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HomeMy WebLinkAbout0097 SIXTH AVENUE (HYANNIS) - Health 97 SIXTH AVE. , HYANNIS A = 245 067 i i I I 0 I COMMONWEALTH OF MASSACHUSETTS F EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS d DEPARTMENT OF ENVIRONMENTAL PROTECTION A I� Wt O y�0 � SV� TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION as,3 0 (,7 Property Address: 97 Sixth Avenue West Hyannisport,MA. 02672 Owner's Name: Elizabeth Shortsleeve Owner's Address: 11 Valley Forgeway ,:r€ Foxboro,MA.02035 .. r� Ewa Date of Inspection: 03/02/2006 ct: Name of Inspector: lease print) Brad J White - _ P (P P Company Name:Windriver Enviromental7 Mailing Address: 107 N.Main Street r-► Carver,MA 02330 Telephone Number: (508)-866-2576 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: e X Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: /:)drAd Date: 03/02/2006 The system inspector shall submit a copy f 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 System Passes. Recommend zabel filter. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 Page of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 97 Sixth Avenue West Hyannisport,MA.02672 Owner: Elizabeth Shortsleeve Date of Inspection: 03/02/2006 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 passes.Recommend regular service. 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(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: Page 3 of 11 z OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 97 Sixth Avenue West Hyannisport,MA. 02672 Owner: Elizabeth Shortsleeve Date of Inspection: 03/02/2006 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 "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: f T41. c r .,f;—F,,,-.,,All s0000 3 f Page.4 of 11 OFFICIAL INSPECTION FORM=NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 97 Sixth Avenue West Hyannisport,MA. 02672 Owner: Elizabeth Shortsleeve Date of Inspection: 03/02/2006 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No _X_ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool —X— Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool —X_ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool _X_ Liquid depth in cesspool is less than 6"below invert or available volume is less than''/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 _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 the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered "yes"in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. Page.5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 97 Sixth Avenue West Hyannisport,MA. 02672 Owner: Elizabeth Shortsleeve Date of Inspection: 03/02/2006 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)] Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 97 Sixth Avenue West Hyannisport,MA. 02672 Owner: Elizabeth Shortsleeve Date of Inspection: 03/02/2006 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): Number of bedrooms(actual):3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330gpd Number of current residents: 0 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):Yes(yr round use approx 1 year ago) Water meter readings, if available(last 2 years usage(gpd)): N/A Sump pump(yes or no):NO Last date of occupancy: Approx 3 months C OMMERCIALANDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no):_ Non-sanitary waste discharged to the Title 5 system(yes or no):_ Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Pumped after Inspection. Was system pumped as part of the inspection(yes or no):Yes If yes,volume pumped: 1,500 gallons--How was quantity pumped determined?Sight tube on truck Reason for pumping: Check tanks structural integrity. TYPE OF SYSTEM _X_Septic tank, distribution box, soil absorption system Single cesspool Overflow cesspool _Privy No Shared system(yes or no)(if yes,attach previous inspection records,if any) _Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight tank _Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: System was installed in 2000 per as built plan of system. Were sewage odors detected when arriving at the site(yes or no): NO Page,7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 97 Sixth Avenue West Hyannisport,MA. 02672 Owner: Elizabeth Shortsleeve Date of Inspection: 03/02/2006 BUILDING SEWER(locate on site plan) Depth below grade: 19" Materials of construction:_cast iron X 40 PVC_other(explain): Distance from private water supply well or suction line:N/A Comments(on condition of joints,venting,evidence of leakage,etc.): Building sewer is in good condition. SEPTIC TANK: X (locate on site plan)(Inlet has riser 4"below grade) Depth below grade: I I" Material of construction: X concrete_metal_fiberglass polyethylene —other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions: 8' x 5'-8" x 5'-2" Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle: 31" Scum thickness: 1 '/2" Distance from top of scum to top of outlet tee or baffle: 12" Distance from bottom of scum to bottom of outlet tee or baffle: 18" 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.): tees in good condition.Tank is structurally sound.No evidence of leakage in or out. 