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HomeMy WebLinkAbout0137 STRAIGHTWAY - Health 11, STRAIGHTWAY, HYANNIS A=268 216 o ` e L o , 4 Commonwealth of Massachusetts y�J� _ Title 5 Official Inspection Forums Subsurface Sewage Disposal System Form .-Not for Voluntary Assessments 137 Straight Way Property Address Pereira Owner Owner's Name information is Hyannis ✓ MA 02660 09/01/2013 required for every y 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. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information on the computer, use only the tab 1. Inspector: - key to move your cursor-do not A.Riker T7 use the return Name of Inspector �+ y Riker Land Construction cel), rah Company Name M PO Box 726 ' Company Address South Yarmouth MA 02664 P-R " ? City/Town State Zip Code_ , 508-776-6460 S14590 Telephone Number License Number B. Certification 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 ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 09/01/2013 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. /bM t5ins•3l13 Title 5 Official Inspection Vub..ftce Sewage Disposal g posy System•Page 1 0117 Commonwealth of Massachusetts Title 5 Official Inspection Foam a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 137 Straight Way Property Address Pereira Owner Owner's Name information is required for every Hyannis MA 02660 09/01/2013 page. City/Town 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: On inspection of septic system there were no obvious failures observed . B) System Conditionally Passes: ❑±One or more system components as described in the "Conditional Pass"section need to be replaced or repaired.The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements.If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): st5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts _ r Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 137 Straight Way Property Address Pereira Owner Owner's Name information is required for every Hyannis MA 02660 09/01/2013 page. City/Town State Zip Code Date of Inspection -B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.) ❑ Observation of sewage backup or break out or high static water level in the distribution box due 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 ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):. ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed^ ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water El Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13' _ Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Tile 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 137 Straight Way Property Address Pereira Owner Owner's Name information is required for every Hyannis MA 02660 09/01/2013 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health(and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health,, safety and environment: " ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within `. . 100 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 aseptic tank and SAS and the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis,performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 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 1/2 day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 F Commonwealth of Massachusetts W Title 5 Official inspection Fora o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 137 Straight Way Property Address ' Pereira Owner Owner's Name information is required for every Hyannis MA 02660 09/01/2013 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. t ❑ ® 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 F laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] The system is a cesspool serving a facility with a design flow of 2000gpd- - ® 10,000gpd. The system fails. I have determined that one or more of the above failure ® criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. 'For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area-1WPA)or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins 3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 ti Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 137 Straight Way Property Address Pereira Owner Owner's Name information is required for every Hyannis MA 02660 09/01/2013 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate "yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? Z ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ' ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 GPD t5ins•3113 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth-of Massachusetts. u Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 137 Straight Way Property Address Pereira Owner Owner's Name information is required for every Hyannis MA 02660 09/01/2013 page. City/Town State Zip Code Date of Inspection D. System Information Description: System was installed in April 12,1994 per date on C.O.C. Number of current residents: 2 Does residence have a garbage grinder? - ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection El Yes ® No information in this report.) Laundry system inspected?, ® Yes ❑ No Seasonal use? ❑ Yes Z No Water meter readings, if available Oast 2 ears usage 2012 = 126 GPD 9 y 9 (gPd)) 2011=114 GPD Detail Sump pump? ,. ❑ Yes ® No Last date of occupancy: current 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: t5ins•3/13 Title 5 Official Inspecdon Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts lugTitle 5 official Inspection Forums Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 137 Straight Way Property Address Pereira Owner Owner's Name information is required for every Hyannis MA 02660 09/01/2013 page. City/Town State Zip Code Date of Inspection D. System Information (cont.)