HomeMy WebLinkAbout0046 SECOND AVENUE (HYANNIS) - Health 46 Second Avenue
Hyannis P
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LOCATION SEWAGE PERMIT NO.
L/( SACcad
VILLAGE II
G(no aa- me
I N S T A lL 11 A M E & ADDRESS
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8 U I L D E R OR OWNER
DATE PERMIT ISSUED
DAT E C, 0MPLIANCE ISSUED
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THE COMMONWEALTH OF MASSACHUSETTS
BOAR® PF H�EA TH
� .............OF.................. . ....
Applirtaffou for Dispati al Workii Tomitrurtiun rautit
Application is hereby made for a Permit to Construct ( ) or Repair (�n Individual Sewage Disposal
System at:
..__..:. . .... - ..
--- Location-Address -•-•-- - --•- ------•-----•or Lot No.
... .......
......................•-••--_•---••----•-_-•_---.. ..._.__...-----_-.....••_•-••_--_•--_-_^•---...-•----
I -ner Address
a '✓O�.r......._ f�.
Installer Address
Type of Building Size Lot............................Sq. feet
►.� Dwelling o. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
Other—T e of Building No. of ersons____________________________ Showers
a YP g --------•------------------- P (---)--- Cafeteria ( )
Otherfixtures ------------------------------------------------------•-•--•--•--•----------•-------------•----------•-•---•. ------•---
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 ( )
Percolation Test Results Performed by.......................................................................... Date--- ....................................
a
Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water------------------------
Gi, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
Ra711• ---------- •_-• -....
ODescription of Soil------•--- .....-�••-• �i -----=-----------------------------•--------------------------------------•---
x
W ----•-•--------------•------------•---•---------------------------------•-------------•-•-••--••--••----------•--------
20
V Nature of Repairs or Alterations—Answer when applicable...........:.....................�-...---.------._.._----_.....___--_.__._______________..
------------------------------------------------•--•----•-----------------------------_..__........-•--•--•-•••-•-•-----••-------••---•-------•-•--•---------•-----------••--••--•-•--•-•._.._.......-•-
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 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 by the boar of he lth.
Signed_ ��� G }= - -•------�
Date,
Application Approved BY = ............................... -•-••-----••1 G !......
Date
Application Disapproved for the following reasons----------------------------------------------------------------------------------•---•-•--•••--•••--••........_
--------------------•--•---•-----------------------•-----------------•---....-----------.....---------------------------.------------------------•----------------------...............................
Date
Permit No..----- �� - 7 ------------------ Issued
Date
i
THE COMMONWEALTH OF MASSACHUSETTS
BOARD ,pja� E HEA TH
.. .Appliration for Disposal Works Tonstrurtion ramit
Application is hereby made for a Permit to Construct ( ) or Repair an Individual Sewage Disposal
System at: t;'
...... a..�.s ' .. , k:_.....!_ ......................................................................-...................-_-----
- -
r Location-Address or Lot No.
........a ..l ."�. - •-•............................
�Owner �� - Address
a ........... , ..
Installer Address
Type of Building Size Lot.................... .....Sq. feet
�-, Dwelling e0of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
aOther—Type
of Building ............................ No. of persons............................. Showers ( ) — Cafeteria ( )
d Other fixtures .........................
Design Flow............................................gallons per person"per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity............gallons Length.,.............. Width................ Diameter---------------- Depth................
x Disposal Trench—No...:................. Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No..................... Diameter..................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
a 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........................
......... --• ------------------
-------------
----
--------------
•.........
--------
•-----------
•............
O Description of Soil......... .......... d," -
-•--•
.......................... •-•-•••••----•-•--•--•--•---•---•---•--•-•-•-•---•---•-••---.------------------
U Nature of Repairs or Alterations—Answer when applicable_..__. ............................'t
----------------------------------------------------------------------------------------------------------------•-----------------------------------------------------------....--------.---------------
Agreement:
The undersigned agrees, to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 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 by the boand of health.