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.): T;rIA r„­ ti—T7-fit nnn 7 Page 8of11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 97 Sixth Avenue West Hyannisport,MA. 02672 Owner: Elizabeth Shortsleeve Date of Inspection: 03/02/2006 TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass_polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: X (if present must be opened)(locate on site plan)(19"below grade) Depth of liquid level above outlet invert: 0 Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): Distribution box is level and distributing evenly.No evidence of solids carryover.No evidence of leakage in or out of the box. PUMP CHAMBER: (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances, etc.): Page0 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 97 Sixth Avenue West Hyannisport,MA. 02672 Owner: Elizabeth Shortsleeve Date of Inspection: 03/02/2006 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required) If SAS not located explain why: Type _ _leaching pits,number: _X_leaching chambers,number: 4 H-20 Infiltrators 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.): Soil is dry.No evidence of hydraulic failure.Vegetation is normal.No ponding on the surface. 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 or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding, condition of vegetation,etc.): PRIVY: (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): Aii;i')nnn 9 i Pagcal0 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 97 Sixth Avenue West Hyannisport,MA.02672 Owner: Elizabeth Shortsleeve Date of Inspection: 03/02/2006 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. . 02 c A is 3 y C31 - i z NIS . T;t1. 1;Tno—t;nn T; r—A 1 nnn 10 i Pagv-, llofII OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 97 Sixth Avenue West Hyannisport,MA. 02672 Owner: Elizabeth Shortsleeve Date of Inspection: 03/02/2006 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 8'+ 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: 7/13/00 _X_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: No indication of groundwater at 8'+ Per local topography.There is a slope in the topography in the neighboring properties.Also information taken from as built plan date 7/13/00 no groundwater encountered @ at least 96". +++ A Title.V inspection is often misunderstood to suggest that we are conducting I complete inspection of your system. A Title V inspection is limited to determining if, at the time of the inspection,the existing septic system is functioning. The State of Massachusetts has outlined specific tests that are to be performed,which will be completed during your Title V inspection. However, a Title V inspection,and the } inspection that Wind River Environmental is performing hereunder,does not evaluate I if the system was installed correctly,has been engineered in accordance I local regulations, or whether the.system will continue to function in he future. It also does not evaluate whether the system would meet the past, current,or future Board a Health or State DEP regulations. A system can pass Title V but still not meet state or local requirements or be suitable for continued use. If the customer would like a complete inspection of their system,including an evaluation as to the design and t suitability of your system,Wind River Environmental can provide a quote as to the cost of such services. As well,Wind River Environmental strongly recommends persons interested in buying a home to have a full and complete system evaluation before purchasing a new home. inspection in determining if the Anew home buyer should not rely on a Title V system will function in the future,and instead should commission a complete system inspection. j T;Ha c r­A f;--W,.,Y„An r,110nn 11 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 97 Sixth Avenue Property Address Maria McFall Owner Owner's Name information is required for West Hy p annis ort MA 02632 05/28/10 every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form.Inspection forms may not be altered in any way. Important: A. General Information When filling out forms on the /, computer,use 1. Inspector: 01 only the tab key to move your Michael Kellett cursor-do not Name of Inspector use the return key. Aardvark Environmental Inspection Company Name P.O. Box 896 Company Address East Dennis MA 02641 ' City/Town State Zip Code 508-385-7608 S13742 Telephone Number License Number B. Certification I certify that 1 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'.inspec ion was performed based on my training and experience in the proper function and maintenance of on site-re sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The System: t ® Passes ❑ Conditionally Passes ❑ Fails I �-j ❑ Needs Further Evaluation by the Local Approving Authority �;G 1.