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HomeMy WebLinkAbout0016 SYLVAN DRIVE - Health 16 SYLVAN DRIVE HYANNIS A = 289` 055 ---- I� j I' I I� J C ✓ TOWN OF BARNSTABLE LOCATION ��y �� r. SEWAGE # ZMZ�-7// rt VILLAGE y�/l%T f 5 ASSESSOR'S MAP & LOT Zd— 4 �� 5� INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type)S.v/1' lk, _ (size) /D'x Ja'x? NO. OF BEDROOMS 3 BUILDER ORQW�NE i PERMITDATE: COMPLIANCE DATE: -JCWq/00 .Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility S Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) /1�,9 Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of.leaching facility) Feet Furnished by BGr . ce ' o ,f • � 1 I I ` 5 0� M - T �. r I 01 s r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address _ Ow ner ON ner's Name information is / /�� ()1�60 �d ,3 required for every ��Is page. Cityrrown State Zip Code Date of Inspeclion 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. Importa f orms. n A. General Information filling out forms on the computer, use only the tab 1. Inspector: key to move your G✓ cursor-do not � p • use the return 7� key. Nameof Inspector '5 1410 O E C�# Company Name -1 �O /� lc�)2 — Company Address L� CiS�VI a tNl , Od fern, City[row n 1 State Zip Code C280 ' Telephone ftfter License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system Inspector pursuant to Section 15.340 of Title 5 (310,GMR 15,000). The system: t Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority _ Inspector' 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. 15ins 3113 TiUe 501flcial Irspec UcnForm:Subset ace Sewage Disposal System.Page 1 3f 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments P / c Property Address / Ow ner ON ner's Name information is required for every page. Cityrrown C74 State Zip Code gate peion B. Certification (cont.) Inspection Summary: Check A,B,C,D or E / always complete all of Section D A) System?asses: L✓J I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Condltionaily 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): t9ns W3 Title 5 Official Im per ton Form Subsvlace Sewage Disposal System.Page2o117 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments F /10r J /i-G✓i t t/2/ Property Address �^ Cw ner ON ner's Name Information is requlred for every ����fs / page. Ctyrrown State Zip Code Date of Insp ction 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): f C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of.Health determines In accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh Uru•3113 Tide 501Acial InspecUcnForat Subsurface SewageOisposel System-Page 3of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments .l��v`e Property Address / I ON ner ON ner's Name q� information is g tS ,{ �ol(, 0� required for every /7 page. Ciy/Town State Zip Code Date o 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 a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 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 3113 Tide 50lficiai In spection Fam:SuDsuAace Sewage Disposal System Page 40l 17 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments • Property Address Ow ner Cw ner's Name C/ information is �4 0.2 L p required for every �'4`�rs page. City/Town State Zip Code Date df 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: . ❑ lJ Any portion of the SAS, cesspool or privy is below high ground water elevation, ❑ Any portion of cesspool or privy is within 100 feet of a surface water supply or —/ tributary to a surface water supply. ❑ E3 Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coiiform 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 forma ❑ The system is a cesspool serving a facility with a design flow of 2000gpd- 10,OOOgpd. ❑ Th ram,"/ The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA) or a mapped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. Wirm•3M3 Tiue501acial MpectlmForm SubSurtace Sevage0isposai System,Page 50117 Commonwealth of Massachusetts : --MEN= Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address ON ner ON ner's Nameinformation is q, required for every page. Cityrfown Slate 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 ❑ umping information was provided by the owner, occupant, or Board of Health ❑ Were any of the system components pumped out in the previous two weeks? ❑ as 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) ® X-a Was the facility or dwelling inspected for signs of sewage back up? ❑ Was the site inspected for signs of break out? L�J Were all system components, excluding the SAS, located on site? fly ❑ 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): Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): One-Y13 TiUe501ficiallnspec bon Form:Subsvface Sewage Disposal System-Peg a60117 i Commonwealth of Massachusetts - Title 5 Official Inspection Form i Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address I of�i Ow ner Cw ner's Name Information is A4 ��b 0/ / ld-L15 required for every h✓�! page. City/Town State Zip Code