Signed. �2" '' Y=-"•- .._
.�
Application Approved B t
Date
Application Disapproved for the f ollowiny reasons .--•--------------------------------------------------•------------------------------------------......---_...._
-•---•-•.......•••--•-------------•--•-...--•-------•-•------•---•------....-••-------•-•------••---------------------...-----------------------------------------------------------------------
Date
PermitNo........ . .................................� Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS r
BOARD OF HEALTH
.' ��% aC /.tom yJ
`d%!.....OF......f�s`.'...... gad . �ri� .::
Tre ifiratr of Toutpliaurr
THIS I$ TO CERTIFY hat the Individual Sewage Disposal System constructed ( ) or Repaired (a ,
by-- %............. x s Yt ¢'� -.............. ' a ........................................................................
•
at. b °. '�`' = %------------= 'f %r,� ,�./ ' - •--------------------------------------------
has been installed,in accordance with the provisions of TITLE" , 5 of The State Sanitary Code as described in the
application for Disposal VVbrks Construction Permit No.......................................... dated-,..............................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION 'SATISFACTORY.
DATE........................ �t------------------------------------------------ Inspector.........................------------------•---.........•--._............_......
THE COMMONWEALTH OF MASSACHUSETTS
BOARD PF HEALTH
EE .......
Permission is hereby granted ----
f( ) `' � � g�c p ,�Y yam ,
to Constr� r Repair an dividual Sewa Dis os stem
at No._--•-.. .__.._ ' - f _ •'`` f' ' ,�'
y
-
Street
as shown on the application for Disposal Works Construction Permit..................... D d...........................................
Board of Health
DATE ----------. '
FORM 1255 A. M. SULKIN. INC., BOSTON
)4-) �2-b 7
TROY WILLIAMS - 3kA
SEPTIC INSPECTIONS to
Certified by MA Department of Environmental Protection _ o, (508) 385-1300
19 Hummel Drive 1 1 I
South Dennis, MA 02660
COMMONWEALTH OF MASSACHUSEI
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
TITLE 5
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A RECEIVED
CERTIFICATION
Property Address: 46 2"d Avenue NJAY 0 6 2003
West Hyannisport,MA
Owner's Nam TOWN F BARNSTABLE
c: Rodney Greaves AL
TH DEFT.
Owner's Aeldres,. 1450 Lincoln Road,Suite 805
Miami Beach, FL 33139 0
Date of Inspection: . April 28,2003
Name of Inspector. Troy M. Williams
Company Name: Troy Williams Septic Inspections
Mailing Address: 19 Hummel Drive
South Dennis,MA 02660
Telephone Number: (508)385-1300
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. 1 am a DEP
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR .15.000). The sv;tem
✓ Passes
Conditionally Passes
Needs Further Evaluation by the Luca) Approving Author it)
Fails
Inspector's Signature: 1 Date: y/-78/63
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of i lealth or
DEP)within 30 days of completing this inspection. If the system it 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
Although system meets the minimum requirements set forth by the.Massachusetts Department of
Environmental Protection,certification Is not to be construed as a guarantee of future working condition
of system,piping or components. This Inspection represents the conditions of the system on the Date of
Inspection noted above.
""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 saute or different
conditions of use.
Title 5 Inspection Form 6/l5/2000 nape I or I I
Page 2 of I I
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 46 2nd Avenue
Owner: West Hyannisport,MA
Date of Inspection:Rodney Greaves
April 28,2003
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
/
_ 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 y Passes:
One or more system components as described in the"Conditional Pass"section n d to be replaced or
repaired. The system, upon completion of the replacement or repair,as approved by th oard of Health,will pass.
Answer yes. no or not determined(Y,N,ND)in the_ for the following state nts. If"not determined"please
explain.
The septic tank is metal and over 20 years old* or the septic tank hether metal or not)is structurally
unsound, exhibits substantial infiltration or'exfiltration or tank failure i imminent..System will pass inspection if the
existing tank is replaced with a complying septic tank as approved b the Board of Health.
