SEWAGE DISPOSAL SYSTE:NZINSPECTION FORAT P R-I- C SYSTE I/I1`�/dFORMATIO\tcomimi ued,) Property-Address: sC N Owner ��✓`'or, Date of Inspection: TIGHT or BOLDING TANK: X/ (tan'_ must be nu_r: d at time of inspecrion)(locate on. site plan) # € Depth below grade: Material of construction: concrete metal fbergzass _polyethyle.ne o lher(explain): Dimensions: Capacity: Uallons Design plow: sallons;'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 svaitches, etc.): DISTRIBUTION BOA:: � if_ sent must be opened (locate on site.plan) Depth of liquid level above outlet invert: l4e9,11✓"P 4 L Comments(note ifbox is level and distribution to outlets equal,any evidence of solids carryover, any evidence of 3 leakage into o out of box, e ) / PUNaP CHAMBI^:R: L(locate on site Plan) Pumps in worlking order(yes or no): �i Alarms in working order(yes or no): Comments (note condition oti pu:—,,p chambe-,condition of pumps and appurtenances; etc.): �t i. i c;,rn o ill III r 1 ,i i., Page 9 of 11 OFFICIAL 1-rSPFCTION FORAM—NOT FOR VOL N'�T R ASSESSMEI TS SUIBSI1RFACE" SEWAGE DISPOSAL .SYSTF1W INSPECTION FO:-!�3 PARi' C // SYSTEM I�' OW I ATION lean iris e d'� Propert -Address: 6a z JG a ki r/' 15" 067 6 ®/ }� Owner:SLL-tv7mu Date of inspection; SOIL ABSORPTION SYSTE=>I(SAS): (locate on Site plan,excavation not required) If SAS not located explain vvhy: TNrDe leaching pits,number:_ �✓ i �'�N$ Leaching chambers,number: leaching galleries.number:leaching trenches,number; length: leaching fields,number, dimensions:_ overflow cesspool_ number: innovative/alternative system Type/name of technoicRy: Conamems (note condition of soil;signs of hydraulic failure, level ofponduia, damp soil. condition of ve?eianon. Y' etc.): Tf CESSPOOLS: lt/ (cesspool must be purnped as par of inspection)(locate on She plan) Number and configuration: Depth—top of liquid to inlet invert: Depth of solids laver: Depth ofscum layer: Dimensions of cesspool: Materials of construction: Indication of 7round xaier inflow(yes or no): Comments (note condition of soil, s gr•s of hydraulic failure; level of ponding, conditon of vecetar_'oil. atc.): PRIVY: eooc-� ate or, site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,si.'ns of hydraulic failure, level of ponair_g ,Lditior•of e atio;;. d -` " T T i�1C� T� T T AS J'i"1 IC -S_L_ 1. SLLCli�i i�ia9`1—PART C Oi FOR -O L:4T_A.RA A'�S.E�•Oli h awn is;In ON Ah l .r'piF.x y F � i 3 i s MA r 135.1 . r t K i:s F x #i r i �:3 t #� s •x t r Y d c i s ! , t ,.a k+a�dC"Tx';'Y s ,�^S�t—..z+?...ac rf'' C 7�€....a�t ur '"e"' 3 PRY {'' Rrk .d� `kkt--�D - - 1 , � i I 1 I b. !! � I 1A9I� j ®r.3 , - jAl �` 6L t y I ' L Li ....-_._.� Estimated depth IC ground n ter _eet 1 I Please indicare (cl---ck) al' ^? -;�h �.a—r:%er :CQS L'seG iG ��icl"'"1ic. _n"' �" oil nd 'at1Cn: Obta-ined from system design plans on reCor.4.-It he:{eC, Care Ot desl2n- p'a e 1 t,v ed: Obsen,ed site(abutting urope.M-observation hole Fb'-ir'nLn !) 22C Gi Checked with local Board of Heait_r•-explain: Checked wli:i local excavators, ysra lets-(anach docum—zniarlo'_) i _=iCcessed i .CvS database-e:<pr2in: j jYou must/describe how you esrablished the NO ground«-iter elevation: I ivy/ [i Gi `IG ca �;� j ' G ✓r _ r1 G " yT � �t /�1��G S Gip �iGvw_ 3A? i?�GL✓ G; �a — r 1-7 (../r,�r) v-r/ GJ G''r �r�• > •S `��'7�2 i%C` �;���c_.,,.. —a,�If.— i i i j �/A, pn i J F COMMONWEALTH OF MASSACHUSETTS ti EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS a DEPARTMENT OF ENVIRONMENTAL PROTECTION 02�� 0 00 J Z-0 i TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 3 v o` JC 'I clNPv- 4 k/z5- Owner's Name: „t—�o,A�a S Owner's Address:— ,e �✓�hs ��H I=c,l r fit/ofy G T p Date of Inspection: atp O Name of Inspector:(please print)"a r4 /0Ise, Company Name: O—T',E-G 1-J Mailing Address: a px . /a a 0a 6�az Telephone Number:6 073 — Z14 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 perforrped 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 Se 15340 of Title 5(310 CMR 15.000). The system Passes Conditionally Passes z Needs Further Evaluation by the Local Approving Authority €.) Fails Inspector's Signature:- Date:- oZO O 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- /. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 Page 2 of i l OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A / CERTIFICATION (continued) Property Address: Owner: o, Date of Inspection: Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. Syst asses: 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: --,"e.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. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,exhibits substantial.infiltration or exfiltration or tank failure is imminent.System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: 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: The system required pumping more than 4 times a year due to broken or obstructed e .The system stem will( ) Y pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: Title G iRCTPI tlnH Rnrm 411 VIMA 2 f Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS F SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: cJ 10 OC se Owner: /"q ec Date of lnspec ion: �p C.