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HomeMy WebLinkAbout0140 SIXTH AVENUE (HYANNIS) - Health 140 Sixth Avenue M Hyannis P A'= 245 095 a r >r . ?� TOWN OF BARNSTABLE I,/ LOCATION / 0 & A Vc- SEWAGE # -=VILLAGE W. ��YT/��lil►�S oTa. ASSESSOR'S MAP & LOTay 091"� 1STALLER'S NAME&PHONE N0. L-a' SEPTIC S �UrlD TANK CAPACITY LEACHING FACILITY: (type) 8 T X Co (size) ^� NO.OF BEDROOMS 3 BUILDER OR OWNER ,�v1�4/>� Se.l �nCr PERMITDATE: COMPLIANCE DATE: 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 teaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leachi��g facility) Feet Furnished by�/1fDGGTI 33 ay 33 y _ O 3 Y 1 ` TOWN OF BARNSTABLE 1 LOCATION SEWAGE # _ VILLAGE ASSESSOR'S ASSESSOR'S MAP & LOT INSTALLER'S NAME& PHONE NO. SEPTIC TANK CAPACITY l�v LEACHING FACILITY: (type) 6` /� (size) NO.OF BEDROOMS BUILDER OR OWNER PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facili (If any wetlands exist within 300 feet o caching f Feet Furnished by y��y/y� / 33` � COMMONWEALTH OF MASSACHUSETTS UV EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 140 Sixth Avenue West Hvannisport, MA 02672 Owner's Name: Rodney Greaves -5r_T,9Sr3 Owner's Address: 5919 Morning Side Avenue Dallas, TX 75206 Date of Inspection:. January 11, 2006 r► Name of Inspector: (Please Print) Janes M. Ford w. Company Name: James M. Ford U) co t Mailing Address: P.O.Box 49 Osterville,MA 02655-0049 a{ ic > Telephone Number: (508)862-9400QU i tv — r- CERTIFICATION STATEMENT '0 M I certify that I have personally inspected the sewage disposal system at this address and that the i formation 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: January 16, 2006 The system inspector shall sub ' 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 I Page 2 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 140 Sixth Avenue West H a� nnisport. MA Owner: Rodney Greaves Date of Inspection: January 11, 2006 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 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: 2 Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 140 Sixth Avenue West Hvannisnort, MA Owner: Rodney Greaves Date of Inspection: January 11, 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 ainmonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: 3 Page 4 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 140 Sixth Avenue West HMA, Owner: _ Rodney Greaves Date of Inspection: January 11. 2006 D. System Failure Criteria applicable to all systems: You must indicate either"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 'h day flow ✓ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped_. ✓ Any portion of the SAS,cesspool or privy is below high ground water elevation. ✓ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ✓ Any portion of a cesspool or privy is within a Zone 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 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 System: 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. 4 Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 140 Sixth Avenue West Hvannisport, MA Owner: Rodney Greaves Date of Inspection: January 11, 2006 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? ✓ 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 detennined based on: Yes No ✓ _ Existing information. For example,a plan at the Board of Health. ✓ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)]. 5 Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 140 Sixth Avenue West Hyannisport. MA Owner: Rodney Greaves. Date of Inspection: January 11, 2006 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 Number of bedrooms(actual): 2 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 or no): No Is laundry on a separate sewage system(yes or no): No [if yes separate inspection required] Laundry system inspected(yes or no): No Seasonal use(yes or no): No Water meter readings,if available(last 2 years usage(gpd)): Unavailable Sump Pump(yes or no): No Last date of occupancy: Unknown COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present.(yes or no): Industrial waste holding tank present(yes or no) Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings,if available: Last date of occupancy/use`. OTHER(describe): GENERAL INFORMATION Pumping Records Source of infonnation: Unavailable Was system pumped as part of the inspection(yes or no): 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/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: Date of installation unknown Were sewage odors detected when arriving at the site(yes or no): No 6 Page 7 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 140 Sixth Avenue West Hvannisport, MA Owner: Rodney Greaves Date of Inspection: January 11, 2006 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 plan) Depth below grade: 16" 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: 1000 izal. Sludge depth: I" Distance from top of sludge to bottom of outlet tee or baffle: 30" Scum thickness: I" Distance from top of scum to top of outlet tee or baffle: 8" Distance from bottom of scum to bottom of outlet tee or baffle: 14" How