Date of Inspection D. System Information Description: / j)(_r4/( LAO—) rSv�C Number of current residents: O Does residence have a garbage grinder? ❑ Yes L`7 N Is laundry on a separate sewage system? (Include laundry system inspection information in this report.) ❑ Yes 0/ No - Laundry system inspected? ❑ Yes E Nqi Seasonal use? ❑ Yes ID/No Water meter readings, If available (last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes No Last date of occupancy; C'Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CM R 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: _ 15ns•3f13 Tide 501Aciel Ins pectlonForm Subsuf ace SewageDlsposal System-Page 7of17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewageems Disposal System Form - Not for Voluntary Assessments /V —� Mr,t.1 r v'G Property Address ON ner Cw ner's Name/7� information is required for every �� _ page. Cityffown State Zip Code Dale of Inspeation D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records; Source of information: j Was system pumped as part of the inspection? ❑ Yes ❑ No If yes, volume pumped; gallons Howwas quantity pumped determined? Reason for pump�pg- Typ.,e, of System: L`1 Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool Cl Privy ❑ Shared system (yes or no) (If yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other (describe): Ons-3113 Tide 5018cial lrepecOonForm SubstAace SewogeDisposel System-Page 8o117 Commonwealth of Massachusetts lugTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ' Property Address �� I / ON ner Cw ner's Name J d information is 0 required for every dl lS / �01 �3 page. City/Town State Zip Code hate of In pection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: ocio — per Were sewage odors detected when arriving at the site? ❑ Yes Building Sewer (locate on site plan): '33 Depth below grade: feet Material of construction: LJ ❑ cast iron 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank (locate on site plan): Depth below grade: C�2 feet Materialiof construction: Ea"concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: Sludge depth: t5ins•3113 Ti0e50rficia1 lnspac6onFcrrnr Sub�aoe Sewage Disposal System-Pago goW Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments r / S 1 1/,6i V, 191-7 lam_ Property Address Cw ner O�v ner's Name information is required f or every ✓I✓17f i/ �� page. C4y7Town State Zip Code Date of Ifispect' n D. System Information (cont.) Septic Tank (cont,) Distance from top of sludge to bottom of outlet tee or baffle [o`� 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 baffl e How were dimensions determined? Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): ✓t'7 i✓7 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: mate 151re-3h3 Title5015cisl InspecknForm Subsurface Sewage Disposal System-Page 10d 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for V))oluntary Assessments /VGV1 /mac' P Property Address / m I ow ner ow ner's Name information is - ? required for every C"�0y1 page. Otylrown C71 State Zip Code Date of spection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc,): Tight or Holding Tank (tank must be pumped at time of Inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pum ping: Date i Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No t5M 3113 Tise5aficiel IrspecdcnForm Subelrlace Sewage Disposal System Page 11 d 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal S stem Form - Not for Voluntary Assessments Property Address " I Cw nor CW ner's Name vJ information is required for every page. 5 flrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plate Depth of liquid level above outlet invert 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.): Live n Sri 1, c�f /1/0 I k,-s Pump Chamber (locate on site plan): Pumps in working order: ❑ Yes ❑ No' Alarms in working order: ❑ Yes ❑ No" Comments (note condition of pump chamber, condition of pumps and appurtenances, etc,): *.If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5lns-W3 Tide 5Official ins DecticnForm Subsurface Sewage Disposes System-Peg 12d 17 Commonwealth of Massachusetts _ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address " / Cw ner Cw ner's Name v/ — information is l required for every Ln'lvll /7 0o`6,0 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type. (Z7,c// �/� ✓/7/ /G / / 7o 7� S S�o �e.. � ❑ leaching pits number: ❑ leaching chambers number: Cl leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): S1 A c 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 tyre,3113 Title50fhciel Inspection Form Substrfece Sewageolsposal System.Page 13 ct 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address C71 ON ner Cw ner's Name G/ information is required for every a✓1✓1 I page. Crty/Town (:�;.7'— State Zip Code Date of Inspectio D. System Information (cont.) 