- , Last date of occupancy/use: Date Other(describe below): General Information - Pumping Records: ' Source of information: homeowner Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons a , How was quantity pumped determined?'. Reason for pumping: Recommended every two years 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) El Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract (to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract El Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): a t5ins•.3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 137 Straight Way Property Address Pereira Owner Owner's Name information is required for every Hyannis MA 02660 09/01/2013 page. . City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age,of all components, date installed (if known) and source of information: Installed in 1994 Were sewage odors detected when arriving at the site? ❑ Yes ® 'No k Building Sewer(locate on site plan): ` M Depth below grade: 1.5 ,,. feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): ,Distance from private water supply well or suction line: feet k Comments(on condition,of joints, venting, evidence of leakage, etc.): Dry PVC on interior with no obvious leaks or stains Septic Tank(locate on site plan): 3 Depth below grade: 2 feet Material of construction: ® conc'rete El me ❑fiberglass El polyethylene ❑ other(explain) 1000 gallon precast concrete'`, If tank is metal, list age: years Is age confirmed by a'Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 5'x5'x8'6" .Sludge depth: t5ins•:3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ° 137 Straight Way Property Address Pereira Owner . Owner's Name information is required for every Hyannis MA 02660 09/01/2013 page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 26" Scum thickness 2" Distance from top of scum to top of outlet tee or baffle 5" Distance from bottom of scum to bottom of outlet tee or baffle 13" How were dimensions determined? Sludge Judge Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): No obvious failures observed. Recommended risers on inlet and outlet. 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 t5ins'•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 137 Straight Way Property Address Pereira Owner Owner's Name information is required for every Hyannis 'MA 02660 09/01/2013 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: i ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts _ Tide 5 Official Inspection Forums Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,.' 137 Straight Way Property Address Pereira Owner Owner's Name information is required for every Hyannis MA 02660 09/01/2013 page. City/Town State Zip Code Date of Inspection D. System Information (cunt.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert equal to invert on outlet pipe Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): no evidence of failures or carryover at distribution box Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No` F Alarms in working order: ❑ Yes ❑ No" Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): *8 f,pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins, 113. Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Tile 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 137 Straight Way Property Address Pereira Owner Owner's Name information is required for every Hyannis MA 02660 09/01/2013 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 4x Hi-Capacity infiltrators ❑ leaching galleries~ number: leaching trenches number, length: El 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.): System is constructed of four High Capacity Infiltrators with stone wioth no indications of failure in area of S.A.S. 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 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 137 Straight Way '`• Property Address i Pereira r Owner Owner's Name information is required for every Hyannis MA 02660 09/01/2013 page. City/Town State Zip Code Date of Inspection D. System Information (cont ) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): v� 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.) y . t5ins 3113 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 14 of 17 � a Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 'I o 137 Straight Way Property Address Pereira Owner Owner's Name information is required for every Hyannis MA 02660 09/01/2013 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary:A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 w Commonwealth of Massachusetts Title S Official Inspection Forums s Subsurface Sewage Disposal System Form Not for Voluntary Assessments 137 Straight Way Property Address Pereira Owner Owner's Name information is required for every Hyannis MA 02660 09/01/2013 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building..Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately a 3 o o 711, t5ins•.3l13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 - Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 137 Straight Way Property Address Pereira Owner Owner's Name information is required for every Hyannis MA 02660 09/01/2013 page. City/Town 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: 10+ 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: Permit on file dated 4/12/1994 ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database- explain: You must describe how you established the high ground water elevation: Abutting observation hole with in proximity of S.A.S. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONTMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION t � y• TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 137 STRAIGHTWAY HYANNIS Owners Name: PEREIRA Owner's Address: SAME Date of Inspection:5/2/06 Name of Inspector: (please print) Douglas A.Brown Company Name: Douglas A.Brown Septic Inspections Mailing Address:P.0 Box 145 Centerville,MA 02632 Telephone Number: 508-420-4534 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: X Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: 5/2/06 The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer,if applicable, and the approving, authority. Notes and Commentsl.,-_ system installed 1994 MEETS MINIMUM REQUMNENTS AT THIS TM E,INFILTRATORS WERE NOT OPENED CAN NOT PREDICT FUTURE PREFORMANCE ****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 Revised on 10/31/2000 I Page 2 of 11 OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 137 STRAIGHTWAY HYANNIS Owner's Name: PEREIRA Owner's Address: SAME Date of Inspection: 5/2/06 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 winch indicates that any of the failure criteria described in 3 10 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: INFILTRATORS WERE NOT OPENED,NO OBSERVATION PORT B. System Conditionally Passes: one or more system components as described in the"Conditional Pase'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 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): f µ _ �. rbroken pipes)are:replaced obstruction is removed distribution box is leveled or replaced 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 ` Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 137 STRAIGHTWAY HYANNIS Owner's Name: PEREIRA Owner's Address: SAME Date of Inspection: 5/2/06 C.Further-Evaluation is Required by the Board,ofHealth: 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 15.3030)(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 I of a public water supply. _ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well".Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: Page 4 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 137 STRAIGHTWAY HYANNIS Owner's Name: PEREIRA Owner's Address: SAME Date of Inspection:5/2/06 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 1/2 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 An ortion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface - - YP P P vY ppy ry s e 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 3 10 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 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 y8$'m 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 Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 137 STRAIGHTWAY HYANNIS Owner: PEREIRA Date of Inspection: 5/2/06 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. _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is'nnacceptable) [310 CMR 15.302(3 ))(b)j 5 Page 6 of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 137 STRAIGHTWAY HYANNIS Owner's Name: PEREIRA Owner's Address: SAME Date of Inspection. 5/2/06 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN How based on 3 10 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Number of current residents: 2 Does residence have a garbage grinder(yes or no): NO Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required] Laundry system inspected(yes or no): NA Seasonal use: (yes or no): NO (� - Water meter readings,if available(last 2 years usage(gpd)): OS ' 2�0 0 V� Sump pump (yes or no): NO Last date of occupancy: COMMERCIAL/INDUSTRIAL: Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sqft,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: OWNER PUMPED 2-06 Was system pumped as part of the inspection(yes or no): NO If yes,volume pumped: 1000 gal gallons--How was quantity pumped determined? Reason for pumping: MAINTENANCE TYPE OF SYSTEM X Septic tank,distribution box, soil absorption system _Single cesspool _Overflow cesspool _Privy --- -- _Shared system(yes or no)(if yes,attach previous inspection records,if any) _Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system awner) —Tight tank _Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: 4 HIGH CAP INFILTRATORS INSTALLED 1994 J.P MACOMBER 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 137 STRAIGHTWAY HYANNIS Owner's Name: PEREIRA Owner's Address: SAME Date of Inspection: 5/2/06 BUELDING 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: 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: 1000 gal Sludge depth: TRACE Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: TRACE Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: How were dimensions determined: TAPE Comments(on pumping recommendations,inlet'and outlet tee or baffle condition, structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.)- TANK LOOKS STRUCTUALLY SOUND AT THIS TR E.PUMOED 02-06 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.): Page 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 137 STRAIGHTWAY HYANNIS Owner's Name: PEREIRA Owner's Address: SAME Date of Inspection: 5/2/06 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: (if present must be opened)(locate on site plan) 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.): 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.): Page 9 of 11 OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address:..13 7 STRAIGHTWAY HYANNIS Owner's Name: PEREIRA Owner's Address: SAME Date of Inspection: 5/2/06 SOIL ABSORPTION SYSTEM(SAS): _(locate on site plan,excavation not required) If SAS not located explain why: 4 HIGH CAP INFILTRATORS INSTALLED 1994 J.P MACOMBER NO OBSERVATION PORTS FOUND Type leaching pits,number: leaching chambers,number: leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number: X innovative/alternative system Type/name of technology: INFILTRATORS Comments(note condition of soil, signs of hydraulic failure,level of ponding,damp soil, condition of vegetation, etc.): COULD NOT OPEN,NO OBSERVATION PORTS FOUND 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.): Page 10 of 11 OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: I13377ASTTNIAISGHTWAY Owner's Name: PEREIRA Owner's Address: SAME Date of Inspection: 5/2/06 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. 3- 9-7 y--39 13 ,1 2- 3G 3, 0 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: 137 STRAIGHTWAY HYANNIS Owner's Name: PEREIRA Owner's Address: SAME Date of Inspection: 5/2/06 SITE EXAM Slopc: 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: TOWN OF BARNSTABLE k LOCATION X"I~I TV V,*X � SEWAGE # VILLAGES _ASSESSOR'S MAP& LOT Lb INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY, LEACHING FACILITY: (type) 1��I.t'n c,d1.0 (size) NO.OF BEDROOMS BUILDER OR OWNER LJ CA PERMI TDATE: ,i0� COMPLIANCE DATE: Separation Distance Between the: k C)I Feet Maximum Adjusted Groundwater Table and Bottom of Leaching Facility 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 A. Feet within 300 feet of leaching facility) Furnished by �° N w r l5 O dc7 .G Co N i tro w o w s - r TOWN OF BARNSTABLE LO _AT1ON /l 7 S I'sgi cHr tu/^ y SEWAGE # VILLAGE q.V.t//S ASSESSOR'S MAP & LOT INSTALLER'S NAME & PHONE NO. i0,4 c o A4 Be,C r SEPTIC TANK CAPACITY / 000 LEACHING FACILITY:(type) //jc �/ 'i (size)-3, zY NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER OR OWNER ',r% DATE PERMIT ISSUED: "^ DATE COMPLIANCE ISSUED: � '• � VARIANCE GRANTED: Yes No /� d d` o r; ,\ i , LOCATION I ✓� SEWAGE PERMIT NO. VIL/LAGS INSTA LLER'S NAME i ADDRESS a0u �)ol/ .M&6:2, , , / BUILDER OR OWNER DATE PERMIT ISSUED DATE COMPLIANCE ISSUED .� I .mil �� '� .. 8 _ COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL DEPARTMENT OF EN jRoNMENTAL PROTE ONOor ONE WINTER STREET, BOSTON MA 02108 (617) 292-5500 � 8 1998 WILLIAM F.WELD TRUDY'G'OXE Secretary Governor ARGEO PAU OL CELLUCCI IIs ILA STRUHS C ,nt++;ssioner Lt. Governor Mk n �`� SUBSURFACE SEWAGE DISPOSAL SYST'Eb1 IIVSPECTION FORM f PART A WT— t b CERTIFICATION Property Address to �tS Address of Owner: V "`� �� � 1uC_-� Date of Inspection: �(t O O r (If different) Name of Inspector: M t C ire z" I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000) Company Name: r ` 1-- Mailing Address:'7 i'i r� T< Telephone Number: Cry •— "11— 1 c`- CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: Passes _ Conditionally Passes _ Needs Further Evaluation By the Local Approving Authority Fails Inspector's Signature: Date: u, The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (30) days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. INSPECTION SUMMARY: Check A, B, C, or A A] SYSTEM PASSES: I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. CO NTS: B] SYSTEM CONDITIONALLY PASSES: One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain why not. _ The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection. or the �. septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfrltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approve by the Board of Health. (revised 04/2SM). Page 1 or to I' t SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A ' CERTIFICATION (continued) Property Address: e m Owner:`• t Date of Inspection: B) SYSTECONDITIONALLY PASSES (continued) . _ Sew/age backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or __`due'to a broken. settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health). oj a °Describe observations: broken pipe(s) are replaced obstruction is removed distribution box is levelled or:replaced The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will'pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed CJ FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further eva luation b 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 DETER.Mr4ES THAT THE SYSTEM IS NOT FUNCTIOh-P4G EN A . MANNER WIUCH WILL PROTECT THE PUBLIC HEALTH AND SAFETY A:ti'D THE ENVERONNIENT: _ Cesspool or privy is within 50 feet of a surface water vegetated wetland or a salt marsh. Cesspool or privy is within 50 (eel of a bordering ve g 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERNIINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet to a surface water supply or tributary to a surface water supply. _ The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well. _ The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis fcr coli(otm 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 (appro)dmation not valid). 3) OTHER (revised 04125/97) Page 2 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Owner: Date of.Inspection: D] SYSTEM FAILS: You must indicate either "Yes" or "No" as to each of the following: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped _. Any portion of the Soil Absorption System. cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet-but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E] 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: The system serves a facility with a design (low of 10,000 gpd or greater (Largc System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area - IWPA) or a mapped Zone II 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 04125/97) Page 3 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 3 I J�►� y�� Owner: N Date of Inspection:160(�L II �j 6 Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Yes No Y _ Pumping information was provided by the owner, occupant, or Board of Health. None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. As built plans have been obtained and examined. Note if they are not available with 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. excluding 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 conditior of baffles or tees, naterial of construction, dimensions, depth of liquid, depth of sludge, depth of scum. —The size and location of the Soil Absorption System or.the site has been determined based on: +X'c The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of Sub- Surface Disposal System. r IA 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 04M/97) 'Page 4 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: { 5QM4,Tw Ownerpc, 1 Date of Inspection: a(/ ( C' 4 V FLOW CONDITIONS a RESIDENTIAL: Design flow: Q p.d./bedroom for S.A.S. Number of bedrooms: Number of current residents:_Q Garbage grinder (yes or no): jQ Laundry connected to system (yes or no): Seasonal use (yes or no):_jV Water meter readings, if available (last two (2) year usage (gpd): Aj Sump Pump (yes or no):__ Last date of occupancy: (a COMMERCIAL/INDUSTRIAL: Type of establishment: Design flow:_gallons/day Grease trap present: (yes or no)_ Industrial Waste Holding Tank present: (yes or no)_ Non-sanitary waste discharged to the Title S system: (yes or no)_ Water meter readines, if available: Last date of occupancy: OTHER: (Describe) Last date of occupancy: GE\'ERAL INTOPUN ATION, PUNEPING RECORDS and source of information: IL nO• p c(Ij 1J System pumped as part of inspection: (yes or no)­LJO) If yes, volume pumped: s•allons Reason for pumping: F SYSTEM i Septic tic tank/distribu[ion box/soil absorption system Single cesspool Overflow cesspool Privy Shared system (yes or no) (if yes, attach previous inspection records, if any) I/A Technology etc. Copy of up to date contract? Other APPROXIMATE AGE of all components, date installed (if known) and source of information: _tI1L, Sewage odors detected when arriving at the site: (yes or no) 1 (tensed 04/25197) Page S of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C ' SYSTEM INFORMATION (continued) Property Address: 131 U-6A-4-, Owner: NC7 Date of Inspection:<�(,b BUILDING SEWER.- (Locate on site plan) Depth below grade: Material of construction: _cast iron _40 PVC other (explain) Distance from private water supply well or suction line Diameter Comments: (condition of joints, venting. evidence of leakage, etc.) SEPTIC TANK: �J (locate on site plan Depth below grade:7,*,�I (2 Material of construction: _&concrete _metal_Fiberglass _Polyethylene —other(explain) If tank is metal. list ace _ Is age confirmed by Certificate of Compliance _(Yes/No) Dimensions: (060�64' Sludge depth:_ Distance from top of sludge to bottom of outlet tee or baffle:_ Scum thickness: I Ct Distance from top of scum to top of outlet tee or baffle:1L .) Distance from bottom of scum to bottom of outlet ee or baffle:__ How dimensions were determined: Comments: recommendation for pumping. condition of,nlet and outlet tees or baffles, depth of liquid level in relation to outl t invert, structural integri ( evi encc of leakage. etc.) U r '� p r.� 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: (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.) (revised 04/25/97) Page 6 of 10 x A SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C r SYSTEM INFORMATION (continued) Property Address: Owner: �j(, 1 Date of Inspection: TIGHT OR HOLDING TANK: (Tank must be pumped prior to, or at time, of inspection) (locate on site plan) Depth below grade: Material of construction: _concrete _metal _Fiberglass _Polyethylene _other(explain) Dimensions: Capacity: gallons Design flow: gallons/day Alarm level: Alarm in working order _ Yes. _ No Date of previous pumping: Comments: (condition of inlet tee, condition of alarm and float switches. etc.) tISTRIBUTION BOX:��(,S (locate on site plan) VV Depth of liquid level above outlet invert: VA d Comments: note if level nd distr''bution^is equal. evidence of solids car over, a Bence of leaks a into Rr out of box, etc.) ( �h l� � y�(� �d 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.) (revised 04/25/97) Page 7 or to ' h SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: UvQ Date of Inspeon: SOIL ABSORPTION SYSTEM (SAS): (locate on site plan, if possible: excavation of required, but may be approximated by non-intrusive methods) If not determined to be present, explain: Type: leaching pits, number:_leaching chambers, number: '.�V- t t_ Q(f{� leaching galleries, number: leaching trenches. number.length: leaching fields, number, dimensions: overflow cesspool, number: Alternative system: Name of Technology: Comments: (note condition of soil signs of ydraulic failure, level of ponding Qnditto of ve cation, etc.) No ( N - CESSPOOLS:.._L—o (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 (cesspool must be pumped as part of inspection) 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.) (raised 04/25/97) Page 8 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: NC-1 Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) L ° - 39 �L-- 2, N- W A3 - �,� �3- 31 M -3z, `�' 32 (revised O4/2S/97) Page 9 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property�A`ddress: Owner: \v Date of Inspection: !to ��I[„ lv � r � v Depth to Groundwater Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observation of Site (Abutting property, observation hole, basement sump etc.) Determine it from local conditions Check with local Board of health Check FEMA Maps Check pumping records Check local excavators, installers Use USGS Data Describe in your own words how you established the High Groundwater Elevation. Must be completed) ►2 I 161 Nu w�. `� o i o►� �� rnr T-qS A-T- 6� (rerlsed O4/25/97) Page 10 of 10 APPROVED DV ............ ' •\CtyTHE COMMONWEALTH OF MASSACHUSETTS h BOARD OF HEALTH TOWN OF BARNSTABLE Ap.pliration fur Di-tipasal lVarkii Tongtrnrtiun ramit Application is hereby made for a Permit to Construct ( ) or Repair TXk§ an Individual Sewage Disposal System at: 137 Straight Way Hyannis ,Mass . 0 .......................................................-..........-•.............................. .-----•••-----••••••-•----•-••------•---•----------•-•---•-•-----...._.........-------•--•-•••--•. Anna Ng Location-Address or Lot No. Owner Address W J .P.Macomber Jr . Installer Address Type of Building Size Lot............................Sq. feet .� Dwelling-X No. of Bedrooms--------------2---------------------.-----Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ---------------------------- No. of persons---------................... Showers ( ) — Cafeteria ( ) dOther fixtures --------------------------------------------------------------------------------------- -----•---------•-•----•-•-•••--•-•--•---•--••-----••--....... 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 ( ) Percolation Test Results Performed by.............................................................. ----------- Date....................................... Test Pit No. 1................minutes per inch Depth of Test Pit......-_----.-...__ Depth to ground water------------------------ 44 Test Pit No. 2................minutes per inch Depth of Test Pit..........------.... Depth.to ground water........................ 9 .......-•--•..............................................••----•...--••--------•-•••---•---.._......._..••-•-••••••-•-----••----•.........-•••--•-•--••-•-- O Description of Soil......................................Sand & Gravel .•--•-•---•-•--•-••-••••----------•--------------------------•---------------•--•••......----•-••••----•-•-•••................ W U W x ------------------------------------------------------------------------------ -•--------------•-•-------•-----------•---------------------------------••---•-•----•••-•--•...