HomeMy WebLinkAbout0005 SYLVAN DRIVE - Health 5 SYLVAN DRIVE, HYANNIS �
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TOWN OF BARNSTABLE
LOCATION EWAGE # "
VILLAGE }�pJ ASSESSOR'S MAP St LOT
'S NAME 6i PHONE NO. A & B CANCO -
INSTALLER 775 6264
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SEPTIC TANK CAPACITY 1600
LEACHING FACILITY:(type) Z- (size) O O
NO. OF BEDROOMS_,J_PRIVATE WELL OR PUBLIC WATER ,I
BUILDER O OWNER Z7bN N i r iC GO�►��`��—
DATE PERMIT ISSUED: O - S5 s
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DATE COMPLIANCE ISSUED: a- 9 Sl
VARIANCE GRANTED: Yes No '�
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Town of Barnstable
P.0, Box 534
q, _ �?�l Hyannis, Massschus tts Q�''�1
No.... _ Fxs....a 4?._..:............
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
....'�G+W.IJ....................0F....�IP RRPS`i'A.:S�-L�
Appliration for Dispaa al Workii Cnnnitrnrtiun runfit
Application is hereby made for a Permit to Construct ( ) or Repair (J() an Individual Sewage Disposal
System at:
S_.........................................LY N �NtvoS��c�R' ...
-......-•••--•••....... .•-•--•---•-...•-•-••••...............••--•-- ------••-•--•--------•-•......-••--•-----•
Location.Address or Lot No.
......5...§_AAA.P•.:!� - .......N Au iS?Oa`r.
Owner Address
a ! " ,&?► G ....... ----•...........� nw1�w� --=--`''e �- lq_r .Srn�. .......
Instal ler Address
Type of Building Size Lot............................Sq. feet
U
r Dwelling—No. of Bedrooms...............I...........................Expansion Attic ( ) Garbage Grinder ( )
C14 Other—Type of Building ---------------------------- No. of persons.....................------. Showers ( ) — Cafeteria ( )
a' Other fixtures ............................... . .
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
c4 Septic Tank—Liquid'capacity............gallons Length................ Width................ Diameter---............. Depth................
W Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft.
x
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....----------........--.
Test Pit No. 2................minutes per inch Depth of Test Pit............---..... Depth to ground water.....----...........----
--------•-------------------------------------------------••----------------•---•--------•-••.-•----.........................................................
0 Description of Soil........................................................................................................................................................................
x
U ------------------••---•--------------•---------------------------------------------•-•............----•-•-••-•------------------•---•-------....------------------------••-•-------------•------------
W
---------------------------------------------------------------------------------------•-•------------------------------------------------------------------------------------------•---
U Nat re of Repairs or Alterations—Answer when applicable-.-- ....J,.P---1.0.0-0...-�HGj�l1 -•- •1-Ir
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of iITI LE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health.
p
Signed. 1 ................................. ......j..`111%.-•-
Date
Application Approved By................ --••-•-•------------------ ••--•---- e' ^
Date
Application Disapproved for the following reasons:---•--....-•---•-•---------••------•---••----------•---•-•----....-•---•-------•---------•---------•------•••---
---•------•----------------•-----------•-----•------....--•---------•----...-----••-•---••-•-••••----------••-•-•-•---•-••---••-----••------...-----•---•-----.........................................
Date
Permit No.-------- C S �' ------------- Issued-........................................................
Date
4? THE COMM ON.WEAL7TH. 'OF NI'ASSACH,USETTS
BO,A;R�D O"F H'EALT1-1.
v...
4n n prntf -
G-- Application i's hereby`made for a !Permit Ito Construct ( ) of -Repair ( " ); an. Individual ;5'ewage: +Disposal'`,
• " Sy8tP1114$t::' I - -
Location Address or Iota 2v0.
'�to _G.�- .- S�F�.a.. ..... :. ..---. ...�YLI+'!� �3�5-,• hY i
...
. Owner
........................... _ 4 rr•tN � r+ + �o u K .
W ul• �1
' Inataller � � Address
I Type%of Building. � � �� � � � � Size Lot: _ ::Sq ofeet
aD'wellin —No of Bedrooms _, Expansion`.Attic, {: )'_ Garbage, Grinder. ( )`
Other g T e ,of BuildinN,o: of persons
I Other
g -- (.. ..)
+ Other fixtures,
owers et eria
Design, Flow::... gallons per,person per day Total daily flow .._ gallons..
Septic Tank—Liquid.capacity gallons Length..................Width. Diameter t Depth
+' W` Disposal;Trench" N'o ... .. Width... _- ."T,,otal Length " _ .. ,'Total,leachi`g�area=;. _ ._sq. ft, `
' r Diameter inlet....... .......... Total leachin urea.. s -f SeeP a PtNo De th below qt
Z
Other Oisfiibufibnbox ( ): Dosing tank,( )
Percolations Test,Results Performed .by Date.:
~. Test Pit No; L.—_ ........minutes per inch Depth of Test Pit .........._.__...Depth ao;ground water
L�,r Test Pi't'No. 2..... ........nunutes�ner.;inch Depth;of Test,Pit ., Depth to ground,,'water___.:.:
+ a
O. Description oi'Soil'.- ... ---
... ----.. .._ ... .
V Nature of Repairs or Alterations Answer when applicable •s'v S. 9r4-t,. L r� 10,00 t-17&C.F,[q k
.. : .:_....... :__ ... ... . .....
Agreement f r
The undersigned..agrees to install then afoiedescnbed 'Indvvidual _Sewage Disposal System+m accordance with
the revisions of TI IE :5 of'th`e State'�Sanitar.: Code—The undersi"ned,further a 'ees not:to lace,the•s stem in
p z y g, gr P y
operation i n-til ca Certificate,of'Compliance,has been,issued by-the board.of'health.
.- c .. `
Signed
Applica`tiott Approved By} J .. � Date .
:Application Disapproved f or.'the f oldounng;'reasons:;. ,......
- G .._ .......................................................... ___
I . `P,ermit No.. JI f �G 47 Issued: - - Date
�; I. • ;Date et.,I"
T,HE COMMONWEA�LTI OF INASSACHUSETTS'
a.
BOARD OAF HEALt.H�;
t:.. OF
f�rr ftralb of in"'
l -
TFIIS IS CE' IFY, That the Ind uidual, Sewage Disposal System constructed ) or Repaired x
. _ ( ( )
by .. - �- ..........................
4, at .... --►� �8
I la
has been insfiffed in*'ccordance with th& royisions of TTT 5� h State Sanitary Code as descnbed in the
pp p kss Construction Permit No.:. � dated a hcanon for Dis oral Wor
1;.
YHE ISS4JANCE;eOF THIS CERTIFICATE,!SI-IALLPIOT'BE CONSYRIlEDAASPA GVARANYEE TIIAY.�NE
6 4 r µ, p
Sy' sum,•WILL, FUNCTION,9SATISFACT,OR�Y;, r
DATE. �. c. Inspector
__ . ,
THE,',COMMON-WEALTH OF MASSACHUSETTS' r ~`
' BOARD'- OF HEALTH
.... OF. :F � _..
w PeTrrussiori is'hereby;,granted !'J.� „^�� r r
to Construct )� Repair an Indivi Sewage Disposal System x
.a'
at No.. ..�.... i ._
'--...... .�. ..... -�-•-- -:Street ... ....... � ........ .........
as shown,on the application°for Disposals Works Construction Permit NO .::.5 l� .ated - ........,
22 t ..... ..... f.d-. .-. ..
•+ P'� } f'H a o c
r DATE..: ,, _
Board ; lth
FORM i!258 HOBBS W wARREN, INC -PUBLISHERS
lii.i.�•R_ � }}_ F�L .fir-.4 LMr� ._ ..-i. Yr�rL '_V. .'.L -_ _ . . -.�• ._ .� - _ �.. _ .-.. . _
FORM 30 �IhW HOBBSS WARREN THE COMMONWEALTH OF MASSACHUSETTS
• BOA D�EEhATH
CITIY TOWN
W —t
a '^ — �, D DEP TMENT 0) S,
'W� SV•.•` ADDRE /508) Q61 --L(&—1
TELEPHONE v
Address_ _ __Occupant___
Floor_NA- partrrent No.__/_✓____ No.of Occupants_ ._/l!►�"
No. of Habitable Rooms -t__ _ No.Sleeping Rooms __
No. dwelling or rooming units_ o.St ries
Name and addre s of ow r P
SPi
OL� emarks Reg. Vio.
YARD Out Bld s.: Fences.-
Garbage and Rubbish
Containers:
Drainage IV
Infestation Rats or other:
STRUCTURE EXT. Steps,Stairs, Porches: —
Dual Egress:and Obst'n.:
❑ B ❑ F ❑ M Doors,Windows:
Roof
Gutters, Drains.-
Walls:
Foundation:
Chimney:
BASEMENT Gen.Sanitation:
Dampness:
Stairs:
Li htin :
STRUCTURE INT. Hall,Stairway:
Obst'n.:
Hall, Floor,Wall,Ceiling:
Hall Lighting:
Hall Windows.-
HEATING Chimneys:
Central ❑ Y ❑ N E ui . Repair
TYPE: Stacks, Flues,Vents:
PLUMBING: Supply Line:
❑ MS ❑ ST ❑ P Waste Line:
H.W.Tanks Safety and Vent(s)
ELECTRICAL Panels, Meters,Cir.:
❑ 110 ❑ 220 Fusing,Grnd.:
AMP: Gen.Cond. Distrib. Box:
Gen. Basement Wiring:
DWELLING UNIT
Ventil. L to . Outlets Walls Ceils. Wind. Doors Floors Locks
Kitchen
Bathroom
Pantrys'
Den
Living Room
Bedroom 1
Bedroom 2
Bedroom 3
Bedroom 4 -]
Hot Water Facil. Sup.Ten.,Gas, Oil, Elect.:
St ks, Flues,V t feties:
Kitchen Facilities i
ove
Bathing,Toilet Facil. Vent., Plumb.,Sanit'n.:
Wash Basin,Shower or Tub:
Infestation Rats, Mice, Roaches or Other:
Egress Dual and Obst'n:
General :Building Posted
Locks on Doors:
ONE OR MORE OF THE VIOLATIONS CHECKED ABOVE IS A CONDITION WHICH
MAY MATERIALLY IMPAIR THE HEALTH OR SAFETY AND WELL-BEING OF THE
OCCUPANT AS DETERMINED BY 105CMR 410.750 OF THE CODE OR THE
AUTHORIZED INSPECTOR. See Over)
"THIS INSPECTION REPO T S SIGNED AND CERTIFIED UNDER THE PAINS AND
PENALTIES OF PERJU
INSPECTOR TITLE_(
DATE - .. O TIME l _
A.M.
THE NEXT SCHEDULED REINSPECTION A P.M.
t *''• is •r,.,° -1o+f v Nk` .t :'6�«` +';ar'..?n 'Cy" {.�,_,.
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410.750: Conditions Deemed to Endanger or Impair Health or Safety
The following conditions,when foundto exist in residential premises, shali be deemed conditions which may endanger or
impair the heaith, or safety and well-being of a person or persons occupying the premises. This listing is composed of those
items which are deemed to always have the potential to endanger or materially impair the health or safety, and well-being of the
occupants or the public. Because Chapter 11, 105 GMR 410.100 through 410.620 state minimum requirements of fitness for
human habitation, any other violation has the potential to fall within this category in any given specific situation but may not do so
in every case and therefore is not included in.this listing. Failure to include shall in no way be construed.as a determination that
other violations or conditions may not be found to fall within this category. Nor shall failure to include affect the duty of the local
health official to order repair or correction of such v olation(s) pursuant to 105 CMR 410.830 through 410.833 nor shall failure to
include affect the legal obligation of the person to whom the order is issued to comply with such order.
(A) Failure to provide a supply of water sufficient in quantity, pressure and.temperature, both hot and cold, to meet the ordinary
needs of the occupant in accordance with 105 CMR 410.180 and 410.190 for a period of 24 hours or longer.
(B),. Failure to provide heat"as required by 105 CMR 410.201 or improper venting or use of a space heater or water heater as
prohibited by 105 CMR 410.200(B)and 410.202.
(C) ,Shutoff'•and/or failure to restore electricity or gas.
(D) Failure to provide the electrical facilities required by 105 CMR 410.250(B), 410.251(A), 410.253 and the lighting in com-
mon area required by 105 CMR 410.254.
(E) Failure to provide a'safe supply of water.
(F) Failure to provide a toilet and maintain a sewage disposal system in operable condition as required by 105 CMR
410.150(A)(1)and 410.300.
(G) Failure to provide adequate exits, or the obstruction of any exit, passageway or common area caused by any object,
including garbage or trash, which prevents egress in case of an emergency 105 CMR 410.450, 410.451 and 410.452.
(H) Failure to comply with the security requirements of 105 CMR 410.480(D).
(1) Failure to comply with any provisions of 105 CMR 410.600, 410.601 or 410.602 which results in any accumulation of gar-
bage, rubbish, filth or other causes of sickness which may provide a food source or harborage for rodents, insects or other pests
or otherwise contribute to accidents or to the creation or spread of disease.
(J) The presence of leadbased paint on a dwelling or dwelling unit in violation of the Massachusetts Department of Public
Health Regulations for Lead Poisoning Prevention and Control, 105 CMR 460.000. (See M.G.L. c. 111 @@ 190 through 199.)
(K) Roof, foundation, or other structural defects that may expose the occupant or anyone else to fire, burns, shock, accident or
other dangers or impairment to health or safety.
(L) Failure to install electrical, plumbing, heating and gas-burning facilities in accordance with accepted plumbing, heating,
gas-fitting and electrical wiring standards or failure to maintain such facilties as are required by 105 CMR 410.351 and 410.352,
so as to expose the occupant or anyone else to fire, burns, shock, accident or other danger or impairment to health or safety.
(M) Any defect in asbestos material used as insulation or covering on a pipe, boiler or furnace which may result in the release
of asbestos dust or which may result in the release of powdered, crumbled or pulverized asbestos material in violation of 105
CMR 410.353.
(N) Failure to provide a smoke detector required by 105 CMR 410.482.
(0) Any of the following conditions which remain incorrected for a period of five or more days following the notice to or
knowledge of the owner of said condition or Condit ons:
(1) Lack of a kitchen sink of sufficient size and capacity for washing dishes and kitchen utensils or lack of a stove and oven
or any defect that renders either inoperable.
(2) Failure to provide a washbasin and showe-or bathtub as regdired in 105 CMR 410.150(A)(2)and 410.150(A)(3)or any
defect which renders them inoperable.
(3) Any defect in the electrical, plumbing or heating system which makes such system or any part thereof in violation of
generally accepted plumbing, heating, gasfitting,o-electrical wiring standards that do not create an immediate hazard.
(4) Failure to maintain a safe handrail or protective railing for every stairway, porch balcony, roof or similar place as
required by 105 CMR 410.503(A)and 410.503(B).
(5) Failure to eliminate rodents, cockroaches, insect infestations and other pests as required by 105 CMR 410.550.
(P) Any other violation of 105 CMR 410.000 not enumerated in 105 CMR 410.750(A)through (0)shall be deemed to be a con- `
dition which may endanger or materially impair the health or safety and well-being of an occupant upon the failure of the owner
to remedy said condition within the.time so ordered by the Board of Health.
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Parcel Lookup
Parcellnfo
Parcel ID'289-059-001 I Developer LOT 1
Lot
Location 15 SYLVAN DRIVE I Pri Frontage 1107
Sec Road PITCHER'S WAY I Sec
Frontage 128
Village HYANNIS I Fire District I HYANNIS
Sewer Acct I I Road Index 1678
Interactive ,
Map
Owner Info
i Owner JANDERSON, KARL E ( Co-owner
Streetl 50 GREAT WESTERN DR I Street2
city I HARWICH I State MA zip 02645 Country IUS
Land Info
Acres 10.28 use ISingle Fam MDL-01 I zoning I RB Nghbd 0107
Topography Level I Road Paved
Utilities Public Water,Gas,Septic ( Location
Construction Info
Building 1 of 1
Year 1957 ( Roof Gable/Hip I Ext Wood Shingle
Built Struct Wall
Effect AC
2514 I Roof Asph/F GIs/Cmp I pe None I
Area Cover Type
Bed
Style Cape Cod I wan Drywall I Rooms 3 Bedrooms
Model Int Bath
Residential I Floor Hardwood I Rooms 2 Full
Grade Average I Type Hot Water `I Rooms i8 Rooms
http://issgl/lntranet!propdata/ParcelDetail.aspx?ID=22058 3/27/2007
' Parcel Detail Page 2 of 3
GAR S "1
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Heat Found- ,
Stories 11 1/2 Stories Fuel Oil ( ation Conc. Block
FF+s;
BAD
Permit History
Issue Date Purpose Permit# Amount Insp Date Comments
- Visit History
Date Who Purpose
2/10/2005 12:00:00 AM Gary Brennan Data Mailer
11/9/2004 12:00:00 AM Paul Talbot Meas/Est
2/11/2002 12:00:00 AM Paul Talbot Meas/Listed
6/15/1988 12:00:00 AM ML•
- Sales History
Line Sale Date Owner Book/Page Sale P
1 9/17/2004 ANDERSON, KARL E C174428
2 11/7/2002 DALEY, MARSTON E &JEAN M TRS C167209
3 7/10/1998 DALEY, MARSTON F &JEAN M C149314
4 10/31/1996 MCCONNELL, ADRIENNE M C26069
5 MCCONNELL, JOHN.J&ADRIENNE C26069
Assessment History
Save# Year Building Value XF Value OB Value Land Value Total Parc(
1 2007 $199,000 $8,700 $0 $183,300
2 2006 $174,400 $8,700 $0 $184,600
3 2005 $156,500 $2,400 $0 $131,200
4 2004 $125,100 $2,400 $0 $98,400
5 2003 $111,300 $2,400 $0 $43,000
6 2002 $111,300 $2,400 $0 $43,000
7 2001 $111,300 $2,600 $0 $43,000
8 2000 $92,400 $2,500 $0 $32,100
9 1999 $92,400 $2,500 $0 $32,100
10 1998 $92,400 $2,500 $0 $32,100
11 1997 $84,200 $0 $0 $32,100
http://issql/intranet/propdata/ParcelDetail.aspx?ID=22058 3/27/2007
Commonwealth of Massachusetts
Executive Office of Environmental Affairs
Dept. of Environmental Protection
.titl
One winter Street' D.E.P. Title
V Septic
Boston Ma. 02108 pti
eptic Inspector
Y.O. Box 2119
Teaticta 2536
WILLIAM F.WELD 81564-6813
Governor t✓
ARGEO PAUL CELLUCCI
Lt.Governor C
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
c,te a� 5 Per o59 r��
Property Address: 5 Sylvan Dr.Hyannis Address of Owner: c�
Date of Inspection: 6/25/98 (If different) ®�
Name of Inspector: John Graci McConnell c/o Everson:21 Wren Ln.Mars tb a Milrs=026.48
I am a DEP approved syste inspector pursuant to Section 15.340 of Title%(310 CMR 15.000) I °
Company Name,Address and relephone Number:
CERTIFICATION STATEMENT
I certify that I have personally in pected the sewage disposal system at this address and that the information reported below is true, accurate
and complete as of the time of i pection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage isposal systems. The system:
x Passes This Inspection Is based on criteria defined In Title V
_ Conditio all aS5e5 code 310 CMR 15.303.My findings are of how the system is
y performing at the time of the Inspection.My Inspection does
_ Needs rt r Evaluation By the Local Approving Authority not Imply any warranty or guarantee of the longevity,of the
Fells septic system and any of Its components useful life.
Inspector's Signature: Date: 6130198
The System Inspector shall subn it a copy of this inspection report to the Approving Authority within thirty(30)days of completing this
inspections. If the system is a s iared 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 reg onal office of the Department of Environmental Protection.
The original should be sent to th system owner and copies sent to the buyer,if applicable and the approving authority.
INSPECTION SUMMARY:
Check A, B,C,or D:
A] SYSTEM PASSES:
x I have not found any inforr iation which indicates that the system violates any of the failure criteria
defined as in 310 CMR 15.303. Any failure criteria not evaluated are indicated below.
COMMENTS:
B] SYSTEM CONDITIONALLY PASSES:
_One or more system components need to be replaced or repaired. The system, upon completion
of the replacement or repa r,passes inspection.