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.): 15n9•3113 Title 50fficial Impaction Form Suburface Sewage Disposal Slstem•Pape 14 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal S stem Form - Not for Voluntary Assessments �J Property Address ON net Cw ner's Name Information is required for every page. City/Town State Zip Code Date of In pectin 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 w�here�pudic water supply enters the building. Check one of the boxes below: band-sketch in the area below ❑ drawing attached separately ULT R Ise, 14) 1 - 33. 6 / dl _l9 A lt3 - 5c) 0_� ) l5ins-W 3 Title 5Official Inspection Form Subsviace Sewage Disposal System-Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form 6 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments . i Property Address ON ner ON ner's Name Information is required for every page. CityRown State Zip Code Oate Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers - (attach documentation) ❑ Accessed USGS database - explain; You must describe how you established the high ground water elevation: 4�C �iH �O /o< ,,-I /w-4- (c�Co C, Before filing this Inspection Report, please see Report Completeness Checklist on next page., t5ins•3113 Tide 5 Official lnspectionForm sut—lace Sewage Disposal System Page 16of 17 i C Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 16 c Property Address ON ner Cw ner's Name information Is Od E;0/required for every G �� page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist Inspection Summary: A, B, C, D, or E checked EK'IInspection Summary D (System Failure Criteria Applicable to All Systems) completed L� stem Information— Estimated depth to high groundwater Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file i i i tams-3113 Title 501Bciallnspec6onFam Subsurface SewageDlsposel System•Page 17 of 17 ' -\ COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS. �� DEPARTmENT OF.ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM,'-'NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACES V/A,GE DISPOSAL SYSTEM FORM PA12T A 9 CERTIFICATI ON d' Property Address: Owner's Name:� I Owner's Address: 0 ' Date of Inspection: Name of l'nspectAp (p1e se p t�/I 1'r6 Company Name e.7", _7 Mailing Address: , . A-1A_ Telephone Number: f i 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 m), training and experience in the proper function and.maintenance of on.site sewage disposal systems. I am a DE.P approved system inspector pursuant to Section 15.340 of Title 5'(310 CMR 15.000). The system: Passes Conditionally Passes Needs Further Evaluation by the Local'Approving Authority Fails Inspector's Signature: Date: The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner"an'd copies sent to the buyer, if applicable,and the approving authority. Notes and Comment (,foci � /C,. �✓(���' *uo"L.,I ****This report only describes conditions at the.time of inspection•and under the conditions of use at that time. This inspection does not address'liow the system will perform in the future under the same or different conditions of use.. Title.5 Inspection form 6/I 5/2000 page I Page 3 of 11 OFFICIAL INSPECTION FORM =.NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE S£ lAGE.DISPOSAL SYSTEM INSPECTION'FORM PART'A CERTIFICATION (continued) Property Address: ky6 L Owner: Jt- � Date ofInspec'tion:_ r)n(4 . C. Further.Evaluation is Required by the Board.of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance.with 310 CMR 15.303(1)(b) that the system is not functioning in a manner:which will protect public health,safety and the environment: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier, if any).determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system (SAS)and the SAS is.within 100 feet of a surface water supply or tributary to a surface water.supply. The system has a septic tank and SAS and the SAS is within a Zone ] of a public water supply. The system has a septic tank-and SAS'and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and.SAS and the SAS is less than 100 feet but 50 feet or more from a, private water supply.well". Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is.free'from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this.form. 3. Other: f. .t• 3 Page 5 of I 1 OFFICIAL INSPECTION FO M—.NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART.B CHECKLIST Property Address: 1Q Date of Inspection: 6 4tp 1, Check if the followLLhave been done.You must indicate"yes"or"no"as to each of the following: Yes o 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? v Has the system received normal flows in the previous two week period ? — Have large volumes of water been introduced to the system recently or as part of this inspection? Were as built plans of the system obtained and examined?(If they were not available note as N/A) —' Was the facility or dwelling inspected for-signs of sewage back up? _ Was the site inspected for signs of break out? _ Were all system components, excluding'the SAS, located on site? _ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for..the condition of the baffles or tees, material of construction, dimensions, depth of liquid,depth of sludge and.depth of scum'? Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems The size and location of the Soil Absorption System (SAS)on the.site has been determined based on: Yes �o Existing information.For example, a plan at the Board of Health. Determined in the field.(if any of the failure criteria"related to Part C is at issue approximation of distance. is unacceptable) [310.CMR l 5.302(3)(b)] 31 : 5• Page 7 of] l OFFICIAL INSPECTION FORM'=NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE.SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM'.I.NFORMATION (continued) Property Address: Owner: Date of Inspection: BUILDING SEWER(locate on site plan) /k/ 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 constriction: 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) 4 Dimensions: 91.6 �� k Sludge depth: y Distance from top pf sludge to bottom of outlet tee or baffle: Scum thickness: _ �y Distance from top of scum to fop of outlet tee or baffle: _ �J Distance froth bottom of scum to bottom Pf outlet tee.or baffle: How were dimensions determined: Comments ('on pumping recommen ations,Inlet and outlet tee or baffle condition,structural integrity, liquid levels related to outlet invert, evidence of leakage, etc.): �,�2aw , GREASE TRAP locate on site plan) r�� fl- Cl� 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.ptimping: 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 9 of I l OFFICIAL INSPECTION FORM.-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM,i(NFORMATION,(continued) Property.Address: !��4G101L/ Owner: Date of In pection: g . SOIL ABSORPTI N SYSTEM-(SAS): (locate on,site plan,excavation not required) If SAS'not located explain why: , Type leaching pits,number:_ chin-chambers, number: leaching galleries, number: leaching trenches, number, length: leaching fields,-number, dimensions: overflow cesspool,number: __.innovative/alternative system Type/name of technology: _ Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil,condition of vegetation, etc.): � v L ev CESSPOOLS:A&(cesspool must be pumped.as part of inspecti(on)(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: /1 (locate on site plan) Materials of constriction: Dimensions: Depth of solids: Comments (note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.): 9 Page I l of I 1 OFFICIAL INSPECTION FORM. ''NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: l( 64 4 Owner: } Date of lt}• pection: J, d0(o SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record -If checked, date of design plan reviewed: Observed site (abuttirig 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 groundwater elevatio51 n: > . i i 11 i Permit Number: Date: Completed by: x 1 117 'HIGH GROUND-WATER LEVEL COMPUTATION. r , Site Location: y ( ��,�/.. ! ✓ / tl� Lot No. Owner: f- _ 1� Address: ,�1----------- --y_� .. Contractor: ! le A; .-���� Address: Ci7�� i Notes: STEP 1 Measure depth to water table p , tonearest 1/10 ft. .................................................:............................. .Date hI / e'l ®� 'month/day/year STEP 2 Using Water-Level Range Zone. : and Index Well Map locate :....:.: ....:- site.and determine OA .Ap.propriate;mdex..well.........:.......... ................�/.............. ! © Water aevel:range zone ..................................... STEP 3 Using monthly r`eport"Current -Water'.Resources'-Condition�s determine current tleptlito` ''' •• --water-level for index well 6 L a, month/year STEP 4 Using Table of Water-level-Adjustments for index.=weI14ST,EP.;2A),.current depth to water:level for index--' I (STEP 3), and-water-level zone (STEP 213) {�D determine"water-level.'adjustment .......................................................................................... STEP 5 Estimate depth to high water by subtracting the water- level adjustment (STEP 4) from measured depth to water levelat site (STEP 1) ............................................................................................................. Figure 13.—.Reproducible computation form. 15 i . No. �� �Y/ .: Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: s PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 2pprication for Migpoml *pgtem Cow5truction 3permit Application for a Permit to Construct( . )Repair( . )Upgrade( )Abandon( ) El Complete System O Individual Components Location Address or Lot No. j � ��e Owner's Na y dress and Tel.No. '""• Assessor's Map/Parcel f�`�jy h�/S Installer's Name,Address,and Tel.No. //JLl,/ Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder(� Other Type of Building C�No.of Persons Showers( Cafeteria( ) Other Fixtures Design Flow &152 gallons per day. Calculated daily flow 3-3c,55 gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank `�$-OD Type of S.A.S. c, ��frq��� Description of Soil Nature of Repairs or Alterations(Answer when applicable) ��� Zg �/� Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by t 's Board f Health. Signed Date Application Approved by Date Application Disapproved for the following reasons Permit No. t§70 / Date Issued A7 p—' �� r'•-r,, �z�� _ � - - -'fin. - '. .,�.7„�—/.