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HomeMy WebLinkAbout0099 SEVENTH AVENUE (HYANNIS) - Health 99 Seventh Avenue Hyannis P A = 245 057 I ' 1 , 1 J .2 ` Commonwealth .of Massachusetts T -I `Title 5 Official , Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 99 Seventh Ave P Property Address ro Melisa Fox - w Owner Owner's Name �+ information is �/ -►t required for every Hyannis port Ma 02601 2/11/17 page. City/Town State Zip Code Date of Inspection R] Inspection results must'be submitted"on this form. Inspection forms"may not be alteredl4R'any way. Please see completeness checklist at the end of the form. Important:When A. General Information filling out forms on the computer, use only the tab- 1. Inspector: key to move your cursor-do not Michael DiBuono.l use the return Name of Inspector key. DiBuonb_Sewer and Drain _ eb Company Name 8 Johns path Company Address ,arum S Yarmouth MA__ 02664 City/Town State Zip Code 508-364-9587 S113522 _ Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: _ ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the local Approving Authority -- -�— -=-- ------ ----- - ------- - 2/14/17 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 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. ""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. t5ins•3113 - - Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts a K W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 99 Seventh Ave Property Address------....— ----- --------------- — Cti: : .� Melisa Fox Owner Owner's Name - i_lformation is required for every Hyannis port Ma 02601 2/11/17 page. City/Town State Zip Code Date of Inspection r.. B. Certification (cont.) 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. An y failure criteria not evaluated are indicated below. Comments: System contains a 1,000 Gallon septic as well as a concrete Distribution box and a 1,000 GI leach pit. staining in pit indicates the level has not been within 24" of invert pipe —_ 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. Check the box for"yes", "no" or"not determined" (Y, N, ND) 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 p g tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): - x l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of'Massachusetts `title 5 Official Inspection Form, Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 99 Seventh Ave Property Address Melisa Fox Owner Owner's Name information is H annis ort Ma 02601 2/11/17 required for every � --�. ------- ------.------- --- — - page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): Observation of sewage backup or break out or high static water level in the distribution box due Act 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): i E r ❑ broken pipes) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled.or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ 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 ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 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 t5ins-3/13. Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts : Title 5 Official Inspection For m Subsurface Sewage Disposal System-Form - Not for Voluntary Assessments 99.Seventh Ave Property Address Melisa Fox - Owner Owner's Name information is required for every Hyannis port Ma 02601 2/11/17 page. City/Town _ — State Zip Code Date of Inspection B. Certification (cont.) 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 fee t of a surfac e wat er 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 fecal coliform.bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 pprn provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: 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 theground or surface 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 '/z day flow Sins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts u Title 5 Official Inspection Form { Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 99 Seventh Ave b Property Address Melisa Fox Owner Owner's Name information is required for every Hyannis port" - Ma - 02601 " _ ' 2/11/17 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® 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 1 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. [This system passes if the well water analysis, performed at a DEP certified ._laboratory, for fecal coliform bacteria indicates.absent 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 and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® 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. For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the questions in Section D. 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. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth.of.Massachusetts F W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 99 Seventh Ave Property Address Melisa Fox - Owner Owner's Name information is required for every Hyannis port Ma 02601 2/11/17 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate '`yes" or"no" as to each of the following: Yes No ❑ ® 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? . ❑ , N 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 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: ® ❑ 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(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203'(for example: 110 god x#of bedrooms): 330 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface.Sewage Disposal System Form - Not for Voluntary Assessments 99 Seventh Ave Property Address Melisa Fox Owner Owner's Name information is required for every Hyannis port Ma 021501""" 2/11/17 page. City/Town State Zip Code Date of Inspection D. System Information Description: System contains a 1,000 Gallon septic as well as a concrete Distribution box and a 1,000 GI leach pit. staininn in pit indicates the level has not been within 24" of inyert pi e Number of current residents: ' Vacant Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection Yes ® No information in this report.) El Laundry system inspected? ® Yes ❑ No Seasonal use? ® Yes ❑ No Water meter readings, if available last 2 ears usage d 217 GPD 9 ( Y 9 (gp ))� Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): — Gallons per day(gpd) Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No y Water meter readings, if available: tins•3111 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 99 Seventh Ave Property Address Melisa Fox Owner Owner's Name information is required for every Hyannis port Ma 02601 2/11/17 ;page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: 8/24/15 Was system pumped as part of the inspection? ❑ Yes ® No 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 record s, if any) Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval.. ❑ Other(describe): l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts W Title 5 Offici 1 Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 99 Seventh Ave Property Address Melisa Fox Owner Owner's Name information is - required for every Hyannis port Ma 02601" 2/11)17 page. City/Town State Zip Code Date of Inspection D. System Ifformatlon (cont.) Approximate age of all components, date installed (if known) and source of information: 1987 Were sewage odors detected when arriving at the site?_ ❑ Yes ® No Building Sewer (locate on site plan): ' 2 Depth below grade: feet Material of construction: ® cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): System is vented•at the roof line Septic Tank (locate on site plan): 1.5 Depth below grade: feet Material of construction: ®.concrete ❑ metal ❑_fiberglass ❑ polyethylene ❑ other(explain) 1000 If tank is metal, list age: yearn Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: — Sludge depth: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts.- Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 99 Seventh Ave Property Address .Melisa Fox _ Owner Owner's Name information is required for every Hyannis port Ma 02601 2/11/17 . page. City/Town State' Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 24" — Scum thickness 3" _ Distance from top of scum to top of outlet tee or baffle 42 Distance from bottom of scum to bottom of outlet tee or baffle Sludge stick How were dimensions determined? Tape Measure Comments (on pumping recommendations, inlet and outlet tee or baffle condition', structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Baffles are in place tank is at normal level Grease Trap (locate on site plan): Depth below grade: ' feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene El 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: Date l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts W Title 5 Official I,nsecti®n Fora Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 99 Seventh Ave Property Address Melisa Fox Owner Owner's Name information is required for every Hyannis port Ma 02601 2/11/17 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 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 per day Alarm present: ❑ Yes ❑ No Alarm level: — Alarm in working order: ❑ Yes ❑ No Date,of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract (required). Is copy attached?' ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts 71 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments r a 99 Seventh Ave - Property Address Melisa Fox - Owner I Owner's Name information is required for every Hyannis port Ma 02601 2/11/17 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert Level and at normal level` 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.): t Pump Chamber (locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12.of 17 Commonwealth of Massachusetts W `title 5 Official Inspection ,Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 99 Seventh Ave _ Property Address -- Melisa Fox Owner Owner's Name information is required for every Hyannis port _ Ma 02601 2/11/17 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1 ❑ 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.): No ponding no breakout Cesspools (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 ❑ No l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts - W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 99 Seventh Ave Property Address Melisa Fox Owner Owner's Name Information is required for every Hyannis port Ma 02601 2/11/17 page, City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): -_No signs of failure Privy (locate on site plan): Materials of construction: Dimensions Depth of solids — Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•3/13 - Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts W `title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 99 Seventh Ave _ Property Address Melisa Fox Owner Owner's Name information is required for every Hyannis port ort _Ma_ _02601 2/11/17 _ _ _ page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view 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. Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately. e r t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts W Title 5 Official -Inspection Form t Subsurface Sewage Disposal System Form Not for Voluntary Assessments 99 Seventh Ave Property Address Melisa Fox Owner Owner's Name information is required for every Hyannis port Ma 02601 2/11/17 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check.Slope ❑ Surface water ❑ Check cellar r. ❑ Shallow wells , , Estimated depth to high ground water: 10 plus ft feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ 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) ❑ Accessed USGS database -explain: 4 _ You must describe how you established the high ground water elevation: Elevation at river behind home Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 AsBuilt Page 1 of 1 TOWN OF B ARNSTABLE LUCATION SEW VILLAGE . ' ASSESSOR'S MA INSTALLER'S NAME S: PHONE NO. L , L (� E SEPTIC TANK CAPACITY Carj C LEACHING PACILITYr(tppe} r NO.OF BEDROOMS v; PRIV- TE WELL OR PU.' BUILDER OR OWNER AL, DATE PERMIT ISSUER. DATE .COMPLIANCE ISSUED- VARIANCE GRANTED: Yes rJo F e i P � A 7, 3 htip://issgl2/intraiiet/propdata/prebuilt.aspx?mappar=24505 7&seq=1 10/14/2009 Commonwealth of Massachusetts W Title 5 Official Inspection Form ' Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 99 Seventh Ave Property Address Melisa Fox Owner Owner's Name information is required for every Hyannis port Ma 02-601 2/11/17 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ❑ Inspection Summary: A, B, C, D, or E checked ❑ Inspection Summary D (System Failure Criteria Applicable to All Systems) completed` ❑ System Information— Estimated depth to high groundwater ❑ Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 �-� COMMOINT 6rTALTH OF K-kSSACHUSETTS _f EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS y�I DEPARTMENT OF ENVIRONMENTAL PROTECTION :J MAP ��. .�...�,.e..� PARCEL S LOT TITLE 5 OFFICIAL,INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: L t yW Owner's Name: ` Owner's Address: 6 ({E(aEWED o/l0(,a Date of Inspection: MAR 17 2004 Name of Inspector: leas pr'nt) } #„ Company Name: — TOWN OF BARNSTABLE Mailing Address: ,•v q HEALTH DEPT. 14 C)�D Telephone Number: CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true; accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 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 - 1 Page 2.of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address- 9q - Owner: DZjei A. Date of Inspectio t Inspection.Summary: Check A,B,C,D or E l ALWAYS complete all of Section D. A. /System Passes: V 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:. 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. 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(wifh. 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 pipe(s).The system will pass inspection if(with approval of the Board of Health):. broken pipe(s)are replaced obstruction is removed ND explain:. Page 3 of I'l OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: % ,qq 0 G�k Owner: Date of Inspect' 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. L System wall 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 systern 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 I 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,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: 3 ' 4 Page 4 of I I OFFICIAL.INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM.INSPECTION FORM PART A CERTIFICATION(continued) Property.Address: ' 161A Owner: / Date of InspectiodYMOWA- 00� D. System Failure Criteria applicable to all systems: You must indicate"yes''or"no"to each of the following for all inspections: Yes Ng V 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,anoverloaded or clogged SAS or cesspool Static liquid level in the distribution.box above outlet invert due to an overloaded.or clogged SAS or / cesspool _ V 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 y water supply. Any portion of a cesspool or privy is within a Zone 1 of a public well. _ V Any portion of a cesspool or privy is within 50 feet of a private water supply well. �i 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: - _... r- 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—I WPA)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 " Section yes"in Q S ion 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 P� 15.304.The system owner should contact the appropriate regional office of the Department.. 4 Page 5 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B ; CHECKLIST Property Address: 9We1A / AM Owner: Date of Inspect' Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No _ _ Pumping:infor,mation.was providedty the owner;occupant,'or Board of Heald 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? 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 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 o 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 4 Page 6 of l 1 OFFICIAL-INSPECTION-FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYST E M INSPECTION FORM PANT C SYSTEM INFORMATION Property Address: . 14 Ownerdn"WeI4 Date of Inspecti A FLOW CONDITIONS RESIDENTIAL V Number of bedrooms(design):- .� Number of bedrooms(actual): _ DESIGN flow based on 3 1 OgMR 15.203 (for example: I W gpd x n of bedrooms): Number of current residents: Does residence.have a garbage grinder(yes or no)jj ` Is laundry on a separate sewage system es or ho):/�.[if ves separate inspection required] :._- . --• Laundry system inspecte lailable or no): J**� Seasonal use: (yes or no) 1 �� Water meter readings; if (last 2 years usage(gpd)):®,3"Z 1/,7� 7�n,, p_/ Sump pump(yes or no Last date of occupancy: COMMERCIAL/INDUSTRIAL./'/t& Type of establishment: Designs 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 system (yes or no): Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records o Source of information: _ Was system pumped as part of the inspect yes or no): If yes, volume pumped: gallons--How was quantity pumped determined? Reason Tor pumping: TYP F 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 copyof the DEP.approval _ _Other-(describe): Approximate age of all compone ts, date installed(if known)and ourcgl of i ormation: / S Were sewage odors detected when arriving.at the site(yes or no):A -' 6 Page 7 of 1 1 OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C n SYSTEM INFORMATION(continued) Property Address: "� L I D� Owner: M Date of Inspectio ) BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction: cast iron _40 PVC_other(explain): Distance from private water,supply well or suction line: Comments(on condition of joints, venting,-evidence of leakage, etc.): SEPTIC TANK: (locate on site Ian) alp Depth below grade: �' a Material of construction: concrete_metal_fiberglass polyethylene —other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions: k p ' jr Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: ZD Scum thickness:c ,��r Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom qf outlet tee or baffle: /D How were dimensions determined: J'6_J�j,� ,000�I-A,,p ZZ92 Comments (on pumping recommen ations; nlet and outlet tee or baffle condition, structural integrity, liquid levels as elated to outlet invert, evidence of leakage, etc.): _ lw'-fj : 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.): y 7 Page 8 of I 1 .OFFICIAL INSPECTION FORM.—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued). ,Property Address: Owner: fd, Date of InspectioiQlZa TIGHT or HOLDING TAN��(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) Depth of,Iiquid.level above outlet invert: Comments,(note if box is level and distribution to outletuaI, any evidence of solids carryover, any evidence of akage into or out of box, .): CIA PUMP CHAMBERAA(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.): 8 Page 9 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner: Date of Inspectio 02 SOIL AIBSORPTION SYSTEM (SAS): (locate on site plan, excavation not required) If SAS not located explain why: Type eaching pits;number: 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. , CESSPOOLS: A.14cesspool must be pumped as part of inspect ion)(]ocate 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`J� IVV cafe 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.): 9 Page 10 of 1 l OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: A Owner: Date of Inspecti 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. Ap 0 to 10 Paae I 1 of 1 I OFFICIAL INSPECTION.FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner: AAA Date of Inspectio : SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water /0 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) Accessed USGS database-explain: You must describe how you established the high ground water elevation: /' 4 [ U' dz�f&5' 11 Permit Number: Date: Completed by: � HIGH GROUND-WATER LEVEL COMPUTATION Site Location: L �����i 4'//'� lit/ > /J Q�/J�rl��t No. Owner: /#�/Q?/�/_ /�9i?D j� Address: Contractor: G�D�4,1f�� G®G.�ri,�Address: Notes: STEP 1 Measure depth to water table tonearest 1/10 'Ft. ...:......................:.........:......................................... .Date month/day/year STEP 2 Using Water-Level Range Zone and Index Well Map locate site and determine: OA Appropriate index well............................ CWater-level range zone ...................................................... I STEP 3 Using monthly report "Current Water Resources Conditions" determine current depth to /®� g water level for index well ........................:.. month/year STEP 4 Using Table of Water-level Adjustments for index well (STEP 2A), current depth to water level for index well(STEP 3), and water-level zone (STEP 2B) determine water-level adjustment .......................................................................................... Z. STEP 5 Estimate depth to high water by subtracting the water- level adjustment (STEP 4) from measured depth to water Z� level at site (STEP 1) ........................... Figure 13.