�� .� 05/28/10 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. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 97 Sixth Avenue Property Address Maria McFall Owner Owner's Name information is required for West Hy p annis ort MA 02632 05/28/10 every page. Cgrrown State Zip Code Date of Inspection 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.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 exfiftration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. * A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND Explain: ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ obstruction is removed Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 97 Sixth Avenue Property Address Maria McFall Owner Owner's Name information is sequined for West Hy p annis ort MA 02632 05/28/10 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ 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: 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. Commonwealth of Massachusetts Title 5 Official Inspection Form MINW Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 97 Sixth Avenue Property Address Maria McFall Owner Owner's Name information is required for West Hyannisport MA 02632 05/28/10 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ 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 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 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 the ground 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 Y2 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. El ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 97 Sixth Avenue Property Address Maria McFall Owner Owner's Name information is required for West Hy p annis ort MA 02632 05/28/10 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cunt.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No ❑ ® 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 eyes"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 11 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. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M , 97 Sixth Avenue Property Address Maria McFall Owner Owner's Name information is required for West Hy p annis ort MA 02632 05/28/10 every page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done.You must indicate ayes"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? ® ❑ 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? ® El available 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 ® El 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(f any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)) c r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 97 Sixth Avenue Property Address Maria McFall Owner Owner's Name information is required for y p West H annis ort MA 02632 05/28/10 every page. Cityrrown State Zip Code Date of Inspection 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 gpd x#of bedrooms): 330 Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Sump pump? ❑ Yes ® No 10/09 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 Water meter readings, if available: Last date of occupancy/use: Date Other(describe): Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 97 Sixth Avenue Property Address Maria McFall Owner Owner's Name information is required for West Hy p annis ort MA 02632 05/28/10 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: 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 records, if any) ❑ Innovative/Altemative technology.Attach a copy of the current operation and maintenance contract (to be obtained from system owner) ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components,date installed (f known) and source of information: 08/13/02 per BOH Were sewage odors detected when arriving at the site? ❑ Yes ® No Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 97 Sixth Avenue Property Address Maria McFall Owner Owner's Name information is required for West Hy p annis ort MA 02632 05/28/10 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): Depth below grade: 1.4 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.): Septic Tank(locate on site plan): Depth below grade: 0.7 feet Material of construction: concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: Years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No -------------------------------------------------------------------------------------------------------------------------- Dimensions: 1500 gal _ 3„ Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle 28" 210 Scum thickness Distance from top of scum to top of outlet tee or baffle 7„ Distance from bottom of scum to bottom of outlet tee or baffle 16" How were dimensions determined? measured Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments '7M 97 Sixth Avenue Property Address Maria McFall Owner Owner's Name information is required for y p West H annis ort MA 02632 05/28/10 every page. Cityrrown state Zip Code Date of Inspection D. System Information (cunt.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage, etc.): The tank was sound and tight with tees in place and liquid at outlet invert. Grease Trap (locate on site plan): Depth below grade: feet 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: Date 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): r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ' M 97 Sixth Avenue Property Address Maria McFall Owner Owner's Name information is West H annisport MA 02632 05/28/10 required for y every page. City/Town State Zip Code Date of Inspection D. System Information (cunt.) Tight or Holding Tank(cont.) 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 Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert even 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.): The box was level and tight with no sign of carryover. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No • Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 97 Sixth Avenue Property Address Maria McFall Owner Owner's Name information is required for West Hy p annis ort MA 02632 05/28/10 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): i Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ® leaching chambers number: 4 ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number,dimensions: ❑ overflow cesspool number. ❑ innovative/attemative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding,damp soil, condition of vegetation, etc.): The system has four infiltrators surrounded by three feet of stone.There was no sign of ponding or failure in the stones. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM 97 Sixth Avenue Property Address Maria McFall Owner Owner's Flame information is sequined for West Hyannisport MA 02632 05/28/10 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 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 Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 97 Sixth Avenue Property Address Maria McFall Owner Owner's Name information is West Hyartnisport MA 02632 05/28/10 requiredfor State Zip Code Date of Inspwion every page. ( !town D. System information (cant.) 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. ra 3a r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments wM 97 Sixth Avenue Property Address Maria McFall Owner Owner's Name information is required for y p West H annis ort MA 02632 05/28/10 every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ❑ Surface water ® Check cellar ❑ Shallow wells Estimated depth to high ground water: 4.6 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: You must describe how you established the high ground water elevation: I augered to 5.0 feet and found no water. I adjusted to 4.6 feet. Bottom of leaching is at 3.0 feet HIGH GROUND-WATER LEVEL COMPUTATION Date: (� (� Permit: Site Location: '1 Phone: Owner: phone: Contractor: (dotes: STEP 1 Measure depth to water table / Et 0to nearest 1/10 ft. Date: ��! r'D(depth is in feet below land surface) m d yye w STEP 2 Using Water-level Range Zone and Index Well Map locate site and determine: w A) Appropriate index well g) Water-level range zone. STEP 3 Using monthly"Current Water Resources 6 f r Conditions" determine current depth to water level for index well. mm/yy STEP 4 Using Table of potential Water Level Rise for index well(STEP 2A),current depth to via l level for index well (STEP 3), leve D 4 0 zone (STEP 20) determine water-level adjustment. STEP ` � 0 Estimate depth to high water by subtracting the water-level adjustment(STEP 4)from measured depth to water level at site (STEP 1). NOTE* Tables 1-9 Pote�a{Water-Level (Rise are attached asworksheeEs�this file. monthly index well data: www•cape�cDtnmission.org/wells.htmI No. Dl(lib& Fee 5 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: es PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 2pplication for Migo!5al *p5tem Construction Permit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) Complete System ❑Individual Components Location Address or Lot No. 4 6 L).�_ Owner's Name,Address and Tel.No. 111•••� Assessor's Map/Parcel k �� ��'V Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. 1lINA 1S p�►s �Dt \� • Type of Building: Dwelling No.of Bedrooms _3;1 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 3O gallons per day. Calculated daily flow -7s - N gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. "I kKCA �— Description of Soil —j.A- S ' Nature of Repairs or Alterations(Answer when applicably 9 Se j ( '(-�a�V, 0- 1 ^ k. S �A- sin—.:— u 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 nvironmental Code and not to place the system in operation until a Certifi- cate of Compliance h of Health. Signed Date Application Approved by A Date DD Application Disapproved for the fol o tng easons Permit No.a 0fa' — q C'? Date Issued No. '. ." Fee THE COMMONWEALTH OF MASSACHUSETTS ;Entered in computer: des PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 01pplicatiop for Diopoe al 6potem Construction 3permit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) Complete System ❑Individual Components \Location Address or Lot No. c � A U Owner's Name,Address and Tel.No. Assessor's Ma /Parcel Assess p �, (� r `�1 --�X p`7 Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. 