Indicate yes,no,or not determi ed(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
Co7hpliance(attz ched)indicating that the tank was installed within twenty(20)years prior to the date of the inspection, or
i the septic tank,whether or not metal, is cracked,structurally unsound, shows substantial infiltration or exfiltration,or tank
failure is imminent.The system will pass inspection if the existing septic tank is replaced with a conforming septic tank
as approved by the Board of Health.
(revised 007M)
One Winter Street • Boston,Massachusetts 02108 • FAX(617)556-1049 • Telephone(617)292-5500
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 5 Sylvan Dr.Hyannis
Owner: McConnell c/o Everson:21 Wren Ln.Marstons Mills 02648
Date of Inspection:6125198
_ Sewaae backup or.breakout.or. hiah.static water level observed.in.the distribution box is due to a broken.
or obstructed pipe(s)or due to broken,settled or uneven distribution box.The system will pass inspection if
(with approval of the Board of Health). Describe observations:
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled 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
C] FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
Conditions exist which require further evaluation by the Board of Health in order to determine if the
system is failing to protect the public health, safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS
NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND
SAFETY AND THE ENVIRONMENT:
Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER,IF APPROPRIATE) DETERMINES
THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
The system has a septic tank and soil absorption system and is within 100 feet to a
surface of water supply or tributary to a surface water supply.
The system has a septic tank and soil absorption system and is within a Zone 1 of a public watersupply well.
The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well.
The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a
private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that
the well is free from pollution from that facility and the presense of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm. Method usedto determine distance (approximation not valid)
3)Other
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 in 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 duo to on overloaded or clogged
cesspool.
SAS is in hydraulic failure.
(revleed 04127S7)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 5 Sylvan Dr.Hyannis
Owner: McConnell c/o Everson:21 Wren Ln.Marstons Mills 02648
Date of Inspection:6125199
D]SYSTEM FAILS(continued)
Yes No
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 112 day flow.
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Numbers of times pumped
Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation.
i — — 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 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. 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:
The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to
public health and safety and the environment because one or more of the following conditions exist:
Yes No
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area(IWPA)or a mapped Zone 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 04127197)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECLIST
Property Address: 5 sylvan Dr.Hyannis
Owner: McConnell do Everson:21 Wren Ln.Marstons Mills 02648
Date of Inspection:6125198
Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following:
_c_ — Pumping information was requested of the owner,occupant,and Board of Health.
x None of the system components have been pumped for at least two weeks and the 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.
x As built plans have been obtained and examined. Note if they are not available with N/A.
x The facility or dwelling was inspected for signs of sewage back-up.
x — The system does not receive non-sanitary or industrial waste flow.
-x_ — The site was inspected for signs of breakout.
x All system components, excluding the Soil Absorption System, have been located on the site.
x 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.
x 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 Systens.
x Existing information. Ex. Plan at B.O.H.
x Determined in the field(if any failure criteria related to Part C is at issue,approximation of distance is
unacceptable)(15.302(3)(b)]
(revised 04127197)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 5 sylvan or.Hyannis
Owner: McConnell c/o Everson:.21 Wren Ln.Marstons Mills 02648
Date of Inspection:6125199
FLOW CONDITIONS
RESIDENTIAL:
Design flow: 440 g•p•d./bedroom for S.A.S.
Number of bedrooms: 4
Number of current residents: 0
Garbage grinder(yes or no): No
Laundry connected to system(yes or no): Yes
Seasonal use(yes or no): No
Water meter readings, if available:(Iast two(2)year usage(gpd):
rda
Sump Pump(yes or no): No
Last date of occupancy:6 months ago
i
COMMERCIAL/INDUSTRIAL:
Type of establishment: nia
Design flow:0 gallons/day
Grease trap present: (yes or no) No
Industrial Waste Holding Tank present:(yes or no) No
Non-sanitary waste discharged to the Title 5 system:(yes or no) No
Water meter readings,if available: n1a
Last date of occupancy: n1a
OTHER:(Describe) rda
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
rtla
System pumped as part of inspection: (yes or no)No
If yes,volume pumped:0 gallons
Reason for pumping: n1a
TYPE OF SYSTEM
Septic tank/distribution box/soil absorptions system
x Single cesspool
x 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 Information:
40 years old
Sewage odors detected when arriving at the site:(yes or no) No
t ,
irevlsed 0427/971
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 5 sylvan Dr.Hyannis
Owner: McConnell c/o Everson:21 Wren Ln.Marstons Mills 02648
Date of Inspection:6125199
SEPTIC TANK:_
(locate on site plan)
Depth below grade: rda
Material of construction: concreate metal FRP Polyethylene_other(explain)
If tank is metal, list age nia . Is age confirmed by Certificate of Compliance No (Yes/No)
Dimensions: rva
Sludge depth:rda
Distance from top of sludge to bottom of outlet tee or baffle: Wa
Scum thickness:rva
Distance from top of scum to top of outlet tee or baffle:rda
Distance form bottom of scum to bottom of outlet tee or baffle: Na
How dimensions were determined: rda
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.)
^la
GREASE TRAP:_
(locate on site plan)
Depth below grade: rda
Material of construction: _concrete_metal_FRP_Polyethylene_other(explain)
Dimensions: rda
Scum thickness:rda
Distance from top of scum to top of outlet tee or baffle:rda
Distance from bottom of scum to bottom of outlet tee or baffle: Na
Date of last pumping;v.
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.)
rda
BUILDING SEWER:
(Locate on site plan)
Depth below grade: t in,
Material of construction:_cast iron_40 PVC_other(explain)
Distance from private water supply well or suction lin0o—
Diameter: 4• r
rw,-Imments: (conditions of joints,venting,evidence of leakage, etc.)
(revised 04117)971
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 5 sylvan Dr.Hyannis
Owner: McConnell clo Everson:21 Wren Ln.Marstons Mills 02648
Date of Inspection:6125199
TIGHT OR HOLDING TANK:
(locate on site plan)
Depth below grade: rda
Material of construction:_concrete_metal_FRP_Polyethylene—other(explain)
Dimensions: nra
Capacity: rda gallons
Design flow: rva gallons/day
Alarm level:_nla Alarm in working order?_Yes_No
Date of previous pumping:
Comments:
(condition of inlet tee,condition of alarm and float switches,etc.)
rda
DISTRIBUTION BOX:
(locate on site plan)
Depth of liquid level above outlet invert: nia
Comments:
(note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box etc.)
rda
PUMP CHAMBER:
(locate on site plan)
Pumps in working order:(yes or no)No
Alarms in working order(yes or no)—Yes
Comments:
(note condition of pump chamber, condition of pumps and appurtenances, etc.)
n!a
pevleed 04R77B7)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:•5 Sylvan Dr.Hyannis
Owner: McConnell do Everson:21 Wren Ln.Marstons Mills 02648
Date of Inspection:61251g8
SOIL ABSORPTION SYSTEM (SAS):x
(locate on site plan, if possible;excavation not required,but may be approximated by non-intrusive methods)
If not determined to be present,explain:
nla
Type:
leaching pits, number: 1o00gallon leach pit
leaching chambers,number:We
leaching galleries,number: rda
leaching trenches,number,length: nfa
leaching fields, number, dimensions:nla
overflow cesspool,number:nla
I Alternate system: nra Name of Technology:_nra
i Comments: (note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.)
System and all components are structurally sound and functioning properly.System never had more than 1'of avatar In It
CESSPOOLS:x
(locate on site plan)
Number and configuration: one
Depth-top of liquid to inlet invert: empty
Depth of solids layer: nla
Depth of scum layer: nla
Dimensions of cesspool: 8'xT
Materials of construction: block
Indication of groundwater: n1a
inflow(cesspool must be pumped as part of inspection)
rda
Comments: (note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.)
The cesspool and all components are structurally sound.Recommend pumping aystem everyone year for maintenance.
PRIVY:_
(locate on site plan)
Materials of construction: rda Dimensions: Na
Depth of solids: rva
Comments: (note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.)
rJa
(revlaed 04I17)97)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
5 Sylvan Dr.Hyannis
McConnell c/o Everson:21 Wren Ln.Marstons Mills 02049
6125198
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)
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(revised002T19T) pays ! of 10 _ -
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(contlnued)
5 Sylvan Dr.Hyannis
McConnell do Everson:21 Wren Ln.Marstons Mills 02648
6125198
Depth of groundwater 12.
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
X Use USGS Data
' Describe in your own words how you established the High Groundwater Elevation.(MUST be completed)
USGS maps and charts
I
I
(revised0021ST) page 10 of 10
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