�F�urther Evaluation is Required by the Board of Health: '" Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. y 1. System will pass unless Board of Health determines in accordance with 310 CVIl215.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: — Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public,Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. _ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. _ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well".Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform bacteria and-volatile organic compounds indicates that the well­isfree 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: 3 Page 4 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: C"I dc-�B►� �l/� /� GN✓1 S d /� ©� (� (F Owner: G'q Date of Inspechon: O 0 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No/' _ I/ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or <logged SAS or cesspool Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or /cesspool ✓ kquid depth in cesspool is less than 6"below invert or available volume is less than'/z day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number Ftimes pumped . _ y portion of the SAS,cesspool or privy is below high ground water elevation- Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ./ portion of a cesspool or privy is within a Zone 1 of a public well. y portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To 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. Talo i Tnenontinn Rnrm Ai/7 1;/7nnh 4 f Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: A;- 5C ,, Owner: 0' Date of Inspection" dol 04 Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes o Pumping information was provided by the owner,occupant,or Board of Health Were any of the system components pumped out in the previous two weeks? Vo Has the system received normal flows in the previous two week period . Have large volumes of water been introduced to the system recently or as part of this inspection? ✓ Were as built plans of the system obtained and examined?(If they were not available note as N/A) Was the facility or dwelling inspected for signs of sewage back up? Was the site inspected for signs of break out? Were all,system components, excluding the SAS,located on site? ✓ — Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the bat s or tees, material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no / —/Existing information.For example,a plan at the Board of Health. ://_ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)] Title S fnencrtinn Anrm All;11)O n 5 Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 0� sC '41/� Owner: ti Date of Inspection: p 0 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): Number of bedrooms(actual): oZ DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): Number of current residents:' 0 Does residence have a garbage grinder(yes or no):/j/J Is laundry on a separate sewage system(xxe-s_or no :i!/0 [if yes separate inspection required] Laundry system inspected(yes or no): /vim Seasonal use: (yes or no): Pf Water meter readings, if avail9ble(last 2 years usage(gpd)): Sump pump(yes or no): Last date of occupancy. y/ice ' COMMERCIALANDUST�RIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sg8(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: �✓ �aj�2 of ''� ��S p r✓ � Was system pumped as part of the inspection(yes or no): /!ice If yes,volume pumped: gallons--How was quantity pumped determined? Reason for pumping: OF SYSTEM _Septic tank,distribution box,soil absorption system _Single cesspool _Overflow cesspool _Privy Shared system(yes or no)(if yes,attach previous inspection records,if any) -,Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) _Tight tank _Attach a copy of the DEP approval _Other(describe): Approximate age of all components,date installed(if known)and source of information: Were sewage odors detected when arriving at the site(yes or no): / Title S Incncertinn P—M All VIAn I 6 Page 7 of i l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM IN/FORMATION(continued)VC,p Property Address: 3 st!„� Owner: i9cwas Date of Inspection: d o 016 BUILDING SEWER(locate on site plan) Depth below grade: �J Materials of construction:_ ast iron —4-6C_other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK:_(�te on site plan) Depth below grade: Material of construction:_ o.�c�ncrete_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) i Dimensions: X Sludge depth: 02 ' Distance from top of sludge to bottom of outlet tee or baffle: o2g Scum thickness: 0 Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom gf outlet tee or baffle: How were dimensions determined: �o/e 2cr�, vi Comments(on pumping recommendations,inlet and outlKtee or baffle condition,structural integrity,liquid levels as re ted to outlet invert,evid nce of leaks e,a c.): �►✓"r l✓t s�o dI ePGCca GI fs T + Ole, G y!s/ G L' �/✓1 L C, OH z �� /vi GREASE TRAP:&(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(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): Titlo Incnortinn Gnrm ail�nnnn 7 Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORIN�I PART C 11 SYSTEM INFORMATION(continued) Property Address: /� vt n o QoL 6 41 Owner: PC-1 a f Date of Inspection: d o 0 TIGHT or HOLDING TANK: �(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: (`� if present must be opened(locate on site plan) ) P ) Depth of liquid level above outlet invert: ✓0/i/'?A Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover, any evidence of leakage ' o or out of box, jtc..): O p [� PUMP CHAMBER:Zlocate 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.): Tirlo ; Tncr�or*inn Rnrrr� l.