were dimensions determined:. Measuring stick 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 were present. The liquid level was even with the outlet invert. There did not appear to be any signs of leakage GREASE TRAP: None (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.): 7 4 Page 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 140 Sixth Avenue West Hyannis,2ort, MA Owner: Rodney Greaves Date of Inspection: January 11, 2006 TIGHT or HOLDING TANK: None (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 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 D-Box was level. No solids were present. PUMP CHAMBER: None (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 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 140 Sixth Avenue West Hvannisport. MA Owner: Rodney Greaves Date-of Inspection: January 11. 2006 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type ✓ leaching pits,number: 1 -6'x 6'(1000 QaQ w/1'stone-Der as built card 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.): The nit was dry. The scum line was approximately 6"up from the bottom There did not appear to be any signs offailure The bottom to grade was 9'. The cover was 2'below grade CESSPOOLS: None (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: None (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.): - 9 Page 10 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 140 Sixth Avenue West Hyannisport, MA Owner: Rodney Greaves Date of Inspection: January 11, 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. A 3 q133 a �a 3a- 3 I� 33 g" 33 y ay 3a A y 0 O 3 y � a 10 7 - Page 11 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 140 Sixth Avenue West Hyannisport, MA Owner: Rodney Greaves Date of Inspection: January 11, 2006 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water. 18+/- 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: topographic and water contours snaps Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: Using Barnstable topographic and water contours maps the snaps were showing y roxitnately 18'+1-to-around water at this site: On the last inspection, I hand augered down to 11.5'below grade and no ground water was observed This report has been prepared and the system inspected and passed as of the date of inspection. This report is not a warranty or guarantee that the system will function properly in the future. There have been no warranties or guarantees, either expressed,written or implied,relating to the system, the inspection and/or this report. 11 I TOWN OF BARNSTABLE - ISI � LOCATION q1 sue%�i JG nl� SEWAGE # VILLAGE ASSESSOR'S MAP & LOT INSTALLER'S NAME S& PHONE NO. 6 SEPTIC TANK CAPACITY odd LEACHING FACILITY:(type) j (size) NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER (iL DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No )� i Fxs.... ...30.00 THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH� APPROVED TOWN OF BARNSTABLE Barnstable'rn rnstable Conservation Department(J Appliratilan for Dhgpaaal Works Tonstrurt' rust Date " . Application is hereby made for a Permit to Construct ( ) or Repair t'X? an Individual Sewage Disposal System at: 491 6th Ave West Hyannisport ............ _.........................................•-----------------------.........------ ....................................................--•-.......................................... Location-Address or Lot No. Bordon Bond Owner Address W J.P Macomber Jr. > W ........................................ ......................................... Installer Address UType of Building Size Lot............................Sq. feet DwellingXX No. of Bedrooms..............2_......._.._---------------Expansion Attic ( ) Garbage Grinder ( ) a Other—Type of Building ............................ ------------------.� No. of persons............................ Showers ( ) — Cafeteria ( ) 04 Other fixtures -------------------------------------------•----------.-----•---------•---•---------------•--•--•---••---------------------•••---••--.............---- y W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 01 ••-•----••-------•--•--•-----•-•--•---••••••--••----•••-----•-•--•--...-------•.....--•----•-.-•----......................................................... 0 Description of Soil........ a --- nd & Grave 1 x - --- ------------ W --•--------•----------------------------------------------------------------------------------------------------------------------------------------------............................................ U Nature of Repairs or Alteration —Answer when applicable._.............................................................................................. 1-1Q00___gallon tank-�._1-1000 gallon leaching pit. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Complia ce has ben i ued by the boa of hea h. Signed -.. . . -....... Dace Application Approved B . . ......� �/,/.. ------------------------------- - ,� '. ...... Dace Application Disapproved for the following reasons: ........................................ .............................................................