� .--.�_ .-�..-.ter ..... .-.mow-`'.._.ate..-. � -�- y No. �®s� ,'� //, { I'+: " Fee 1� THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS ZIppYication for Migooal *pgtem Construction Permit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. 4 Sy k17--e )ue Owner's Name,AQ�d/ress and Tel.No. Assessor'sMap/Parcel �/�d� Installer's Name,Address,and Tel.No. / Designer's Name,Address and Tel.No. 130� �% Type of Building: f Dwelling No.of Bedrooms Lot Size` sq. ft. Garbage Grinder Other Type of Building XrS%GI��yCeNo. of Persons Showers( ) Cafeteria( ) Other,Fixtures 2 Design Flow 1l gallons per day. Calculated daily flow J-3� gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank 1 ---Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) / J7 Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been_issued by t 's BoarOf He th. Signed Date Z/� Application Approved by Date Application Disapproved for the following reasons 'Permit No. lyj 0�G Date Issued ZZ 4- '&iCirC , --------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY, that toe On-site Sewage Disposal System Constructed( ) Repaired(Upgraded( ) Abandoned( )by at / s y 1,�14 040 �f/�!l�iS has been constructed in accordance with the provisions 11 of Title 5 and the for Disposal System Construction Permit N V492 t 1 /l dated AF Installer Designer < The issuance of this pe t�sal}no be cons. ued as a guarantee that the syst rn w':;functtionas desgned.D to l� Ins ector V No. 4✓�� =-----------------Zg -Os •Si Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS Mopozai 6pgtem Congtruction Permit Permission is hereby grante to Construct(�)Repair(tom)Upgrade( )Abandon( ) System located at and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of t��his�e�>;mit. Date: �� � -�� APProved y �- ' M99 . NOTICE: This Form Is To Betsed For the Repair Of Failed ed Se tic Systems. Only. _ CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT(ATTHOUT DESIGNED PLANS) hereby certify that the application for disposal works construction permit signed by me dated Zll l�l concerning the property located.at meets all of the followin$ criteria:. /The faded system is connected to a residential dwelling only. There are no commercial or business "es associated with the dwelling. /1 ae soil is classified as CLASS I and the pe.coiation rate is :ess'than or equal :o 5 minutes aer inc2 +' T'ne:a are no we•.lands within 100 feet of the zi000sed '/ _ sepnc system �' There are no private wets within.l=0 `eet of T.he prop osed semic s�sem. 1 here is no in=se in flow and/or change in use proposed There are no variances.requested or needed_ +' The bottom.of the proposed leaching:aclity will not be located less than five fee.above the maximum adjusted groundwater table elevation. (Adjust the groundwater.table.using the rimptor ethod when applicable], if_the S.A.S. will be located with.250 feet of any vegetated wetlands. the bottom of the proposed leaching facility will not be Iocated less than fourteen(14)feet above the m=imum adjusted groundwater table elevation, Please complete the following:' A) Top of Ground Surface Elevation(using GIS information) lJ B) GM.Elevation �D +the MAX High G.W. Adjus=ent. DUTERENCE BETWEEN A and B 7 S SIGNED : DATE: (Sketch Proposd Plan of system on back]. ¢haft Uder an TOWN OF BARNSTABLE LocATTON SEWAGE # VILLAGE ASSESSOR'S MAP & LOT Z,`- —z2 7 INSTALLER'S NAME&PHONE N0. '/foLD�/'`i i SEPTIC TANK CAPACITY 1 3�_e/1 G9� LEACHING FACILITY: (type)S.y12 Aw.,,4r Cy�_ (size) /O 'x 3,v NO. OF BEDROOMS 3 BUILDER U_ VWN� PERMITDATE: /Z __q—6V COMPLIANCE DATE: q OIL Separation Distance Between the: I Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility (If any wetlands exist � � within 300 feet of leaching facility) --w�;' --Feet Furnished by A r _ . ..71 Ad . . I I LC 0 0 9.rh ol, • l o X, o6n #'PAY v�y a�G 1�4 TOWN OF BARNSTABLE LOCATION VILLAGE ASSESSOR'S MAP INSTALLER'S NAME & PHONE NO. SEPTIC TANK CAPACITY /dDO LEACHING FACILITY:(type), (size) /C100 NO. OF BEDROOMS ✓� PRIVATE WELL OR PUBLIC WATER BUfEb6 OR OWNER V"22h otl DATE PERMIT ISSUED: DATE ' COMPLIANCE,ISSUED: / 7� 1 VARIANCE GRANTED: Yes No y � 7 r { sk i 11 1�OL `O qq No..__l. .7.>�5-y.� Fas..$.....30.00 ............... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH aF�?- Os-6 TOWN OF BARNSTABLE Appliration for Di-tip 1 ial Workli Tomitrur#ion Permit Application is hereby made for a Permit to Construct ( ) or Repair )(X)) an Individual Sewage Disposal System at: 12 Sylvan Drive Hy John Atkinson annis - Location-Address or Lot No. W J.P .Macomber Jr. Owner Address Installer Address Type of Building Size Lot............................Sq. feet Dwelling-X No. of Bedrooms------3------------------------------------Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) a' 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........................................ a Test Pit No. I................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 --------------------------------------------------------------------------------•-----------.....