--Reproducible computation form. 15 C • ! C 1 i e ' C C .k 2 c pp I yE ti • 2� if 1 4 S 4 i } 1 Ir �-\ COMMUNWEALTH OF MASSACHL•SETTS ,r O _ EXECUTIVE OFFICE OF E\VIRONMENTAL AFF qU >' DEPARTMENT OF ENVIRONMENTAL PROT TIO\C t ONE WINTER STREET. BO5T0N. MA G'_!OS 61"-'_9'-5:00 � OF 199� � N WILLIAM F.WELD Sep l�b COXT Govcrnc• ` Se;rctar% ARGEO PAUL CELLIXCI DAVID B.STRUHS Lt.Govemor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Commissioner PART A Se v N 1"64_ CERTIFICATION Property Address: l L e _ b& y CL µ�fl'4ddress of Owner: W►1,��� S o�.•�+c+J�� Date of Inspection: g 30A� Y (If different) St O �W"M'�U& ST Name of Inspector: "s a o P �E3) —IFWQI t ), t �I�l Air I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000) o2t•5"7 Company Name:1±1& c r'r•I ,J x A.-C P H � Mailing Address: R O 6oA P 3�?C f /uJ�QS�Ot2SL /`� /e} © O-C4 51 Telephone Number: _�SG _C �-- /L& Zy CERTIFICATION STATEMENT I certi y that I have personally inspected the seN•age disposal system at this address and that the information reported belo% is true, accurate and complete as of the time of inspeczio7. The inspection was performed based on.my training and experience in the proper function and maintenance of on-site sewage disposa: systems. The system: Passes _ Conaitionaik Passes tieeo� Further cal Approving Authorm Fa. s Inspector's Signature. Date: The S%,sterr Inspector shal' 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 o, ha; a design flov.• 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 origina! 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: 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. COMMENTS: B] SYSTEM CONDITIONALLY PASSES: One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Indicate yes, no, or not determined (Y, N, or 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 within twenty (20) years prior to the date of the inspection; or the septic tank, whether or not metal, is cracked,.structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. - (rev.:zed 04/25/97) Page 1 of 10 DEp on tree Wond Wde Wee hmirwww magnet state ma.usrdec Pnntea on Recycled Paoe, - f ti SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM o PART A CERTIFICATION (continued) t •Pro ert Address: �' "r P Y r Date of Inspection: B] SYSTEM CONDITIONA LY PAS ES (contini-d _ Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipets) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health;. Describe observations: 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 pipets) are replaced obstruction is removed CJ 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 prn-\ is within 50 feet of a surface water Cesspool or prn) 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 PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet 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 (zsvisod 04/25/97) Page 2 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: bt Owner: 5,AA1v#vS4v1 [�L/_ �L if Date Date of Inspection: a �3 D] SYSTEM FAILS: You must indicate either "Yes" or "No' as 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 or surface waters due to an overloaded or clogged SAS or cesspool. Static liquid levei to the distribution boa 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 flov.. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipes:. Number of times pumped Any pomon of the Soil Absorption System, cesspool or privy is below the high groundwater eievatior, An% por„on of a cesspool or privy is within, 100 feet of a surface water supple or tributan to a surface water supply. And pot-ion of a cesspoo' or prey is within a Zone I of a public well. An,. po,io-. of a cesspool or prnv is within 50 feet of a private water supply.well. Any por,ion 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 qualm analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E] LARGE SYSTEM FAILS: You must indicate either "Yes" or "No- as to each of the following: The following criteria aopiv to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater (Large System; and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No . 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'lI of a public water supply well) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 04/25/97) Page 3 of 10 o . SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST �r Property Address: �! v� Owner: 'SotgrcNso.J Date of Inspection.. —7 /q Check if the following have been done:You must indicate either "Yes" or "No"as to each of the following: Yes No Pumping information was provided by the owner, occupant, or Board of Health. None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. As built plans have been obtained and examined. Note if they are not available with NIA. The facili;, or dwelling ,,as inspected for signs o`sewage back-up. 1 _ The system does not receive non-sanitary or industrial waste flow. _ The site %%as inspected for signs of breakout. _ All system components. excluding the Soil Absorption System, have been located on the site. _ The septic tank manhoies were uncovered. opened. and the interior of the septic tank was inspected for condition of baffies or tees. material o-'construction. dimensions, depth of liquid, depth of sludge, depth of scum. The size and location of the Soil .Absorption Svstem on the site has been determined based on: _ The facilrt, owner ;ano occupants. if difierent from owneri were provided with information on the proper maintenance of Sub-Surface Disposal,Svstem. Existing information. Ex. Plan at B.O.H. _ Determined in the field it an, of the failure criteria related to Pan C is at issue, approximation of distance is unacceptabie (15.302;3)t!1 (revised 04/25/97) Page 4 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Properh Address: Owner: 'Oq,C�aCgp Date of Inspection: FLOW CONDITIONS RESIDENTIAL: Design flo�,%.3—% e.P.d./bedroom for S..q�S Number of bedrooms: 03 Number o-'current residents: C Garbage g,; der (yes or nw: Nlra Laundry cc—ected to system (yes or no)-I C Seasonal use ryes or nw1 A 0 Water meter readings, if available (last two !2: year usage tgpd): [JCl Sump Pump eves or no): u0 Last date of occupancy tJ Pr. COMMERC14 INDUSTRIAL: Type of establishment. Design fio�% eahons/daN Grease trap present. Ives or no' Industrial Taste Holding Tank present. Ives or no 'ion-sanitan Naste discnarged to the Tthe 5 system: ;ves or no \later meter readings, if availabie Las:fuze of o .upanc-� OTHER: .De�cribe Last date of occupant. GENERAL INFORMATION .PUMPING RECORDS and source of information. System pumped as par, of inspection. tees or no, If yes,.volume pumped ¢allons Reason for pumping TYPE OF SYSTEM Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Prny Shared system (yes or no) (if yes, attach previous inspection records, if any) I/A Technology etc. Copy of up to date contract? Other APPROXIMATE AGE of all components, date installed (if known) and source of information: t S\-VLA Sewage odors detected when arriving at the site. (yes or no) t� (revised 04/25/97) Page S of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C c/ SYSTEM INFORMATION (continued) Property Address: 17 ` � a�[ca Owner: Seaja-wv Date of Inspection: BUILDING SEWER: NC) l (Locate on site plan) Depth below grade. Material of construction: _cast iron _40 PVC _other (explain,, Distance from private water supply well or suction li-t Diameter Comments: (condition of joints, venting, evidence of leakage, etc.) SEPTIC TANK: I'CS .locate on site plan Depth below gradef . Material of construction: &concrete _meta' _Fiberglass _Polyethylene _othenexplam; If tank is metal, Iis: age _ Is age confirmed b\ Cen;fjcate of Compliance _(Yes.No Dimensions 10005�a� Sludge depth 1111i �t Distance from top of sludge to boron of outie: tee or bade Scum thickness: 01111 Distance from top of scum to top of outlet tee or ba^ie Distance from bottom of scum to bocoT o*outlet tee or bare A. How dimensions were determined wk t eA . Comments trecommendation 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.i V= ► s °W e1�, w•& ow-M- vat, GREASE TRAP: Po (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 i:ilet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.; (rovisad 04/25:9-,) Fag• 6 of 10 f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Properh Address: Q t�2- OM ner: Date of Inspection: ") TIGHT OR HOLDING TANK: PO '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: 4w ..,.•.. , . n; Capacity: gallons Design floe galions.•da, T Alarm level Alarm in working order _ Yes: _ No Date of previous pumping Comments (condition of inlet tee. condition o! alarm and float switches, etc.) DISTRIBUTION BOV t+ct (locate on site pa- Depth of liquid le4 above outie: in,e-: g9 ,euTL1"�N�16=— Comments: (note if level and distribution ), eaua'. evidence of solids car over, evidence of leakage into or out of box, etc.) PUMP CHAMBERJ�o (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.) (=eviaed 04/25/9') Page 7 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) -- Propert� Address: 6 ! 7�" cY ci�2 fj�. e�C>: �.c ct 0 2'4 - Owner: I t ovewue-0 / Date of Inspediono--/3 p /Ce� SOIL ABSORPTION SYSTEM (SAS): (locate on sue"plan, if possible; exca� ,ion not required, but may be 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. overflow cesspool, number Alternative system Name of Technology. Comments. mote condition of soil, sighs of hydraulic failure, level of pondir;g, c ndrtion of vegetation, etc.) o o CESSPOOLS: (locate on site plan- Number and configura:-on Depth-top of liquid to inlet Inver, Depth of solids layer- Depth of scum layer. Dimensions of cesspoo; Materials of construction Indication of groundwater inflow icesspool must De pumper as par, of inspection! Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY:ja (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.) (revased 04/2S/97) Page / of 10 " " SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: �7 �— �� _ &- � 4 Owner: 164Va1cw5Up Date of Inspection: 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) r� A � Q 2� 63- g'tj -30 (revised 04125/51) Page 9 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C 7� SYSTEM INFORMATION (continued) ' Property Address: a � ,r". (� Q Owner: '$a2°rcW-;p Date of Inspection: 3 Depth to Groundwater 1 Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained irom Design Plans on record Observation of Site (Abutting property o servat�on hole--)basement sump etc.) Determine it from local conditions Check with Iota! Board o: health Checi FEMA mans Check pumping records Check local excavators. installers use I-SCS Da-a f Describe in vourown �%oras no%% you established the High Groundwater Elevation. (Must be completed; 63 Maw --t PIT'— (rev-sod 01;25!9'. Page 10 of 10 VX TOWN OF BARNSTABLE !