1 `L' ,C C % i \T � Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures e" Design Flower gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank ���Q�.� 't Type of S.A.S. F7 Description of Soil Vil`- <'c c t Y t Nature of Repairs or Iterations(Answer when applicabl ) 1 �� Se E,C—�au"V_ 0-eoc Ce,41 d,Gt'l r !)b-_ t ( tr(( U to w wee,A-f 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 nvironmental Code and not to place the system in operation until a Certifi- cate of Compliance ha`s�ieen-rs9Ted_15Y_ s of Health Signed f Date Application Approved by Date — //- Do Application Disapproved for the following reasons Permit No.96100 Date Issued --------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS (Certificate of Compliance THIS IS TO CERTIFY,that the On-site S wage Disposal System Constructed( )Repaired ( )Upgraded Abandoned( )by at D _45 ir/1+— ( has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No.)Qk2n— dated Insttaller Designer ~ The issuance of this pe t eshall1 not bconstrued as a guaranteeothat t e_s stem ill fat cti,n s esilned. Date'% InspectorL� J ��i r - ----c- ©--------------------------------' No. 8 Feer�J 4f' THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS , ig oar pgtefn Construction J)ermit Permission is hereby granted to Construct( )Repair( )Upgrad c--)~Abandon( ) System located at 70 51-A7� ✓C o r 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. Provided:Construction must be completed within three years of the date of this permit. Date: ' f — U Approved by U U6i99 ..rr NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. CER=CATION OF SKETCH -ND APPLICATION FORA DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANS) I, ® � hereby . that the application for y ce�y , p o disposal works construction permit sided by me dated '�'7--J VC/P concerning the property located at -00 SfeT(A-640e- meets all of the following criteria: F ZThe failed system is cone-ed to a residential dwelling only. T"nere are no commerc-.ai or business es associated with the dwellinz. The soil is classified as ,.S LAB y CT I and the percolation rate is less than or equal to 5 minutes pe:inch. n1/Tizere are no wetlands within 100 Fee;of the arocosed septic sysem ere are no private wets within 1:0 Pee:of the proposed septic srse:n There is no increase in flow and/or change in use proposed • nere are no variances requested or needed 4/ i ae bottom of the proposed leaching Pacility will not be located less than five feet above the ma..atnum adjured-oundwaier table elevation. [Adjust the g*oundwater table using the F-imntpr p �methcd when applicable] If the S.A.S. will be located with 2J0 Pee;of anv ve,euated wetlands, the b4ctom of the proposed leaching fac-Hirt'will net be located less than Ppurteea(1Y) fee,above the maxcimum adjured a*oundwater table e!evation, Please complete the following: 1�A) lop of Ground Surace -Elevation(using CIS in.formatian) G B) G.W. Elcr,,ation s1 - =the:NL-�-C ,i�h G.bV. .�djus-snent D=,RE`iCE BE-17V-E=N'a.and d SIGNED : DATE: [SI:e,Ch proposed plan Of System On backj. G:health roldcr. c ', :� o Q c� � Y w I �' TOWN OF BARNSTABLE _ n LOCATION ��7y Sy'�7��f SEWAGE # �'i 4.4 V VILLAGE % ASSESSOR'S MAP & LOT V IU I INSTALLER'S NAME&PHONE NO. AX/ SEPTIC TANK CAPACITY . LEACHING FACILITY: (type) ���D I i7617 r'��(size) i NO. OF BEDROOMS ��'' i BUILDER OR OWNS koPERMITDATE: COMPLIANCE DATE: 1 Separation Distance Between the: Maximum Adjusted Groundwater Table to the 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 l within 300 feet of leaching facility) Feet I. „Furnished by f'7 TOWN OF BARNSTABLE LOCATION v S 1X h SEWAGE # VII.LAGE ASSESSOR'S MAP & LOT V {. . ..INSTALLER'S NAME&PHONE NO. ��� � ��i � Av/--o SEPTIC TANK CAPACITY LEACHING FACILITY: (type) �9 i�f17-r (size) I C' NO. OF BEDROOMS BUILDER OR OWNE PERMITDATE. ��� COMPLIANCE DATE: Separation Distance Between the: i Maximum Adjusted Groundwater Table to the 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 exi-st within 300 feet of leaching facility) Feet Fttrrttsheds:hy r, 9147 t' .. .'- :.. I TOWN OF BARNSTABLE LOCATI 'ri D S/ 4 41t SEWAGE # rkQ0 —40� VILLAGE r. -o 'a' ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. ,N�/V SEPTIC TANK CAPACITY LEACHING FACILITY: (ty ) � /���T� (size) NO. OF BEDROOMS BUILDER OR OWNEF ell, PERMITDATE: COMPLIANCE DATE: 0 Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility �r' 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 16Tik fl i y y x d V IN� l