�T;nnnn 8 ' Page 9 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 6,1 �� d JP, G�N n 1L Bpi��f� Owner: �a q Date of Inspec n: ao 0� SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why: Typeleaching pits,number: -49 ( J ( J i0 1-2-� leaching chambers,number: ' leaching galleries,number: / del 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.): / / '�Ovte �Nd SOi CLOG CZ 0-1 C�' a�n Lj CESSPOOLS: /l/ (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: /f/ (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.): Title C Tnenuntinn Trnrm�;i cnnnn 9 Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C - SYSTEM INFORMATION(continued) Property Address: 0 CIO Ni pp264t> Owner: ��i/>�4�_ Date of Inspe— chop o 164 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. F�ow� O � � y 1 T,tlo G Inencrt nn Gnrm�ii:i�nnn 10 Page 11 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM/INFORMATION(continued) Property Address: c') /11? Owner: /" Date of Inspection: do 0-6 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water S'9 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) TO F Accessed USGS database-explain: You must d cribe how you established the high round water elevation: // ��O � O / n� (/Z �- prn ,GA{//�)TO// .�I/•.� / /f�?. 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OF BEDROOMS PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED.: Yes No -- �� 'rill ti i i ASSESSORS MAP NO: -172 1; ., PARCEL NO: C FIms...�...... ...0.`........ THE COMMONWEALTH OF MASSACHUSETTS APPROVED BOAR® OF HEALTH Cpnservation Department _ TOWN OF BARNSTABLE JOG swicl V irtt i for 11ispusa1 Vorks Toustrurtinn V amit Application.is hereby made,for,a. Permit to Construct ( ) or.Repair M an Individual Sewage Disposal System at: 362—Scudder Ave H,rannis .... ......... ..... -----•--•---........------•----.....-----•--•-----•---------•------....--•--------............--•- Lpcation-Address or Lot No. Pappas W J.P.Macomber Jr.Owner Address Installer Address UType of Buildig Size Lot............................Sq. feet .•t Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) a Other—T e of Building No. of ersons____________________________ Showers 0.ai YP g ---------------------------- P ( ) Cafeteria ( ) dOther fixtures ------------------------•-------------------•---•-----•-----------•--•---•--------•--- W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. W Septic Tank—Liquid capacity............gallons Length................ Width................ Diameter---------------- Depth................ x Disposal Trench—No_____________________ Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z _ Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 44 Test Pit No. 2................minutes per inch Depth of.Test Pit--- ................ Depth to ground water........................ W •------•-••--•---•---------------------------------•---•-----------•--•---------.....••••---•-------......................................................... 0 Description of Soil- ----- --------------------------------------------------------------------------------------- U --------•------•--•---------••--•----•••-----•-------•----• •-•••-------------•-•---------•--•-••----------•--------------------••-•----•-----•---•-••---------------------.......-----._...__.._.. W - -------•----------------•------•---•-----•--•---•-••------• ------------------._...---------------------------------------------•------------••------------------------------...•-••----•----•--- U Nature of Repairs or Alterations—Answer he a licable............................................................................................... 1-1�J0 r)allon---tank.---3---infid�,trapCpors---•--------------------------------------•-------•---------..-.-----------------------•--•---..._. 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 Comp"a ce has been ssued by the Par f health. Signed . .... .... ... � . ..-............................ .... /3V"'9_2........... Date Application Approved By .............. - ------------------------- ..� .g'..`� ,:u"-1,:, - Date Application Disapp`toved for the following reasons- --------------- -------------------------------------------------------- ----------------...................................... ........................................................... -- ------------------------------------------- ------------ ------------------------------............................................... ......................................- : PermitNo. ©�..v......�.�. ................ Issued ............................................................ - Date 7,$1 30.00 THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH I TOWN OF BARNSTABLE IV iratilan for 11iipuiia1 Marks Cfontitrnrtinn Famit Application is hereby made for a Permit to Construct ( ) or Repair (X� an Individual Sewage Disposal System at: ..362 Scudder Ave Hyannis ..... .••. ....... ---.......... ..... ............ Location-Address or Lot No. Pappas aJ.P.Macomber Jr.Owner Address Installer Address d Type of Build' g Size Lot............................Sq. feet V Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )U aOther—Type of Building ____-_•_____________________ No. of persons............._-------------- Showers ( ) — Cafeteria ( ) dOther fixtures ------------------------------•-----------------------•------------------------------•----••------------...---•--...----------------•............... W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. W x Septic Tank—Li uid ca acit ............gallons Length................ Width................ Diameter__._ _--_------ Depth................ Disposal Trench-No. ................ Width.................... Total Length.................... Total leachingarea....................s . ft. Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date......................--•-•----------- ,� Test Pit No. 1----------------minutes per inch Depth of Test Pit.................... Depth to ground water........................ 44 Test Pit No. 2................minutes per inch Depth of.Test Pit...................,Depth-to ground water........................ P4 •-----•----------------------------------------------------------=.......................................................................................... 0lt4 Description of Soil -�•-•------•-------------------------------- �-----------------•----------- Sana & rave v .............................................. .......................................--•----------•-------------------•--•------------------------- .................................................. W ------------•------------ --••---••--------------------------------- ----••------------------•----------------------------•-•...---------------------------------------------•----------------.-•---- U Nature of Repairs or Alterations—Answer ` hen applicable................................................................................................ 1-1000 gallon tank. 3 1-- i tra hors --- -------------------•----------------•-••--•.....---- 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 Complia ce has been 'ssued by the board of health. g ��Signed _ 6�3��92 -- --- - ---------------6130192 AL Application Approved BY ¢.. --M�i ' ..... — Date Application Disapproved for the following reasons- ------------------------------------------------------------------------------------------------------------------------------------- -------- -- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ................----------------------- Date PermitNo. - _------------_-- Issued .......................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Cer#ifirate of C ontylianre THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (XXX�E by J.P.Macomber Jr. -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- at ----362 Scudder Ave Hyannis Installer ----------------------------- -- ------------------------------------- ----------------------------------------------------------------------------------------------------- ------------------------------------------ ---------- has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in the application for Disposal Works Construction Permit No. .. .r2..-.-r�..1 .......... dated ................................................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE..--................................ ' - ---- ---- 'Inspector ..........--.....-..... l.......... ......................................... THE COMMONWEALTH OF MASSACHUSETTS - BOARD OF HEALTH TOWN OF BARNSTABLE $ 30.00 No._ ..L.2 FEE........................ DWpostt1 Works Ton#rnr�ivit an it J.P.Macomber Jr. Permissionis hereby granted---------- ---------------------•--•-----------•-------------•-------..._...------------.......---------...---------•••----...... to Construct (Sc)aotrdRepakry X)I'An Ann:iSdual Sewage Disposal System atNo............................................................................................................................................................................................... Street pp as shown on the application for Disposal Works Construction Permit No. :).? .._ Dated.......................................... ................................. ............................................................... DATE.................Z-=J� ............................ Board of Health FORM 36508 HOBBS Q WARREN.INC..PUBLISHERS TOWN OF BARNSTABLE • G ' .LOCATION z SGJdr,,- v-4-- e— SEWAGE #" - VILLAGE j'l(�cerr,A 1 I � ASSESSOR'S MAP LOT INSTALLER'S NAME & .PHONE NO. /�,�� -�+�c 7?^ 4 e I C- SEPTIC TANK CAPACITY f,(7o0ja) LEACHING FACILIY:(type)_ CSY,I (size) NO. OF BEDROOMS ` �, PRIVATE WELL QR PUBLIC WATER BUILDER OR OWNER DATE'PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes . No