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HomeMy WebLinkAbout0102 SECOND AVENUE (HYANNIS) - Health 102.Second Aver e Hyannis P S' A = 267 005 I i TOWN OF BARNSTABLE LOCAN IO a P h d PV SEWAGE # VILLAGE A Vl/ i S %DOR4- ASSESSOR'S MAP &LOT INSTALLER'S NAME&PHONE NO.- I'PI7 OCOtnber S-On Q-7C_ SEPTIC TANK CAPACITY lS O O LEACHING FACILITY: (type)3 err (size) 3,70 NO.OF BEDROOMS OR OWNER PERMTTDATE: Y&'COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by IC PV 7104 �o � � �" ��` � �. �d� �� ,I ,� ; ...,J �i __ _ �. ' ((/No. Fee $ 40.00 �- � � THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 01ppYication for Migoaf *p5tem Comaruction 3permit Application is hereby made for a Permit to Construct( )or Repair�X)an On-site Sewage Disposal System at: j Location Address or Lot No. Owner's Name,Address and Tel.No. 102 Second Avenue Anne Marie Cunniff .West Medford West H annis ort Mass 15 Dunbar Avenue Mass . 02155 Installer's Name,Address,and Tel.No.5 0$—r7 r7 5_3 3 3 8 Designer's Name,Address and Tel.No. 5 0 8—7 7 5—6 41 2 Il J.P.Macomber Jr. J.P.Macomber Jr. i Box 66 Centerville,Mass. 02632 Box 66 Centerville�Mass. 02632 Type of Building: Dwelling X No.of Bedrooms 2 Garbage Grinder Ig0) Other Type of Building RES No.of Persons 2 Showers( 1) Cafeteria Other Fixtures Mk Design Flow 330 gallons per day. Calculated daily flow 3 j 1 1 0 == 3 3 0 gallons. Plan Ddte 517L96- Number of sheets 2 Revision Date Title Description of Soil Loamy sand to medium sand Nature of Repairs or Alterations(Answer when applicable) Omit cesspools. T n s t a l l 1—1 5 0 0 gallon tank i 1 — i s .ri b ution box;,3-330 recharg rs 2411 invert.inve7i7t. Packed in stone. Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issu d by this o of H lth. Signed.­NZ" Date 5/7/96 Application Approved by Application Disapproved for the following reasons Permit No. ' Date Issued 1 � r .. . •{ . ,h • ...�... '.�Z"Y`iM"wj.•.y�J'..:E'r'n£�.,9~'..,-... - ' a .rti.Tt7. .,.1is '� 00 $ 40.00 No. T Fee - THE COMMONWEALTH OF MASSACHUSETTS.­­-­-- PUBLIC HEALTH DIVISION - TOWN OF�BARNSTABLES MASSACHUSETTS 0[pptication for Migogal *p.5tem Construction Permit Application is hereby made for a Permit to Construct( )or Repair�X)an On-site Sewage Disposal System at: t r Location Address or Lot No. Owner's Name,Address and Tel.No. ' Anne Marie CuriniffwWest Medford 1.02 Second Avenue 15 Dunbar Avenue MNSS. 02155 West Hyannisport,Mass i , Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. 508-775--641 2- J.P.Macomber Jr. 508-775-3338 J.P.Macomber Jr. Box 66 Centerville Mass. 02632 Box 66 Centerville,Mass. 02632 Type of Building: Dwelling X No.of Bedrooms 2 Garbage Grinder t30) Other Type of Building RES. No.of Persons 2 Showers( 1) Cafeteria(� ) Other Fixtures Design Flow 330 gallons per day. Calculated daily flow 1�1 1 0 == 330 gallons. Plan Date% 5/7/9$ Number of.sheets 2 Revision Date Title Description of Soil Loamy sand to medium sand. Nature of Repairs or Alterations(Answer when applicable) Omit cesspools. Install 1-1 500 gallon tank:1-Distribution box;3-330 rechargers 26^11 invert. Packed in stone. Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issu d by this goar of lth. 'Signed H Date 5/7/96 Application Approved by Application Disapproved for the following reasons A . Permit No. Date Issued THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION- BARNSTABLE, MASSACHUSETTS Certiftcate of (Compliance h4 THIS IS TO CERTIFY,that the On-site Sewage Disposal System installed( )or repaired/replaced�KX)on by J.P.Macomber Jr. for Anne Marie Cunniff as 102 Second Avenue West Hvannistoort Mass. as n constructed in accordan e with the provisions of Title 5 and the for Disposal System Construction Permit No. dated J 7� , . Use of this system is conditioned on compliance with the provisions set fo elow- t 77, .� 4 — —_ No.� 7 ",90 � Fee$ 40.00 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION- BARNSTABLE,. MASSACHUSETTS lwigaar *pgtem construction permit Permission is hereby granted to J-P.Macomber Jr. to construct( )repairXXI)an On-site Sewage System located at 102 Second Avenue West Hyannis-port - and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. All construction must be�co ple w'thin two years of the date below. j// 0 Date: Approved by r CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT(WITHOUT DESIGNED PLANS) j Joseph P. Macomber Jr., hereby certify that the application for disposal works construction permit signed by me dated 5/7/96 , concerning the property located at 102 Second Avenue yh meets all of the following criteria: There are no wetlands within 300 feet of the proposed septic system • There are no private wells within 150 feet of the proposed septic system • The observed groundwater table is 14 feet or greater below the bottom of the leaching facility There is no increase inflow and/or change in use proposed • There are no variances requested or needed. SIGMIE DATE: 5/7./g 6 LICE ED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER [Attach a sketch plan of the proposed system. Also if the licensed installer posesses a certified plot plan, this plan should be submitted]. 0Dry LA)- t4y ,, 1 . Omit cesspools. Install. 2. 1- 500 gallon tank. 3. 1-Distribution box. 4. 3-333 Rechargers 2; invert. 5. Packed in stone. .r54i 6 DATE:_ 5/13/96--- 11 PROPERTY ADDRESS:_ 102-Second-Avenue ----- %R M a'41 f0 j AY West Hyannisport l j99s #� ------------------------ t p/ Mass . 02672 © vim ------------------------ On the above date, I inspected the septic system at the above address. This system consists of the following: 1 . 2-Block cesspools. Based on my inspection, I certify the following conditions: 1 . This is not a title five septic system. 2. This is a sewage system. 3 . The overflow cesspool is on the nieghbors property to the rear. 4. This put the system in failure . Cesspool should be 101 feet off the property line. Standard code. The main cesspool # 1 was pump ed summer of 95. It was in fa- lure t that time. SIGNATURE-_! _� Name: Joseph P. Macomber Jr. Company: J.P.Macomber & Son Inc. P Y'------------------- Address:_ Box 66 Centerville Mass . 02632 ASSESSORS MAP No: ��,�4��,,,,.,...,, ; PARCIL NO:,r- -------------------- Phone:__508_775_3338 THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY LPH P. MACOMBER & SON, INC.Tanks-Cesspools-Leachfields Pumped & InstalledTown Sewer ConnectionsBox 66 Centerville, MA 02632-0066 775-3338 775-6412 8 Commonwealth of Massachusetts I Ct ExecutNe Office of Environmental Affairs Department of -, Environmental Protection WUliam F.Weld Trudy Cox@ Argoo Paul Celluccl avid 0.Struhs tL Gowmw • SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION PropertyAddresa: 102 Second Ave West H annis ort AddressofOwner. Anne Marie Cunniff ection: Y P (If different) 15 Dunbar Ave Date of Insp , 5/13/96 Medford,Mass .021 5 5 Name of Inspector. Lose p}}�� pp Maco mber Jr. Company Name,Address ailti'I'elephone Number: J.P.Macomber & Son Inc. Box 66 Centerville,Mass . 02632 508-7775-3338 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: _ Passes _ Conditionally Passes Beds Further Evaluation By the Local Approving Authority Inspector's to Si tune: Date: v �l gna The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner And copies sent to the buyer, if applicable and the approving authority. INSPECTION SUMMARY: Check A,B,C,or D: A] SYSTEM PASSES: k_ I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. B] SYSTEM CONDITIONALLY PASSES: o One or more system components need to be replaced or repaired. The system,upon completion of the replacement or repair,passes inspection. Indicate�yy'es,no,or not determined(Y,N,or ND). Describe basis of determination in all instances. If"not determined",explain why not) Air; The septic tank is metal,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. (revised 11/03/95) 1 One Wlnier Street a Boston,Massachusetts 02108 a FAX(617)556-1049 a Telephone(617)292•SWO Printed on Recycled Pape V. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) PropertyAddrosa: 102 Second Avenue West Hyanni sport,Mass. Owner. Cunniff Date of Iwpectlon:5/13/96 B)SYSTEM CONDITIONALLY PASSES (continued) Sewage backup or breakout or hVh static water level observed in the distribution boat 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 A-ld 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 C) FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health,safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES 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 PUBLIC WATER SUPPLIER,IF APPROPRIATE) 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 and is within 100 feet to a surface water supply or tributary to a surface water supply. tem and ,W The system has a septic tank and soil absorption sys is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and is within 60 feet of a private water supply well. / The system has a septic tank and soil absorption system and 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 6 ppm. 3) OTHER Two block cesspools They do not violate any of tha C_? (revised 11/03/95) 2 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (oontlnuod) partyAd&os+: 102 Second Ave West Hyannisport,Mass. wnor. Cunniff ate of lwpootlon: 5/13/96 if SYSTEM FAILSs I haw datarmiawd that the systam violotos one or morn of the following falltuw criteria as defSned 510 CUR 16.303. The but for this detarmination is identified below. The Board of Health should be cont.actod to determine what will be necessa:y to correct the . iailura.'. Backup of sewage into facility or system component due to an overloaded or clogged SAS or cwpool DIub.zTV or poadlrts of sMuent to the surface of the tround or surface waters due to an overloaded or clogged SAS or cesspool tNe- Static liquid level in the diotribution box above outlet invert due to an overloaded or clogged SAS or cesspool Alp Liquid depth in cesspool it less than v below invert or available volume is lass than U2 day flow. Roquirod pumping more thin 4 tunes in the last year NOT due to cloggod or obstructed plpo(s). Number of times pumpod _ Aqy portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. .1IG1 Any portion of a cesspool or privy is within 100 foot 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. 40 Any portion of a cesspool Or privy is within 60 feet of a private water supply well. 46 Any portion of a cesspool or privy is lass than IN feet but greater than 60 foot from a private water supply well with no acceptabls water quality analysis. If the well has boon analyzed to be accapta.ble, attach copy of wall wztar analyst for coliform bacteria,volatile orl;a.nic compounds, ammonia nitrogen and citrate nitrogen. Z. , t Second cesspool is on the nieghbors yard. This is why system fails. El LARGE SYSTEM FAILS: System must be filled in and new title five septic system installed. The following criteria apply to large systems in addition to the criteria above: .. .. AO The r Um servos a facility with a deign now of 10,000 gpd or grantor(Largo System) and the system is a signiticant threat to public health and salcty and ths•eavironment bo:,auae one or more of the following conditions exist: the system is within 400 feet of a surface drinking water supply /9 the system is within 2W fret of a tributary to a surface drinking wat.or supply /f 9 the syrtom is located in a nitrogen wnsitive area (Intorim Wellhead Prot•action Aran(IWPA)or a mappod Zone II of a public water supply wall) The owner or operator of any such system sha.1 bring the system and facility Into full complio.nca with the Y VUndwater treatment program roqulrements of 314 CMR 6.00 and 6.00, Plea;a consult the local regional office of the Department for fltrther Information., SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 102 Second Ave West Hyannisport,Mass. Owner. Cunniff Date of Inspection: 5/13/9 6 ' Check if the following have been done: Pumping information was requested of the owner,occupant,and Board of Health. ,,,None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. .L#As built plans have been obtained and examined. Note if they are not available with N/A _L/Ths facility or dwelling was inspected for signs of sewage back-up. 2-The system does not receive non-sanitary or industrial waste flow . / /The site was inspected for signs of breakout. , All system components,Apa/cludiag the Soil Absorption System,have been located on the site. A fW_�:The septic tank manholes were uncovered,opened,and the interior of the septic tank was inspected for condition of bames or tees,material of construction,dimensions,depth of liquid,depth of sludge,depth of acu:n 2- The rise and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods. ZThe facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of Sub. Surface Disposal System. (revised.11/03/95) 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION propartyAddresa; 102 Second Ave West Hyannisport,Mass . Owner. Cunniff Date of Inspection:5/13/9 6 FLOW CONDITIONS RESIDENTIAL: Design flow: & Ral f ns e Number of bedrooms: Number of current residents: Garbage grinder(yes or no): Laundry connected to system(yes or no) y` Seasonal use(yes or no): Water meter readings, if available: All, T8Y' we,1(;'I^ Last date of occupancy:. °IV�A�S COMMERCIAL NDUSTRIAU Type of establishment: Design flow:-12gallons/day Grease trap present: (yes or ao)1l� Industrial Waste Holding Tank present: (yes or no) ,qq Non-sanitary waste discharged to the Title stem: (yes or no)jj!T Water meter readings, if available: Last date of occupancy: OTHER (Describe) AA Last date of oocupanry GENERAL INFORMATION PUMPING RECORD_$ i source of inforatio ��up m �vs%u7 iXi >�>�1-!Y� •fir T" ��s System pumped as part of ins ion: (yes or no)�d if yes,volume pumped: _ kalloru Reason for pumping: A)4 TYPE OF SYSTEM �/ _ Septic tanlddistribution box/soil absorption system —L Single cesspool / Overflow cesspool Privy Shared system(yes or no) (if yes, attach previous inspection records, if any) Other(explain) APPROXIMATE AGE of all components, date installed(if known) and source of information: 7h �� 11 Sewage odors detected when arriving at the site: (yes or no)&v (revised 11/03/95) 5 b . SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) proPertyAddress: 102 Second Ave West Hyanni sport,Mass . Owner. Cunniff Date of Inspection:5/13/9 6 SEPTIQ TANKi e . (locate on site plan) Depth below grade: , Material of construction aooncrete_metal_FRP_other(ezplain) Dimensions: AM Sludge dspth.-_—LA— Distance from top of sludge to bottom of outlet tee or baffle:_ Scum thiclmess:— a Distance Srom top of scum to top of outlet tee or baftle:A)14 Distance from bottom of scum to bottom of outlet tee or baflle:NIq Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity, evi of leakage,etc.)' 4)6 ?� ,4 roe-g)r GREASE TRAP: (locate on site plan) Depth below grade:./n Material of construction, V concrete metal_FRP_other(ezplain) Dimensions. Scum thickaZIE Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: / Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity, evidence o leakage,etc.) f��,42 if'it'�l1J �.i (revised 11/03/95) e SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 102 Second Ave West Hyannisport,Mass . Owner. Cunni f f Date of Inspection: 5/13/96 TIGHT OR HOLDING TANK:AhAV7, (locate on site plan) s Depth below grade:] Material of constiuction:41hooncrete_metal_FRP_-other(ezplain) AI Dimensions: MA — Capacity: ons Design flow: ous/day Alarm level: Comments: (condition of inlet tee,condition of alarm and float switches,etc.) DISTRIBUTION BOX; (locate on site plan) Depth of liquid level above outlet invert:_ Comments: (note if leve�ddutribution is equal, evidence of solids carryover,evidence of leakage into or out of box,etc.) PUMP CHAMBEF.AVe, (locate on site plan) Pumps in working order:(yes or no),�! Comments: (notq co tion of pump S��ber,condition of pumps and appurtenances,etc.) (revised 11/03/95) 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) PropertyAddreae 102 Second Ave West Hyannisport,Mass . Owner. Cunniff Date of Inspection:5/1 3/9 6 SOIL ABSORPTION SYSTEM (SAS):/ (Locate on site plan, if possible; excavation not required, but may tx approximated by non-intrusive methods) If not determined to be present, explain: Type: leaching pits, number: leaching chambers, number: leaching galleries, number: leaching trenches, number,length: leaching fields, number, dimensions: 40 overflow cesspool, number:- Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of ve tation etc.) Soils Loamy sand to sand & gravel to medium sand; No suns of hydraull—c fnilnra nr =onding: ,A11 vegetation is normal. CESSPOOLS: (locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Otw Depth of solids layer: Depth of scum layer: Dimensions of cesspool Materials of construction: M Indication of groundwater: V241Y ) D )inflow(cesspool ust be pumped as part of inspection) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) Same as above under type. PRIVY:"421 (locate on site plan) Materials of construction: Dimensions: /yA Depth of solids: AJ Co nts: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) (revised 11/03/95) 8 r r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(oontinued) PropertyAddr - 102 Second Ave West Hyanni sport,Mass . Owner. Cunniff Date of Inspeotion:5/13/9 6 SKETCH OF SEWAGE DISPOSAL SYSTEM: • include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' Hyannis Water Company House not metered 775-0063 -.._. . ...-.._.._�_... . .-_ ._... . _...._._..__._ CA r DEPTH TO`GiROUNDW kTER Depth to groundwater. + feet . method of determination or approzimation:T n G f 141 . Permit # 28 (revs g V) �7 � b i THE C OHO AL TH OF MASSACHUSETTS PROTECTION DEPARTMENT O F ENVIRONMENTAL P DEPAR . BE IT KNOWN THAT Joseph P. Macomber, Jr. Has satisfied the Department's qualifications as required-and is hereby authorized to use the title CERTIFIED TITLE 5 SYSTEM INSPECTOR as provided in 310 CMR 15.340 and Section 13 of Chapter -2/1lA of the . General Laws. Issued by The Department of Environmental Protection. June 8, 1995 Acting Director of the • ion of Water Pollution Control r :r rnnrrrrtrra--r-- -r:rxr•r.r.—r_-nr..r...r..r.:- r�r:-rrr-r.rr-�r.�—�tr.r. .._ ._ _.. _. rsz•�sr,1-rrs-.r. ...S••r_r. r:.. ;._•... TOWN OF Barnstable BOARD OF HEALTH SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART D •- CE11rIF1CATI0N '�i F•••>:•:-r••.-::•--.iir.-.r.-nrn•n•r.:.>:—r.—.�r...--*'—"r^:.--.—Tr.-:---->.e*r.+rrz�-rr_rtrrrs.�•-•srmmvrr�rarxsasremn•mrrr.rs:•a�rrrrrr�r..•.—.-rr•r.•ter . -TYPE OR PRINT CI.EARLY- PROPERTY INSPECTED STREET ADDRESS 102 second Ave West Hyanniport,Mass . ASSESSORS MAP , BLOCK AND PARCEL # OWNER' s NAME Anne Marid Cunniff PART D - CERTIFICATION -r NAME OF INSPECTOR Joseph P. Macomber Jr.. COMPANY NAME I R.MQaoabQr & Son Ina - COMPANY ADDRESS Box 66 Centerville,Mass . 02632 Street Town or City State LIP COMPANY TELEPHONE ( 508 ) 775 - 3338 FAX ( 508 j 790 _ 1578 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported is true , accurate, and complete as of the time of .,inspection . The inspection was performed and any recommendations regarding upgrade , maintenance , and repair are consistent with my training and experience in the proper function and maintenance of on- site sewage disposal systems . • % Ili{et, Check one: Systeui PASSED Tile inspection which I have conducted has not found any information which indicates that the system fails to adequately protect public health or tile. environment as defined in 310 CMR 15 , 303 . Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form. XXXXXXXX System FAILEll* The inspection wkiich I have conducted has found that the system fails to protect the public health and the environment in accordance with Title 6 , 310 CMR 15 . 303, and as specifically noted on PART C - FAILURE CRITERIA of this inspection form . Inspector Signatur /r4og'/a/ I Date 5/1'.. /96 One copy of this rt.ification must be provided to the OWNER, the BUYER ( where applicable ) and the BOARD OF HEALTH. * It the inspection FAILED, the owner or..I.operator shall upgrade ' the system within one year of the date of the inspection, unless allowed or required otherwise as provided in 310 CMR 15 , 305 . nnrtri _rl.,.. } COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION COP? d A b - e' rev TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 102 SECOND AVE W.HYANNISPORT,MA 02672 NQ I-b c_\S Owner's Name: ANN-MARIE CUNNIFF t Owner's Address: PO BOX'343 W. HYANNISPORT,MA 02672 RECEIVED Date of Inspection: 5/12/03 Name of Inspector: (please print) JOHN GRACI,INC. J U1'd 1 12003 Company Name: SEPTIC INSPECTIONS MailingAddress: P.O. BOX 2119 TEATICKET MA.02536 TOWN OF H DEPT. ' HEALTH DEPT. Telephone Number: 508-564-6813 FAX 508-564-7270 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address,nd that the information reported below is true,accurate and complete as of the time of the inspection. The inspection was perfonned based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: X Passes _ Conditionally Pa s. _ Needs Further Ev u'ation by the Local Approving Autho.ity Fails Inspector's Signature: Date: 5/12/03 The system inspector shall submit a copy of t its inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the s stem 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 SYSTEM PASSED TITLE V INSPECTION. RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE. ****This report only describes conditions at the time of inspection and under :ie 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 S lncnPntinn Fnrm h/1 S0000 1 Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 102 SECOND AVE W.HYANNISPORT,MA 02672 Owner: ANN-MARIE CUNNIFF Date of Inspection: 5/12/03 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: X I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: SYSTEM PASSED TITLE V INSPECTION.RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE.. B. System Conditionally Passes: _ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system, upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements.If"not determined"please explain. n/a The septic tank is metal and over 20 years old* or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or 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: n/a r obstructed n/a Observation of sewage backup or break out or high static water level in the distribution box due to brokeno obstru / Obs o g p g 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: n/a . n/a The system required.pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): _broken pipe(s)are replaced _obstruction is removed ND explain: n/a Page 3 of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 102 SECOND AVE W.HYANNISPORT,MA 02672 Owner: ANN-MARIE CUNNIFF Date of Inspection: 5/12/03 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. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: _ 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 n/a "This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: n/a r Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 102 SECOND AVE W.HYANNISPORT,MA 02672 Owner: ANN-MARIE CUNNIFF Date of Inspection: 5/12/03 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for alLinspections: Yes No X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool X Static liquid level in the distribution box above°outlet invert due to an overloaded or clogged SAS or cesspool - X Liquid depth in cesspool is less than 6"below invert or available volume is less than '/z day flow X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped nLa. X Any portion of the SAS,cesspool or privy is below high ground water elevation. X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. _ X Any portion of a cesspool or privy is within a Zone 1 of a public well. X Any portion of a cesspool or privy is within 50 feet of a private water supply well. - X Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] NO (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in 310 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 X the system is within 400 feet of a surface drinking water supply X the system is within 200 feet of a tributary to a surface drinking water supply X the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well 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. a Page 5 of 11 OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 102 SECOND AVE W.HYANNISPORT,MA 02672 Owner: ANN-MARIE CUNNIFF Date of Inspection: 5/12/03 Check if the following have been done.You must indicate"yes" or"no" as to each of the following: Yes No X _ Pumping information was provided by the owner,occupant,or Board of Health X Were any of the system components pumped out in the previous two weeks X _ Has the system received normal flows in the previous two week period? X Have large volumes of water been introduced to the system recently or as part of this inspection? X - Were as built plans of the system obtained and examined?(If they were not available note as N/A) X _ Was the facility or dwelling inspected for signs of sewage back up? X _ Was the site inspected for signs of break out X _ Were all system components,excluding the SAS, located on site? X _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? X _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no X _ Existing information.For example,a plan at the Board of Health. X _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)] 5 Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 102 SECOND AVE W.HYANNISPORT,MA 02672 Owner: ANN-MARIE CUNNIFF Date of Inspection: 5/12/03 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):2 Number of bedrooms(actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms):220 Number of current residents: 2 Does residence have a garbage grinder(yes or no): NO Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required] Laundry system inspected(yes or no): NO � — Seasonal use: (yes or no): NO Water meter readings, if available(last 2 years usage(gpd)): a� 03 Sump pump(yes or no): NO ` Last date of occupancy: n/a COMMERCIAL/INDUSTRIAL Type of establishment: n/a Design flow(based on 310 CMR 15.203): n/agpd Basis of design flow(seats/persons/sgft,etc.): n/a Grease trap present(yes or no):NO Industrial waste holding tank present(yes or no): NO Non-sanitary waste discharged to the Title 5 system(yes or no): NO Water meter readings,if available: n/a Last date of occupancy/use: n/a OTHER(describe): n/a GENERAL INFORMATION Pumping Records Source of information: n/a Was system pumped as part of the inspection(yes or no): NO If yes,volume pumped: n/agallons--How was quantity pumped determined?n/a Reason for pumping: n/a TYPE OF SYSTEM X Septic tank,distribution box,soil absorption system _Single cesspool _Overflow cesspool _Privy _Shared system(yes or no)(if yes,attach previous inspection records,if any) _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): n/a Approximate age of all components,date_ installed(if known)and source of information: 1996 NEW SYSTEM-ASBUILT Were sewage odors detected when arriving at the site(yes or no): NO Page 7ofII OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 102 SECOND AVE W.HYANNISPORT,MA 02672 Owner: ANN-MARIE CUNNIFF Date of Inspection: 5/12/03 BUILDING SEWER(locate on site plan) Depth below grade: 14" Materials of construction:_cast iron _40 PVC other(explain): n/a Distance from private water supply well or suction line: n/a Comments(on condition of joints,venting,evidence of leakage,etc.): TOWN WATER SEPTIC TANK: X(locate on site plan) Depth below grade: 8" Material of construction: Xconcrete_metal_fiberglass_polyethylene other(explain)n/a If tank is metal list age: n/a Is age confirmed by a Certificate of Compliance(yes or no): NO(attach a copy of certificate) Dimensions: 1500 GALLONS" Sludge depth: 1" Distance from top of sludge to bottom of outlet tee or baffle: 33" Scum thickness: 1" Distance from top of scum to top of outlet tee or baffle: 6" Distance from bottom of scum to bottom of outlet tee or baffle: 17" How were dimensions determined: MEASURED Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY. RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE. GREASE TRAP:_(locate on site plan) Depth below grade: n/a Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a Dimensions: n/a Scum thickness: n/a Distance from top of scum to top of outlet tee or baffle: n/a Distance from bottom of scum to bottom of outlet tee or baffle: n/a Date of last pumping: n/a Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): n/a 7 ^ Page 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 102 SECOND AVE W.HYANNISPORT,MA 02672 Owner: ANN-MARIE CUNNIFF Date of Inspection: 5/12/03 TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: n/a Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a Dimensions: n/a Capacity: n/a gallons Design Flow: n/a gallons/day Alarm present(yes or no): N/A Alarm level: N/A Alarm in working order(yes or no):NO h Date of last pumping: n/a Comments(condition of alarm and float switches,etc.): n/a DISTRIBUTION BOX: X(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: LEVEL WITH BOTTOM OF PIPE Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): D-BOX IS STRUCTURALLY SOUND. PUMP CHAMBER:_(locate on site plan) Pumps in working order(yes or no): NO Alarms in working order(yes or no):NO Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): n/a R Page 9 of 11 OFFICIAL INSPECTION FORM=NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 102 SECOND AVE W.HYANNISPORT,MA 02672 Owner: ANN-MARIE CUNNIFF Date of Inspection: 5/12/03 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required) If SAS not located explain why: n/a Type n/a leaching pits, number: n/a RECHARGERS leaching chambers, number: 3 n/a leaching galleries, number: n/a n/a leaching trenches, number, length: n/a n/a leaching fields, number: n/a n/a overflow cesspool, number: n/a n/a innovative/alternative system Type/name of technology: n/a Comments(note condition of soil, signs of hydraulic failure, level of ponding,damp soil,condition of vegetation,etc.): DID NOT EXPOSE RECHARGERS,APPEAR TO BE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY.THEY WERE PROBED DRY.SYSTEM SHOWS NO SIGNS OF FAILURE. BOTTOM IS AT 5 FT. CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: n/a Depth—top of liquid to inlet invert: n/a Depth of solids layer: n/a Depth of scum layer: n/a Dimensions of cesspool: n/a Materials of construction: n/a Indication of groundwater inflow(yes or no): NO Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): n/a PRIVY: (locate on site plan) Materials of construction: n/a Dimensions: n/a Depth of solids: n/a Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation,etc.): n/a 4 . Page 10 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 102 SECOND AVE W.HYANNISPORT,MA 02672 Owner: ANN-MARIE CUNNIFF Date of Inspection: 5/12/03 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. J 3o y� in i Page I 1 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 102 SECOND AVE W.HYANNISPORT,MA 02672 Owner: ANN-MARIE CUNNIFF Date of Inspection: 5/12/03 SITE EXAM _Slope _Surface water _Check cellar Shallow wells Estimated depth to ground water 10+feet Please indicate(check)all methods used to determine the high ground water elevation: NO Obtained from system design plans on record-If checked,date of design plan reviewed: n/a YES Observed site(abutting property/observation hole within 150 feet of SAS) NO Checked with local Board of Health-explain: n/a NO Checked with local excavators, installers-(attach documentation) NO Accessed USGS database-explain: n/a You must describe how you established the high ground water elevation: HAND AUGER- 10+FT.