% LOCATION o Z SEWAGE # VILLAGE ASSESSOR'S MAP & LOT INSTALLER'S NAME & PHONE NO. 4z e) q q Zz- SEPTIC TANK CAPACITY 050 LEACHING FACILITY:(type) (size) a®Q NO. OF BEDROOMS_ 7 PRIV TE WELL OR PUBLIC WATERy BUILDER OR OWNER AL P a t t C t, DATE PERMIT ISSUED-: DATE .COMPLIANCE ISSUED: W.12 VARIANCE GRANTED: Yes No \ N Y O +.I ` `\ • t _ � i THE COMMONWEALTH OF MASSACHUSETTS 1� BOARD OF H H - ---------------------0 F.. .. .. . .................................... Application for Disposal Works Tonstrurtinn Prrmit Application is hereb made for• a Permit to Construct ( or RepaiX( an Individual Sewage Disposal Sys ... ............../. ........ .. -- ---------------- .................................................... ---.L. lion•Address -•- or Lot No. ... - .. _ ... ................................. ....-- . .................. ............................................... Owner Address W Installer Address �/ Type of Building Size Lot.,//q .2T___ .....Sq. feet U Dwelling—No. of Bedrooms. ............:.............:.. .Expansion Attic (�� Garbage Grinder (Vzf Other—Type of Building ......... No. of persons............................ Showers — Cafeteria Q' Other fi d --------.................. W Design Flow......_.._._. .............gallons per person per day. Total ity.flow.._.. ._. .___.._.........._. Ions. , i' WSeptic Tank—Liquid*ca.pacit/ ..gallons Lengthf�.%....... Width....r gib-.... Diameter................ Depth... ._......... x Disposal Trench—No. ............. Width........... .... Total Length......... ......... Total leaching area_........__ .......sq. ft. /� yrDepth low inlet........... Total leaching area..... sq. ft. Seepage Pit No.....:.... ....... ameter...... .... Z Other Distribution box ( Dosi Percolation Test Results Performed b . .. .... ... ..............................,...................... Date. ...O`.. .........._._. Test Pit No. 1..&.......minutes pe in epth of Test Pit.A............ Depth to ground water.. .. ............. 44 Test Pit No. 2................minutes pe c Depth of Test Pit.................... Depth to ground water......_................. f, O Description of Soil... .T_ fit ., -.. j® /� .5........................................... a2.:.. .o.�!....• 0 ��s ..................................................................................... � # U _ UW ....•-••-----------•-•-----------�.�.'3..._..�..... .... .... ..---•----------•-••----•----•--•-•-••-------•-•.....••------...-••---••---•-------•-••--•----..... Nature of Repairs or Alterations—Answer f y n 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 ce the system in operation until a Certificate of ComT;igne ce has e i e t oar m1th. _ l�_lp ...... Application Approved By............................... ..... .... ... ..... ........... ..Z #'t _-.-- D -------- �x� ....................... ate Application Disapproved for the following reasons:. . •---.•....--• �..?e % . ..............•------••••--•••-----.........•---..................------•--•--•••--•....----....•---.... ............ ............................... Date PermitNo......................................................._ Issued........................................................ Date r No...... ----.. FEs ..................... THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HIEALZTH /�t, 0 F..73.�4�A.A,: .... .. Apptiration for Piipnsal Works Tomitrurtion VrrtAit Application is hereby made for a Permit to Construct ( ) or Repair ( an Individual Sewage Disposal 52 Sys _. .�. ..... •- .................. .. - ............- ._........... f ation..Address or Lot No. (� V A.l I a k:. ;(...A t./l�fn-------- ................................................ Owner Address W Installer Address Type of Building Size Lot./d... 2.&..._._Sq. feet r , Dwelling—No. of Bedrooms .........................Expansion Attic W/6) Garbage Grinder (�✓O `4 Other—T e of Building ............... No. of ersons............................ Showers a YP g --------•---- P ( ) — Cafeteria ( ) Other fixr.s-.................................................•.................................................................................................. : Design Flow............. .....................gallons per person per day. Total�rilx flow 3.3..jQ W 6 WSeptic Tank Liquid capacit}�--....-•_.gallons Length................ Width.,--._----...... Diameter................ Depth...51......... x Disposal Trench—No. .................... Width.................... Total Length ... Total leaching area....................sq. ft. Seepage Pit No...4d1h�...... iameter...... _ Depth below inlet._........... Total leaching area..e-t_ . .sq. ft. Z Other Distribution box ( Dos*in t (r Percolation Test Results Performed b ��'. --------------------•---•---.:----------•-----------. Date. s .._:. .....--.... Test Pit No. 1_ .......minutes pe in epth of Test Pit..j/............. Depth to ground water..Wd----•-._--__. 