•A metal septic tank will pass inspection if it is structurally sound of 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 ngh static water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken,settled or un en distribution box. System will pass inspection if(with
approval of Board of Health):
broken p' e(s)are replaced
obstru on is removed
distr' ution box is leveled or replaced
ND explain:
The system required pu ping more than 4 times a year due to broken or obstructed pipe(s).The system will
pass inspection if(with appr al of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain: .
'r ry y 1.a
J
` Page 3 of 1 I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address:
46 2nd Avenue
Owner: West Hyannisport,MA
Date of Igspectiou: Rodney Greaves
April 28,2003
C. Further Evaluation is Required by the Board of Health:
Conditions exist which require further evaluation by the Board of Health in order to determine if the system
is failing to protect public health, safety or the environment.
I. System will pass unless Board of Health determines in accordance with 310 CMR 15.303 (b)that the
system is not functioning in a manner which will protect public health,safety and the vironment:
— 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 rsh
2. System will fail unless the Board of Health (and Public Water upplier,if any)determines that the
system is functioning in a manner that protects the public heap ,safety and environment:
_ The system has a septic tank and soil absorption sys m(SAS)and the SAS is within 100 feet of a
surface eater supply or tributary to a surface water su ly.
The system has a septic tank and SAS and e SAS is within a "Lome 1 of a public water supply.
The system has a septic tank and SA and the SAS is "ithin 50 feet of a private water supply well.
The system has a septic tank a SAS and the SAS is less than 100 feet but 50 feet or more from a
private water supply well'*. Me od used to determine distance
"This system passes if th ell.water analysis, performed at a DEP certified laboratory, for coliform
bacteria and volatile or is compounds indicates that the well is free from pollution from that facility and
the presence of am is nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
failure criteria ar iggered.A copy of the analysis must be attached to this form.
3. Other:
;:
Page 4 of l l
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A '
CERTIFICATION(continued)
Property Address: 46 2id Avenue
West HyannispoM MA
Owner: Rodney Greaves
Date of Inspection: April 28,2003
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all inspections:
Yes No
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
clogged SAS or cesspool
,,j/A Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
✓ Liquid depth in cesspool is less than 6"below invert or available volume is less than%day flow
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number
of times pumped
✓ Any portion of the 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.
_✓ Any portion of a cesspool or privy is within a 'Zone I of a public well.
✓ Any portion of a cesspool or privy is within 50 feet of a private water supply well.
Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis. IThis 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.)
N0 (Yes/No)The system fails. 1 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 desi 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 ove)
yes no
_ the system is within 400 feet of a surface drinking ter supply
— the system is within 200 feet of a tributary t surface drinking water supply
the system is located in a nitrogen s ttive area(interim Wellhead Protection Area—IWPA)or a mapped
.Zone II of a public water supply ell
If you have answered"yes"to any stion in Section E the system is considered a significant threat,or answered
"yes"in Section D above the lar systettt has failed.The owner or operator of any large system considered a
significant threat under Sect' E or failed under Section D shad upgrade the system in accordance with 310 CMR
15.3.4.The system own hould contact the,appropria[e regtonai office of the Department.
9.
4 ;.
Page 5 of I 1
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address:
46 2nd Avenue
Owner: West Hyannisport,MA
Date of Inspection: Rodney Greaves
April 28,2003
Check if the followine have been done.You mu$t indicate"yes"or"no"as to each of the followine•
Yes No
l'.:::,Ding information was provided by the owner. occupant,or Board of l h altl,
__._ ✓ Were any of the system components pumped out in the previous two weeks
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?
NIA. 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 '?
_ u0 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?
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)]
5 f.�.•
I
Page 6 of 11
OFFICIAL INSPECTION_FORM— NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address:
46 2°d Avenue
Owner: West HyannispoM MA
Date of inspection: Rodney Greaves
Apri128,2003 FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): Number of bedrooms(actual):J—
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): yI/y
Number of current residents: O+
Does residence have a garbage grinder(yes or no): 1't s- (A10
Is laundn on a se paraw sewage system c. o
) N> [if}'es separate inspection required]
Laundry system inspected(yes or no): v
Seasonal use: (yes or no): Ve S
Water meter readings, if available(last 2 years usage(gpd)): !J 14-0 3 = /o, y a� b 1 - o z.
Sump pump(yes or no): .vo
Last date of occupancy: Ci o y_ V s };
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): ___gpd
Basis of design flow(seats/persons/sgft,etc.):
Grease trap present(yes or no):—
Industrial waste holding tank present(yes or no):
Non-sanitary waste discharged to the Title 5 sys (yes or no): _
Water meter readings, if available: _
Last date of occupancy/use.-
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information: Rio I�� .,✓,. �t
Was system pumped as pan of the inspection(yes or no): AW
If yes,volume pumped: gallons-- How was quantity pumped determined?
Reason for pumping:
TYPE 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: y
Ss inA'A i < dr. 5 ' hc.l -4 �. L�-./-� �o +. --- d
/ 77 .s c.,t.. S a�f dlc
..J.., LOr�.p ):... — ci+
Were sewage odors detected when arriving at the site(yes or no): `
4
F '
6
Page 7 of 1 1
OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
46 2nd Avenue
Owner: West HyannispoM MA
Date of inspection: Rodney Greaves
April 28,2003
BUILDING SEWER(locate on site plan)
Depth belu�% grade: 181"L
Materials of construction: _cast iron /40 PVC ,/other(explaut):
Dkianc�r fron, private water supply well or suction line: Ad.o
Comments(on condition of joints,venting, evidence ul leakage,etc.):
S-o-t.t.,� I.L.<5 �..� '/R.� ;,_..._�,_z` ,i. s .J afu c;.1..�Fiv r•.�
SEPTIC TANK: locate on site._( plan)
Depth below grade:
Material of construction:_concrete_metal_fiberglass_polyethyle
—other(explain)
If tank is metal list age:_ Is age confirmed by a Certificate of Co Lance(yes or no):—(attach a copy of
certificate)
Dimensions:
Sludge depth: _
Distance from top of sludge to bottom of outlet tee or bd' e:
Scum thickness:
Distance from top of scum to top of outlet tee or 11c:
Distance from bottom of scum to bottom of o et tee or baffle
How were dimensions determined:
Comments(on pumping recommendat' s, inlet and outlet tee or baffle condition,structural integrity, liquid levels
as related to outlet invert,evidence leakage, etc.):
GREASE TRAP:_(locate on site plan)
Depth below grade:—
Material of construction:_concrete_metal_fiberglass____polye ene_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 out let tee affle:
Date of last pumping:
Comments(on pumping recommendations,in and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leak e,etc.):
4..��.„3;p..
7
' Page 8 of I l
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
46 2°d Avenue
Owner: West Hyannisport,MA
Date of Inspection Rodney Greaves
April 28,2003
TIGHT or HOLDING TANK: (tank must be pumped at time of inspe on)(locate on site plan)
Depth below grade:
Material of construction: concrete - metal fiberglass olyethylene other(explain):
Dimensions:
Capacity: gallons
Design Flue: gallons/day
Alarm present(yes or no):
Alarm level: Alarm in working or (yes or no):
Date of last pumping:
Comments(condition of alarm and fl switches,etc.):
DISTRIBUTION BOX: (if present must be opened)(locate on s' plan)
Depth of liquid level above outlet invert:
Comments(note if box is level and distribution to outlets a al,any evidence of solids carrygver. any evidence of
leakage into or out of box, etc.):
PUMP CHAMBER: (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 o mps and appurtenances,etc.):
rJ x.
8
Page 9 of 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
46 2°d Avenue
Owner: West HyannispoM MA
Date of Inspection: Rodney Greaves
April 28,2003
SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required)
If SAS not located explain wh):
Type
�leaching pits.number: i" 5"319 "t,�w4i^ �; ► �+'f � vZ 'sNh�.
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.):
p. t y,:r,.;_. u�—f....� ., • Lc.�,�t., I�•T (...��. s ,.,A y �V ti w ✓i f
T ✓y v c. S ✓J t '-
—�r—i.�.�2L L... ._�T�.f.`^ :� Gi/: cX«, c_e— o.r—� A.-s
CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration: oi,, �'•� Lt s_��av _l_.
Depth-top of liquid to inlet invert:
Depth of solids layer: 1,
Depth of scum layer. _ar�•v;_
Dimensions of cesspool: y*x�-
Materials of construction: C- -s s,00,, ( /-I—k
Indication of groundwater inflow js or no): A,(u
Comments(note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation,etc.):
c v _ .J —✓� / Nu 1
�✓6✓ ; c
LJ/✓ A. irlo P4 Zvi s 6, ✓ r r. �—cc o i— wc�✓✓c�..`+y o+. 2 Avrt
W'^ ..}�-J�. ) o GS 1,Ov➢ S u v -' <. S t'Yu�'�/ro.. i ti f C�,✓" �y o,JL' c.�S f u G S L. ...
PRIVY: (locate on site plan) 7 �'''"
Cu
Materials of construction:
Dimensions:
Depth of solids:
Comments(note condition of soil,signs of hydrau failure, level of ponding,condition of vegetation,etc.):
zz f �n
'Bd' r SCsrF
9 ,'r.
Page 10 of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 46 2°d Avenue
West HyannispoM MA
Owner: Rodney Greaves
Date of Inspection: April 28,2003
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.
L�w�fit
1 �
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28
s.z
L
L„I I'� 2�S'TL M•� .
3
... YA f
1:0
Page 1 I of 11
OFFICIAL INSPECTION FORM— NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
46 2°d Avenue
Owner: West Hyannisport,MA
Date of Inspection: Rodney Greaves
SITE EXAM April 28,2003
Slope
Surface water
Check cellar ✓
Shallow wells
Estimated depth to ground water R*7 -feet
— Adjusted high ground water elevation — feet
Please indicate(check)all methods used to determine the high ground cater 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: , _ems .
Checked with local excavators, installers-(attach documentation)
t/ Accessed USGS database-explain: -9 2. I 1 Y
You must describe how you established the high ground water elevation:
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This report has been prepared and the system inspected.as of the date of inspection. This report is not a ;
warranty or guarantee that the system will function properly in the future. There have been no warranties or
guarantees,either expressed,written orimplied, relating to the system,the inspection and/or this report. {
II ,
• ' 1t #�
_ COMMONWEALTH OF MASSACHUSETTSF ® �^
"- - EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRSSEp
DEPARTMENT OF ENVIRONMENTAL PROTECTION Or ��
ONE WINTER STREET,BOSTON,MA 02108 (617)292-5500 `� vim' r
TRUI71'p �O�` --
Secretary
ARGEO PAUL CELLUCCI DAVID B. STRUHS
Governor Commissioner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
Property Address: 46 2°d Avenue
W. Hyannisport, MA 02647
Property Owner: Ella Gardner
Date of Inspection: 8/22/00
Name of Inspector: (Please Print) Paul G. Jenner
I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000)
Company Name: PAUL G. JENNER ASSOCIATES, Inc.
Mailing Address: 31 RILEY A VENUE
Telephone Number: EAST WEYMOUTH, MA 02189
(781) 337-8617 Fax (781) 337-1802
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is
true, accurate and complete as of the time of inspection.The inspection was performed based on my training and experience
in the proper function and maintenance of on-site sewage disposal systems.The system:
X Passes
Conditionally Pass
Needs Further aluatio By the A j oving Authority
Fails
Inspector's Signature: Date: September 4,2000
The System Inspector shall submit a copy of this i pe report to the Approving Authority(Board of Health or DEP)
within thirty(30)days of completing this inspecti the system is a shared system or has a design flow of 10,000 gpd or
greater, the inspector and the system owner shal 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
PAUL G. JENNER. ASSOCIATES (Revised 9/2/98) -Page 1
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 46 2°d Avenue
W. Hyannisport, MA 02647
Property Owner: Ella Gardner
Date of Inspection: 8/22/00
INSPECTION SUMMARY: Check A,B,C,or D:
A. SYSTEM PASSES: YES
X I have not found any information within indicates that any of the failure conditions described in 310 CMR 15.303
exist. Any failure criteria not evaluated are indicated below.
B. SYSTEM CONDITIONALLY PASSES: 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.
Indicate yes,no,or not determined(Y,N,or ND). Describe basis of determination in all instances.If"not determined",
explain why not.
The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a
Certificate of Compliance(attached)indicating that the tank was installed twenty(20)years prior to the
date of the inspection;or the septic tank,whether or not metal, is cracked,structurally unsound,shows
substantial infiltration or exfiltration,or tank failure is imminent. The system will pass inspection if the
existing septic tank is replaced with a conforming septic tank as approved by the Board of Health.
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
PAUL G. JENNER ASSOCIATES (Revised 9/2/98) -Page 2
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 46 2°d Avenue
W. Hyannisport, MA 02647
Property Owner: Ella Gardner
Date of Inspection: 8/22/00
C] FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: NO
Conditions exist which require further evaluation by the Board of Health in order to determine if the system is
failing to protect the public health,safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH
310 CMR 15.303 (1)(b) THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH
WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
Cesspool or privy is within 50 feet of 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 THE PUBLIC WATER SUPPLIER,
IF ANY)DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT
THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT.
The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet to a surface
water supply or tributary to a surface water supply.
The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water
supply well.
The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water
supply well.
The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or
more from a private water supply well,unless a well water analysis for coliform bacteria and volatile
organic compounds indicates that the well is free from pollution from that facility and the presence of
ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm.Method used to determine distance
(approximation not valid).
3) OTHER:
II
P'AUL G. JENNER ASSO CUTES (Revised 9/2/98) -Page 3
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 46 2ad Avenue
W. Hyannisport, MA 02647
Property Owner: Ella Gardner
Date of Inspection: 8/22/00
D] SYSTEM FAILS: NO
You must indicate either"Yes"or"No"to each of the following:
I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303.The basis
for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to
correct the failure.
Yes No
Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool.
Discharge or ponding of effluent to the surface of the ground waters due to an overloaded or clogged SAS or cesspool.
Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow.
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped:
Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation.
Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
Any portion of a cesspool or privy is within a Zone I of a public well.
Any portion of a cesspool or privy is within 50 feet of a private water supply well.
Any portion of a cesspool or privy is less than 100 fleet but greater than 50 feet from a private water supply well with no
acceptable water quality analysis.If the well has been analyzed to be acceptable,attach copy of well water analysis for
coliform bacteria,volatile organic compounds,ammonia nitrogen and nitrate nitrogen.
El LARGE SYSTEM FAILS: N/A
You must indicate either"Yes"or"No"to each of the following:
The following criteria apply to large systems in addition to the above criteria:
The system serves a facility with a design flow of system is 10,000 gpd or greater(Large System)and the system is a
significant threat to public health and safety and the environment because one or moreof the following conditions exist:
Yes No
_ _ The system is within 400 feet of a surface drinking water supply
_ _ The system is within 200 feet of a tributary to a surface drinking water supply
_ _ The system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone II of
public water supply well
The owner or operator of any such system shall bring the system in accordance with 310 CMR 15.304(2).Please consult the
local regional office of the Department for further information.
P'AUL G. JEIiNER ASSOCIATES (Revised 9/2/98) -Page 4
f
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 46 2°d Avenue
W. Hyannisport, MA 02647
Property Owner: Ella Gardner
Date of Inspection: 8/22/00
Check if the following have been done: You must indicate either"Yes"or"No"as to each of the following:
Yes No
Y _ Pumping information was requested of the owner,occupant,and Board of Health.
Y _ 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 volumesof water have not been introduced into the
system recently or as part of this inspection.
N/A As built plans have been obtained and examined. Note if they are not available with N/A.
Y _ The facility or dwelling was inspected for signs of sewage back-up.
Y _ The system does not receive non-sanitary or industrial waste flow.
Y _ The site was inspected for signs of breakout.
Y _ All system components,excluding the Soil Absorption System,have been located on the site.
Y _ The septic tank manholes were uncovered,opened,and the interior of the 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:
Y _ Existing information.Ex. Plan at B.O.H.
N Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance
is unacceptable) [15.302(3)(b)]
Y _ The facility owner(and occupants, if different from owner)were provided with information on the proper
maintenance of Sub-Surface Disposal System.
PAUL G. JENNER ASSOCIATES (Revised 9/2/98) -Page 5
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 46 2°d Avenue
W. Hyannisport, MA 02647
Property Owner: Ella Gardner
Date of Inspection: 8/22/00
FLOW CONDITIONS
RESIDENTIAL: YES
Design flow 110 g.p.d./bedroom
Number of bedrooms(design): 4 Number of bedrooms(actual): 4
Total DESIGN flow: 440
Number of current residents: 0
Garbage grinder(yes or no): No
Laundry(separate system)(yes or no):No If yes,separate inspection required
Laundry system inspected(yes or no) N/A
Seasonal use(yes or no): Yes
Water meter readings,if available(last two(2)year usage(gpd):N/A
Sump Pump(yes of no):No
Last date of occupancy: 6/97/Owner
COMMERCIAL/INDUSTRIAL: NO
Type of establishment:
Design flow: gallons/day(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 information)None
System pumped as part of inspection(yes or no) NO If yes,volume pumped gallons
Reason for not pumping: Both pits empty at time of inspection
TYPE OF SYSTEM:
_ Septic tank/distribution box/soil absorption system
X Single cesspool
X Overflow cesspool
Privy
No Shared system(yes or no).If yes,attach previous inspection records,if any.
I/A Technology etc.Attach copy of up to date operation and maintenance contract
Tight Tank Copy of DEP Approval
Other
APPROXIMATE AGE of all components,date installed(if known)and source of information:55/84BOH records
Sewage odors detected when arriving at the site: (yes or no) NO
lPAUL G. JENNER ASSOCIATES (Revised 9/2/98) -Page 6
r
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 46 2°d Avenue
W. Hyannisport, MA 02647
Property Owner: Ella Gardner
Date of Inspection: 8/22/00
BUILDING SEWER
(Locate on site plan)
Depth below grade: 1511
Material of construction: X cast iron_40 pvc _ other(explain)
Distance from private water supply well or suction line:N/A
Diameter:4"
Comments:(condition of joints,venting,evidence of leakage,etc.)No abnormal signs observed
SEPTIC TANK: NO
(Locate on Site Plan)
Depth below grade:
Material of Construction: _ Concrete _ Metal _ Fiberglass _ Polyethylene _ Other(explain):
If tank is metal,list age _ Is age confirmed by Certificate of Compliance _ (Yes/No)
Dimensions:
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
How dimensions were determined:
Comments(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to
outlet invert, structural integrity, evidence of leakage, etc)
GREASE TRAP: NO
(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(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to
outlet invert, structural integrity, evidence of leakage, etc):
lPAUL G. JEll NER ASSOCIATES (Revised 9/2/98) -Page 7
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 46 2°d Avenue
W. Hyannisport, MA 02647
Property Owner: Ella Gardner
Date of Inspection: 8/22/00
TIGHT OR HOLDING TANK: NO (Tank must be pumped prior to,or 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:
Alarm level: Alarm in working order: (Yes/No)
Date of previous pumping:
Comments(condition of inlet tee, condition of alarm andfloat switches, etc.)
DISTRIBUTION BOX: NO
(Locate on Site Plan)
Depth of liquid level above outlet invert:
Comments(note if level and distribution is equal evidence of solids carryover, evidence of leakage into or out of box, etc.)
PUMP CHAMBER: NO
(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)
IPAUL G. JENNER ASSOCIATES (Revised 9/2/98) -Page 8
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 46 2°d Avenue
W. Hyannisport, MA 02647
Property Owner: Ella Gardner
Date of Inspection: 8/22/00
SOIL ABSORPTION SYSTEM(SAS): YES
(locate on site plan, if possible;excavation not required, but may be approximated by non-intrusive methods)
If not located,explain:
TYPE:
leaching pits and number
leaching chambers and number
leaching galleries and number
leaching trenches,number,length
leaching fields,number,dimensions
X overflow cesspool,number J<
Alternative system:
Name of Technology:
Comments(note condition ofsoil,signs ofhydraulicfailure, level ofponding, condition ofvegetation,etc.)No abnormal signs
observed at time of inspection, no ponding, abnormal vegetation or hydraulic failure observed.
CESSPOOLS: YES
(Locate on Site Plan):
number and configuration: 1-Round
depth-top of liquid to inlet invert:0
depth of solids layer: 0
depth of scum layer: 0
dimensions of cesspool: 6' x 6'
materials of construction: Block
indication of groundwater: No
inflow(cesspool must be pumped as part of inspection): None
Comments(note condition of soil,signs of hydraulic failure,level ofponding, condition of vegetation,etc.)
No abnormal signs observed at time of inspection
PRIVY: NO
(Locate on Site Plan)
materials of construction
dimensions
depth of solids
Comments(note condition of soil,signs of hydraulic failure, level ofponding, condition of vegetation,etc.):
]PAUL G. JEl\NEli ASSOCIATES (Revised 9/2/98) -Page 9
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 46 2°d Avenue
W. Hyannisport, MA 02647
Property Owner: Ella Gardner
Date of Inspection: 8/22/00
SKETCH OF SEWAGE DISPOSAL SYSTEM:
(include ties to at least two permanent references landmarks or benchmarks)
(locate all wells within 100)(Locate where public water supply comes into house)
Ae
IPAUL G. JENNER ASSOCIATES (Revised 9/2/98) -Page 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 46 2°d Avenue
W. Hyannisport, MA 02647
Property Owner: Ella Gardner
Date of Inspection: 8/22/00
DEPTH TO GROUNDWATER
NRCS Report name:
Soil Type:
Typical depth to groundwater:
USGS Date website visited:
Observation Wells checked:
Groundwater depth: Shallow Moderate Deep
SITE EXAM Slope none
Surface water none
Check Cellar dry
Shallow wells n/a
Estimated Depth to Groundwater > 6 Feet
Please indicate all the methods used to determine High Groundwater Elevation:
_Obtained from Design Plans on record
X Observation of Site(Abutting property,observation hole,basement sump,etc.)
Determine it from local conditions
_Check with local Board of Health
_Check FEMA Maps
Check pumping records
_Check local excavators,installers
Use USGS Data
Describe in your own words how you established the High Groundwater Elevation. Must be completed)
Both pits empty at time of inspection. There was no indications of any moisture. Bottom of pit
prodded with shovel with no signs of any water.
IPAUL G. JENNER ASSOCIATES (Revised 9/2/98) -Page 11
t ATTENTION
THIS REPORT DOES , NOT CONSTITUTE A
GUARANTEE, WARRANTY OR REPRESENTATION
THAT THE SYSTEM WILL CONTINUE TO OPERATE
AND FUNCTION IN GOOD WORKING ORDER. THIS
REPORT IS SOLELY LIMITED TO REPORTING
WHETHER THE SYSTEM MEETS THE CRITERIA SET
FORTH IN 310 CMR 15.303; THERE MA Y BE LOCAL
LAWS OR REG ULA TIOl ijS APPLICABLE TO THE
SYSTEM WHICH THIS REPORT DOES NOT ADDRESS.
THIS REPORT CONSTITUTES THE ENTIRE REPORT.
THIS REPORT WAS PREPARED ON BEHALF OF THE
PERSON NAMED ON THE FRONT PAGE OF THE
REPORT AND THE ONLY PERSONA UTHORIZED TO
RELY UPON THE CONTENTS OF THIS REPORT IS
SAID PERSON; ANY MATTERS WHICH SAID PERSON
INTENDS TO RELY UPON MUST BE CONTAINED IN
WRITING IN THIS REPORT AND SAID PERSON
ACKNOWLEDGES THAT THEY ARE NOT RELYING
UPON ANY ORAL COMMUNICATIONS OR
DISCUSSIONS CONCERNING THIS REPORT.
IPAUL G. JLNNLR ASSOCIATES (Revised 9/2/98) -Page 12
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