--.....-- ----........... .............................................................................-- -- ------------------------------------- ------------ ......---------------.. .------...... .--------.....-------- ---...----- � Dace Permit No. � //1 1����......... Issued - --------- Date ' I No..-..A' ..� Fps....$ 30.00 THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 1 l� TOWN OF BARNSTABLE Apli irFatiun for Biupusal Works Tondrurtiun�Famd Application is hereby made for a Permit to Construct ( ) or Repair){ an Individual Sewage Disposal System at: 491 6th Ave West Hyannisport ........... -__--- .........................- ---es....-------•----.....------. ._... -...... ---------------------••-----------------...........---------..._..._.._........---... Location-Address or Lot No. Bordon Bond Owner Address a J P Mac omb e r J.....-- ..... --------------- - ..._......._ Installer Address d Type of Building Size Lot............................Sq. feet U Dwellin X�No. of Bedrooms..............?....__.........._...-_.__..Ex Expansion Attic Garbage Grinder Other—T g p ( ) ( ) e of Building a Type g ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Otherfixtures ................. ----------=-- -------------------------------------------------------------- W Design Flow............................................gallons per person per day. Total daily flo`w.............................................gallons. WSeptic Tank—Liquid capacity------------gallons Length--------------_ Width................ Diameter................ Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area--------------------sq. ft. Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area_.................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ W Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 44 Test Pit No. 2................minutes per inch Depth of.Test Pit.................... Depth to ground water........................ a --------------------------------------•-----------•------------•--------------------------......................................................... 0 Description of Soil._...._Sand--_... Grave 1....x ----------------------------------------------•------------------------------------------•--._......... U -----------------------•------------------...--------------------------•----------------•-...-------------------------------------------------------------•-----------------------•--------......_.----- W UNature of Repairs or Alterations.—Answer when applicable............................................................................................... 1.--1..000...fiallon tank' 1-1000 gallon leaching pit. --------------------•----. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued byA�oarof health. Signed �. I % / !Q/2�/92--------- Application Approved B -------- k.�. ---= ;- . .__ /. .. ----- .............................. Date Application Disapproved for the following reasons: -1 ........... ------------- ----------------------------- ------------------------------_--- ------- -------------------...................................................................------------------------.------------------------ ......................................... ----------------------------------- ----- --- Date Permit No. - !"----`_,A. --------------- Issued ----------- ` D to Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Ter#ifiratr of ICTInmyliance THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (XX ) by.....J..P,Macomber Jr. ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- Installer at �91-- 6th....Ave-..Wes-t----Hyanni.spc�.rt--------------------------------------------------------------------------.............................................................. has been installed in accordance with the provisions of TITLE�E?&ONSTRUED The Stale Environmental Code as described in the application for Disposal Works Construction Permit No. . . ���'.;` --- dated ... /-�.._ �1� THE ISSUANCE OF THIS CERTIFICATE SHALL NOT AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATEr ------------------------------------- Inspector -------------- -_--------------------------------------------- f � THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH No TOWN OF BARNSTABLE �, 3...0...-•--..00 ............:.....•-�--• FEE---•-----. .. Disposal Works W"111nutrudivit anti acomber J Permission is hereby granted.----J-'--P--_' --------------------------r--.------------------------------•---------------••-------•-•----•-•-----............---•--•----- to Construct ( ) or RepairX"(;X)l an Individual Sewage Disposal System at No........4RI.bth Ave__West Hyannisport -------------------------------------•------------....--------------------•--------...-----... Street /S �1 as shown on the application for Disposal Works Construction Permit 4No�"'�..°'.:�____.._._._. Dated_..._.'.... ..`.-,�`�. .......... ! . .......... /� . r" Board of Health DATE_ FORM 36508 HOBBS&WARREN.INC..PUBLISHERS COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS _ DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET. BOSTON, MA 02108 617.292.5500 WILLIANI F.WELD TRUD1'CO? Govcmor Sc.reu ARGEO PAUL CELLUCCI D.a\ID B. STRUi Lt.Govcmor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Commissior PART A CERTIFICATION Property Address: 140 6th Ave W. Hyannisport MA Address of Owner: P.O.A. Date of Inspection: 2/19/98 (If different) Edward Bond Name of Inspector:jn--eph P Macomber Jr. 729 Cornerstone Lane I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000) Bryn MaurPA Company Name: J.P.Macomber & Son Inc. 19010 Mailing Address: BOX 66 Centerville,Mass . 02632 Telephone Number: 5OR-775-1138 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: Zpasses- - Conditionally Passes Needs Further Evaluation By the Local Approving Authority, _ Fails Inspector's Signature: Date:The System System Inspecto all submit a copy of this inspection report to the Approving Authority within thirty (30) days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to rfse system owne and copies sent to the buyer, if applicable, and the approving authority. INSPECTION SUMMARY: Check A, B, C, or D: AI 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: BI SYSTEM CONDITIONALLY PASSES: AY One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upor 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 Compthance (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 ex-filtration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 04/25/97) Page 1 of 10 DEP on the World Wide Web: http:/Ayww.magnet.state.ma.0 sloe p Printed on Recycied Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 140 6th Ave West Hyannisport,Mass. Owner: Ruth Bond C/O Edward Bond P.O.A. Date of Inspection: 2/19/98 B) SYSTEM CONDITIONALLY PASSES (continued) .LQ Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, sealed 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 IJO The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed C) FURTHER EVALUATION 15 REQUIRED BY THE BOARD OF HEALTH: /Vt_ 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 PR TECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: LeAah Hl- NO Le"peol mr privy is within 50 feet of a surface water Gr privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT 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. i 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. t-fP 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 X// (approximation not valid). 3) OTHER (revised 04/25/97) Page 2 of 20 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 140 6th Ave West Hyanni sport,Mass . Owner: Ruth Bond C/O Edward Bond P.O.A. Date of Inspection: 2/1 9/9 8 DJ SYSTEM FAILS: You must indicate ewer "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 comet the failure. Yes No _ -lam/ 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 level in tq distribution box above outlet invert due to an overloaded or clogged SAS or cesspool T Liquid depth in c4ccpee4 is less than 6" below invert or available volume is less than 1/2 day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe($). Number of times pumped D Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply Any portion of a cesspool or privy is within a Zone I of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with nc acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. El LARGE SYSTEM FAILS: You must indicate either "Yes" or "No" as to each of the following: The following criteria apply to large systems in addition to the criteria above: 1-16 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 wfery 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 it 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 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 140 6th Ave West Hyanni sport,Mass. owner: Ruth Bond C/O Edward Bond P.O.A. Date of Inspection:2/1 9/9 g Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Yes No •i.z/, Pumping information was provided by the owner, occupant, or Board of Health. 411 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 N/A. _ The facility or dwelling was inspected for signs of sewage back-up. The system does not receive non-sanitary or industrial waste flow. _ The site was inspected for signs of breakout. _ All system components, eluding the Soil Absorption System, have been located on the site. The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. The size and location of the Soil Absorption System on the site has been determined based on: _ The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of Sub-Surface Disposal System. Existing information. Ex. Plan at B.O.H. _ Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) (15.302(3)(b)). (revised 04/25/97) P&g• 4 of 10 651 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 140 6th Ave West Hyanni sport,Mass . Owner: Ruth Bond C/o Edward Bond P.O.A. Date of Inspection: 2/1 9/9 8 FLOW CONDITIONS RESIDENTIAL: Design flow: 3Y6 g.p.d./bedroom for S.A.S. Number of bedrooms: IP Number of current residents: >/ Garbage grinder (yes or no): Vb Laundry connected to system (yes or no):_24 Seasonal use (yes or no): 4.0 Water meter readings, if available (last two (2) year usage (gpd): 7 910K Sump Pump (yes or no): .C/D G r Last date of occupancy:4 < COMMERCIAUINDUSTRIAL: Type of establishment: ill* Design flow: A,�4 allons/day Grease trap present: (yes or no)'VA Industrial Waste Holding Tank present: (yes or no) V4 Non-sanitary waste discharged to the Title 5 system: (yes or no)44 Water meter readings, if available:�J¢ Last date of occupancy:_/'' OTHER: (Describe) Last date of occupancy: x GENERAL INFORMATION PUMPING RECORDS and source of information: 1)W19 System pumped as part of inspection: (yes or no)&0 If yes, volume pumped: allons Reason for pumping: 4,0 TYPE OF SYSTEM ,z,-fleptic tank/distribution box/soil absorption system _GVZ Single cesspool .Ge' Overflow cesspool Privy 1 _ Shared system (yes or no) (if yes, attach previous inspection records, if any) �d _ I/A Technology etc. Copy of up to date contract? Chher -1,4 APPROXIMATE AGE of all components, date installed (if known) and source of information. /U !' .�� �1 Sewage odors detected when arriving at the site: (yes or no)Ab (revised 04/25/97) ?&g• 5 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address:140 6th Ave West Hyanni sport,Mass. Owner: Ruth Bond C/O Edward Bond P.O.A. Date of Inspection:2/1 9/9 8 BUILDING SEWER: (Locate on site plan) Depth below grade: Material of construction: _cast iron /40 PVC _ other (explain) Distance from Iprivate water supply well or suction line Diameter Y_ Comments: (condition of joints, veliting, evidence of leakage, etc.) SEPTIC TANK:ldtV,,4" (locate on site plan) Depth below grader Material of construction: concrete _metal _Fiberglass _Polyethylene _other(explain) If tank is metal, list age Is age confirmed by Certificate of Compliance (Yes/No) Dimensions:Sludge depth: hA . Distance from top of sludge to bottom of outlet tee or baffle:Z?4—ele- Scum thickness: � . Distance from top of scum to top of outlet tee or baffleAaaffle Distance from bottom of scum to bottom of outlet tee How dimensions were determined: Comments: (recommendation for pumping, conditi of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) t GREASE TRAP:/e (locate on site plan) Depth below grade:A'>� Material of con struction;(6lconcrete4gmetaWAFiberglass4Lo4 Polyethylene440ther(explain) Dimensions: �lt14 Scum thickness:--A(r� Distance from top of scum to top of outlet tee or baffle:d/, Distance from bottom of scum to bosom of outlet tee or baffle:10A Date of last pumping: 1111 Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) " 1 ;- (revised 04/25/97) Page 6 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 140 6th Ave West Hyanni sport,Mass . Owner: Ruth Bond C/O Edward Bond P.O.A. Date of Inspection:2/19/98 TIGHT OR HOLDING TANK:�P-(Tank must be pumped prior to, or at time, of inspection) (locate on site plan) Depth below grader Material of construction:NAconcreteaR metal 4ffiberglassN±lPolyethylene/yAother(explain) 014 - AA Dimensions: AM Capacity: IJA gallons Design flow: gallons/day Alarm level: All Alarm� in working order�Yes. �Nu Date of previous pumping: p Comments (condition of inlet tee, condition of alarm and float switches, etc.) �Y 7�A� S ,c7r� 7 /1�c�ifr DISTRIBUTION BOX:,Z (locate on site plan) Depth of hr-, d level above outlet inven: X/0 Comments: (no a if level and distribute is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) i PUMP CHAMBER:Ah4-V (locate on site plan) Pumps in working order: (Yes or No) //9 Alarms in �sorking order (Yes or No)_" Comments: (note condition of pump chamber, condition of pumps and appunenances, etc.) (revisal P.g• 7 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 140 6th Ave West Hyannisport,Mass. Owner: Ruth Bond C/O Edward Bond P.O.A. Date of Inspection: 2/1 9/98 SOIL ABSORPTION SYSTEM (SAS): tfdD ;locate on site plan, if possible, excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: Type: 1 leaching pits, number: leaching chambers, number: leaching galleries, number: leaching trenches, number,length: leaching fields, number, dimgfysions: overflow cesspool, number: D Alternative system: iE A Name of Technology: 7 Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition cif vegetation, etc.) j' s' r O/e jD11 l J7 CESSPOOLS:I��v� (locate on site plan) Number and configuration: ,tli9 r Depth-top of liquid to inlet invert: ,A,4 Depth of solids layer-. AIW Depth of scum layer: IC44 Dimensions of cesspool. Materials of construction: Indication of groundwater: /Y inflow (cesspool must be pumped as part of inspection) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) e"ev PRIVY:xzbv+e (locate on site plan) Materials of construction: Dimensions: Depth of solids:./eA Comments: (note condition of soil, signs of-hydraulic failure, level of ponding, condition of vegetation, etc.) rl//Y (rovis•d 04/25/91) ➢&g• 8 of 10 f 'G SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM:INFORMATION (continued) Properly Address: 140 6th Ave West Hyanni sport,Mass. Owner: Ruth Bond C/O Edward Bond P.O.A. Date of inspection 2/1 9/98 SKETCH OF SEWAGE DISPOSAL SYSTEM: irc'lude ties to at least two permanent references landmarks or benchmarks locate all wells within 100' (locate where public water supply comes into house) I� p Ss*4h Aye, w• oc�}' y t t� MI 1. MI � 1 Bch I (rovlf.d 04/25/97) ➢ay• 9 of 10 SUBSURFACE SEWAGE DISPi : SYSTEM INSPECTION FORM I . C SYSTEM INFOI: . :ION (continued) Property Address: 140 6th Ave West Hyannisport,Mass. Owner: Ruth Bond C/O Edward Bond P.O.A. Date of Inspection: 2/1 9/9 8 Depth to Groundwater 14 'Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Obs rvatio Cite Abuttin rope bservation hole, basenxni-s.rmp etc.) Determine it from local conditions Check with local Board of health Check FEMA Maps heck pumping records Check local excavators, installers Use USGS Data Describe in your own words how you established the High GrounciwaterElevation. Must be completed) Used Groundwater Contours Map. Based on Gahrety & Miller Model 12/16/94 (r.vi..L 04/25/97) of 10 yy ran r,r•n.r:--rr arn.-tm n�rrnn.mr.rr..r.:•.�.:+vn:•nr-e-nm rrs�tt*�a-s�cr.ms+ s*ra*r.--erra-a.rn-r—v- r—r-..- r- TOWN OF Barnstable BOARD OF HEALTH + S(1IISURFACF SFWAQE DISPOSAL SYSTEM INSPFCTION FORM - PART D .- CERTIFICATION If �- F•••-r-.-r•. ..r--.ir-.--nrrm•rtrnr-..rasrxrrT-rn rtimrisrnm-�ms+r r� mnn�.ms•r•+•eiv-m�r.�.:—.r r.-•r--�. •-..A -TYPE OR PRINT CI.EARLY- PROPERTY INSPECTED STREET ADDRES$ 140 6th Ave West Hyanni sport,Mass. ASSESSORS MAP , BLOCK AND PARCEL OWNER' s NAME Ruth Bond• C/0 Edward Bond P.O.A. PART D - CERTIFICATION 1 NAME OF INSPECTOR Joseph P.Macomber Jr. . COMPANY NAME J.P.Macomber & Son Inch ' COMPANY ADDRESS Box 66 Centerville,Mass. 02632 Street Town or City State iIP COMPANY TELEPHONE ( 508 ) 775 - 3338 FAX ( 508 � 790 - 1 578 R CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported is true , accurate , and complete as of the time of :inspection . The inspection was performed and any recommendations regarding upgrade , maintenance , and repair are consistent with my training and experience in the proper function and maintenance of on- site sewage disposal systems . Chec one : 2System PASSED The inspection which I have conducted has not found any information which indicates that the system fails to adequately protect public health or the environment as defined in 310 CMR 16 . 303 . Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form . System FAILED* The inspection which I have con acted has found that the system fails to Protect the j-,ublic health and the environment in accordance with Title .5 , 310 CMR 15 . 303 , and as specifically noted on PART C - FAILURE CRITERIA of this inspection form . Inspector Signature Date7 . One copy of this ce t.ification must be provided to the OWNER, the BUYER ( Where applicable ) and the BOARD OF H EAL711. * If the inspection FAILED, the owner or""operator shall upgrade the system within one ,year of the date of the inspection , unless allowed or required otherwise as provided in 3.10 Ch1R 16 , 305 . purtd . doc /< Fl THE COMMONWEALTH OF M.,A.SS.A.CHUSETTS 7DEPARTMMNT OF ENVIRONMENTAL PROTECTION BE IT KNOWN THAT Joseph P. Macomber, Jr. Has satisfied the Department's qualifications as required and is hereby authorized to use the title CER i i D TITLE S SYSTEM INSPECTOR as provided in 310 CMR 15.340 and Section 13 of Chapter 21A of the General Laws . Issued by The Department of Environmental Protection. June 8. 1"S Arung Dat-cctor of 0he �� 1SIon of W21ct Pollution Control G COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTfi>✓,- JUN _L 7 2003 TOWN OF c- ABLE HEALTH DE'T. TITLE 5 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 140 Sixth Avenue West Hyannisport, MA 02672 Owner's Name: Mark Seidner Owner's Address: Date of Inspection: May 30, 2003 Name of Inspector: (Please Print) James M. Ford Company Name: James M. Ford Map: 245 Mailing Address: P.O. Box 49 Parcel: 095 Osterville,MA 02655-0049 Lot: 491 Telephone Number: (508)862-9400 CERTIFICATION STATEMENT. 1 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 Con .tionally Passes Nee s urther Evaluation by the Local Approving Authority Fail Inspector's Signature: Date: June 1, 2003 The system inspector shall subm copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that - time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 Page 2 of 1 I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 140 Sixth Avenue West Hyannisport, MA Owner: Mark Seidner Date of Inspection: May 30, 2003 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: ✓ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally 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 Hea_Ith): 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: 2 i Page 3 of 1 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 140 Sixth Avenue West Hyannisport, MA Owner: Mark Seidner Date of Inspection: May 30, 2003 C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 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: 3 Page 4 of 1 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 140 Sixth Avenue West Hyannisport, MA Owner: Mark Seidner Date of Inspection: May 30, 2003 D. System Failure Criteria applicable to all systems: You must indicate either`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 '/z day flow ✓ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped_. ✓ Any portion of the SAS,cesspool or privy is below high ground water elevation. ✓ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ✓ Any portion of a cesspool or privy is within a Zone 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 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.l 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 System: 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. 