-••-••--••--•-•••......... U Nature of Repairs or,Alterations—Answer when applicable......l-1000 as l l on tank 1-d s i t r ibut i on box--- .. ..n...�Zt..r:a.t.i7:rG-- Omit two cesspools . ----------------------------------------------------••-•-....-•---- 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 e has b en ' sued y the bo rd of alth. ---- ---------a1 f 9 Date Application Approved y - .._.................._... .. ... .. ............................... �J... ..� �� -...... Dae Application Disapproved for the following reasons- ----------- ---- ------------------------------------------------------------------------------------------------------------------ ....... ....... .............................................................................................................................. Permit No. -------IS?--- -------------------- Issued ..............y h �,....-.. Dto No................--....... Fss.... ,Ag,-\C�yTHE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Appliration for Bi-tipooal lVark.6 Cnon.itriirtion ramit Application is hereby made for a Permit to Construct ( ) or Repair TXh an Individual Sewage Disposal System at: 137 Straight Way Hyannis,Ma_ss. 0 ......................•---------------•-•--•-------------•-••-----•-------•---•--------•--•--..... --------••------------------------•---•-------•-------------•-•-•-•-----------•---•-•....-•-•-..-• Location-Address or Lot No. Anna Ng W J. P.Macomber Jr.Owner Address Installer Address Type of Building Size Lot...........................Sq. feet �-t Dwelling,-X No. of Bedrooms--------------2---------------------------Expansion Attic ( ) Garbage Grinder ( ) a Other—Type of Building ____________________________ No. of persons-------------------_........ Showers ( ) — Cafeteria ( ) Other fixtures 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........................ a --•----------------------------------------•----•-•---------------•----------•-•-----------•--------......................................................... Description of Soil......................................Sand & Gravel x W x ----- --------------- ---- ---------------------•-•------.........--------------..........---------- ---•-----------------------------•-----------------------•-------------•---•-----••---------------- U Nature-of Repairs or Alterations—Answer when applicable.-..--1-1000 gallon tank 1-d s i t r i but i on box Omit two cesspools . •--•- ----------------------••-------------•-•.....----------------•-•-------•----•-------------------•---------•••-••------•---------------------....------..---- 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 C;d7j2 ce has b en issued y the board of ealth. ign lit........ 4/8/9-�------- �`_ Dace ApplicationApproved By r �' .......... ----------.----- ---------------------------------------------------------------------._---- .61. J ��y....... Application Disapproved for the following reafonf- ------------------ ---------- ----------------------------------------------------------------------------------------------------- .... ................................ ............................................. ............ .. . ............................... -- . .... ........................................ PermitNo. ................................ ............................. Issued ............ /2................................ yDate Dare _-- - ———__————.———————---—_---—_———.———.—_.—————— ——.—.— ________ _ _ THE COMMONWEALTH OF MASSACHUSETTS — BOARD OF HEALTH TOWN OF BARNSTABLE (141e tiftrate of (ILTo pliance THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (XXX) J.P.Macomber Jr . by ................................ .. .._.... .........------------------- 1".11- at .---137 Straightway Hyannis ,Mass. - ------------------ - .. .............._..... _... _......._------------------------------------- has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as de cribed in the application for Disposal Works Construction Permit No. ..Gl.`/.`..L. ....._...._.. dated ------ ��./..el Z c�. ....__... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARA, TEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. / -- DATE -------........ '...t�'�. .7- ------------------------------- Inspector - ----- ..-�' ' '' ......_... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Dispopal Workii Tonotrurtion "Permit J P Macomber Jr. Permissionis hereby granted---------------•--------••------------.....---------••---------------------•---------------------------------....------.....---------••••--- to Construc (( ) or Repair (XX) an Individual Sewage Disposal System 1�7 Straightway Hyannis,Mass - atNo............................................................................................................................................................. ....... .................... Stree as shown on the application for Disposal Works Construction Permit tNO. /59._ Dated__<�!C_.��........I/ --------------------------------------------------------------------------------------------------------- Board of Health DATE ---22 -!-•----•---------------------------- FORM 36508 HOBBS WARREN.INC..PUBLISHERS