44 Test Pit No. 2................minutes p ' c Depth of Test Pit.................... Depth to ground water........................ .....................� . ... .7Z......................................... (O� Description of Soil---0=--"A---- � Z ........................ � .......................... W ---•---•------------------------LL)---- -- ...--•-•--•------------•---------•-----.....-•-------...-•-•------..`.... -------------- •-------- Nature of Re or Alterations—Answer x airs U P • � n appli�able............................................................................................... --------------•-----------...------------------...--•----•-•-------•----------------........----------------....----------------------•--•---------•--.....--------------•--•---............._..-•....-- 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 lace the system in operation until a Certificate of Com liance has e i, ue t oard 11h. lea Signe at ApplicationApproved By................................... ------------------------••.................---•-••---------- Application Disapproved for the following reasons:................. ...o .j5,vr,/. ..... f ' .............................................................--••--------- •--•-••-- Date PermitNo......................................................... Issued....................................................... Date t THE COMMONWEALTH OF MASSACHUSETTS �1 BOARD OF HEALTH ............................OF...._.:; .1/ ""_.. �. .... ....................................... .. - (In ifiratr of Tomplianp HIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired 1 by....j ------- ----------------------------••------------ " .. --- .......................... ... .-•-•-•. --- r ef'r 5 - ----s- y - ' at fr - `� ---- ha been installed in accordance with the provisions of TITLE 5 of he State Sanitary Cod . as described in the application for Disposal Works Construction Permit No.. -7...... ............. dated---..___. . Z. _$_�..................... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GU RA TEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE.............. .-- !IS .................................... Inspector-• -- ......•............... )ESIGNING ENGINEER MUST SUPEriVIS' . THE COMMONWEALTH OF MASSACHUSETTS N31� TION AND CERTIFY IN WRITING BOARD OF HEAL.THAE SYSTEM WAS INSTALLED IN STRICT ^^CRMANCE TO PLAN. .......••.............. No. .•.... F E...�. ........... Disposal Works Tonstrnr#ion rrmit ' Permission is hereby granted....................................0........... to Construct ( ) or Re air ( ) an Individual Sewage Disposal System at No................. �.r� �------..5- a ....5-$-4-......... h /4:..--- . � tf�,�.tv.l�_!a ►� Street as shown on the application for Disposal Works Construction Permit N ....�.. ....._. ated. ._..__/ .....�.................. Board of Health DATE--.......................-................................................. ._:.. FORM 1255 A. M. SULKIN, INC.. BOSTON 1 1 f^ ,_ ��".,r' 4 �k%� . ,��/� Zd T �S U�ivTh' A VZ 7 114 y Jo 1986 zu0 F ` �vie Y.0 o � G•o S;0 lJ \ OFF: 'or ) ,3't F�f5�1 051- tl° 'k �. • BG.GO � �!/icti�SHCF. 1 uTiLlTv Poe v • y -VENTn A V�PPERCAPE ENGINEERING zlo•o o ,4A you T ) P.O. BOX 616 E. SANDWICH, MA 02537 E �-v��-I o AI s /3AsEb U,°000/ u..�Gs--_.___ 362-6281 TOP OF FOUNDATION • CONCRETE COVER . .;� CONCRETE COVERS 4"CAST :ON 12"MAX. •; OR SCHEDULE 40 12"MAX. ' P.V,C, PIPE 4"SCHEDULE 40 P.M(ONLY) . �. PIPE- MIN. LEACH • PITCH I/4"PER.FT PITCH.1/4"'PER.FT. PIT.. PRECAST INVERT• /o a LEACHING `•� EL/,13,�y�,,, INVERT INVERT % . 0 e•,' PIT OR .'. SEPTIC TANK �E DIST, y�g w EQUIV. INVERT EL._..XO.�t:. BOX EU. ...... ' : >x l4P.P.... GAL. INVERT INVERT ww '•.. 3/4"TO11/, EL✓3Xz2, . . Ua � wo WASHED STONE Ao �— /Z DIA.-:!q f� PROFI LE OF X'.GROUND WATER TABLE o SEWAGE DISPOSAL SYSTEM E�.: -o ~° NO SCALE SPI L LOG WITNESSED •BY : DATE.,C,IFPII¢. TIME.. BOARD OF HEALTH TEST HOLE 1 "fESfi HOLE ,2 .U1'o , .4Wd le`Wle! . ENGINEER ELFV.✓..1-0. .'. 777*7 . ELEV, ..... . . .. . TL$ . . . . . . . . . . . 6 Ra&- DESIGN DATA - "- NUMBER OF BEDROOMS . . �3 .17 s ^3Xo f) TOTAL ESTIMATED FLOW . �.�C? , , , GALLONS/DAY ` BOTTOM LEACHING AREA ,��3 , , , . 8Q.FT./PIT SIDE LEACHING AREA . . .� ��. . . . . SQ.FT/ PIT i GARBAGE DISPOSAL '. . .'�.'. ..(50% AREA INCREASE) TOTAL LEACHING AREA , a:G . . . . SQ.FT PERCOLATION RATE rCzt7a' . • • . 'MIN/INCH LEACHING AREA PER PERCOLATION RATE . . ... SQ.FT. .......WATER. ENCOUNTERED NUMBER OF LEACHING PITS . .0/l�'` , { APPROVED . . . . . . . . . V Z: .• �/Y.C,3,G,�,_ (/3 S.F. �1; ,//3. ;/;Q7Tot/ BOARD OF HEALTH ' DATE. AGENT 'OR INSPECTOR 6iQw- ,5clArecr To 1o•9•c oQo . U S.G.S: w�rc-� E.c. /9EA•d OF A( UPPERCAPE ENGINEERING J' P.O. BOX 616 • E. SANDWICH; MA 02537 A 9 to 7 Ty d�� • ;2T. . . 362-6281 Fcl S i E� sq � • . , . . �iP AT PETITIONER?: . . : . . . . . . . . . . . . . . po ►>i . � z w Upper Cape Engineering P.O. BOX 616, EAST SANDWICH, MASSACHUSETTS 02537 (617) 362-6281 May 11 , 1987 Barnstable Board of Health Town Hall Barnstable, Mass- REs 7th Ave, W. Hyannisport Dear- Sir: We have caused to inspect the septic system at lots 582/";,tf 584 Seventh Ave, W. hyannisport and found that the in- stallation-.was done in accordance to the plan submitted. Than yo .. 7Jn J cobi R.S.