4 Page 5 of 1 I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 140 Sixth Avenue West Hyannisport, MA Owner: Mark Seidner Date of Inspection: May 30, 2003 Check if the following have been done: You mast 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? ✓ 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 backup? ✓ 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 No ✓ Existing information. For example, a plan at the Board of Health. ✓ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)]. 5 Page 6 of I I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 140 Sixth Avenue West Hyannisport, MA Owner: Mark Seidner Date of Inspection: May 30, 2003 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 Number of bedrooms(actual): 2 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 or no): No Is laundry on a separate sewage system (yes or no): No [if yes separate inspection required] Laundry system inspected(yes or no): No Seasonal use(yes or no): No Water meter readings, if available(last 2 years usage(gpd)): Unavailable Sump Pump(yes or no): No Last date of occupancy: Weekend use COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no) Non-sanitary waste discharged to the Title 5 system (yes or no): Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Unavailable Was system pumped as part of the inspection (yes or no): 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/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: Unknown Were sewage odors detected when arriving at the site(yes or no): No 6 Page 7 of I 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 140 Sixth Avenue West Hyannisport, MA Owner: Mark Seidner Date of Inspection: May 30, 2003 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 plan) Depth below grade: 16" 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: 1000 gal. Sludge depth: /" Distance from top of sludge to bottom of outlet tee or battle: 30" Scum thickness: 1" Distance from top of scum to top of outlet tee or baffle: 8" Distance from bottom of scum to bottom of outlet tee or baffle: 14" How were dimensions determined: Measuring stick 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 were present. The liquid level was even with the outlet invert. Recommend pumping every two years GREASE TRAP: None (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.): 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: 140 Sixth Avenue West Hyannisport, MA Owner: Mark Seidner Date of Inspection: May 30, 2003 TIGHT or HOLDING TANK: None (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 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 D-box was level. No solids were present. PUMP CHAMBER: None (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 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 140 Sixth Avenue West Hyannisport, MA Owner: Mark Seidner Date of Inspection: May 30, 2003 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type ✓ leaching pits, number: 1 -6'x 6'(1000 gal.) with ]'stone-per as built card 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.): The pit was dry. The scum line was approximately 6"up from the bottom. There were no signs of failure. The bottom to grade was 9'. The cover was T below grade. CESSPOOLS: None (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.): PRIM': None (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.): 9 Page 10 of 1 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 140 Sixth Avenue West Hyannisport, MA Owner: Mark Seidner Date of Inspection: May 30, 2003 Map: 245 Parcel: 095 SKETCH OF SEWAGE DISPOSAL SYSTEM Lot: 491 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. A B 1 q 33 a is 3a- 3 33 8A yQy33 3A �A y O O 3 y � a 10 Page I I of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 140 Sixth Avenue West Hyannisport, MA Owner: Mark Seidner Date of Inspection: May 30, 2003 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 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: The bottom of the leach pit to grade was 9'. 1 hand augered down on the bottom of the leach pit to 11'6"below grade, and no water was observed. Using the Cape Cod Commission Technical Bulletin, the high ground water adjustment for this site(M1 W 29 Zone A 4103)was 0.3'. This report has been prepared and the system inspected and passed as of the date of inspection. This report is not a warranty or guarantee that the system will function properly in the future. There have been no warranties or guarantees, either expressed, written or implied, relating to the system, the inspection and/or this report. 11 - . 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