---.......................................................... 0 Description of Soil....................................Sand & Gravel ...................•••----••---------------.••-----------•------•---------•--•-----------------------------...........----- U W UNature of Repairs or Alterations—Answer when applicable..Omit---Cesspools . Install __1-1000 gallon tank 1-distribution box 1-1000 gallon leaching pit pacYec?. in stone -------------------------- -•-------------------------------------....----------------------------------------------------....-----------------------------------------------•-••--•.................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has b en^issued by the oard f health. Signe ...... 4/,/ C........................I............ ............9.1.1.2.19: ... Dace ApplicationApproved By ............. ...' ............................................................................. ............ .. e1.: ....-.� Dat Application Disapproved for the following reasons: , .................... ....................................................................................................................................................................................... ........................................ Da. PermitNo. ...... ..v..-..�`...M..(� Issued ..........................................................1. . ....... `J Dare R No.. l u r; $ 30 00 �.: _ . .� Fa$............................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ap9- os`( TOWN OF BARNSTABLE Appliratilatt for Di-nVn ial Wlarkii Cnowitritr#ion ramit Application is hereby made for a Permit to Construct ( ) or Repair X(.XX) an Individual Sewage Disposal System at: 12 Sylvan Drive Hyannis .................................................................................................. .......-.............................................................................. ... John Atkinson Location-Address or Lot No. W J.P.Macomber Jr. Owner Address Installer \ Address Type of-Building Size Lot............................Sq. feet .—I Dwelling-X No. of Bedrooms.....3____________________________________Expansion Attic ( ) Garbage Grinder ( ) a04 Other—Type of Building No. of persons.......................... Showers g ---------------------------- p -- ( ) — Cafeteria ( ) d 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 tank0-4 ( ) Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1----------------minutes per inch Depth of Test Pit.................... Depth to ground water........................ fS. Test'Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ ............................................................................................................................................................. 0 Description of Soil....................................Sand & Gravel -----------------------------------------------------------------------------------------------------••----------...•••...••.•- U ............ .iV....................................................:.................._.........-----._........_..---------------......._._.._.........------................................._.......... W UNature of Repairs or Alterations—Answer when applicable---Omit Cesspools. Install 1-1000 gallon tank 1—distribution box 1-1000 gallon leaching pit ...in---storie............ ---- -••--•---------•--•----------------------------------------••. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code--The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. SignediA� % .(.. 6� r� 2� ...........'.. 9/ / ..................... ....................12...........94......... Dace Application Approved By ............. _... '. ........... ° Dace Application Disapproved for the following reatons: ................................................................................................................. , ................. .................................................... . ...................................................................................................................:.................................. ........................................ .................. -v--......�`... ..Z'................... Issued .......................................................Permit No. .......7 .. .... Dace THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH �. TOWN OF BARNSTABLE (METEltifirMte of (flompliMnre THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (XXX) by J.P.Macomber Jr. .......................................................... ............ . ......................... Installer 12 Sylvan Drive Hyannis., at ...................... ............................................................. ................... -- ........................- - ................ . ............ . .............................................. has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in the application for Disposal Works Construction Permit No. ..... :...`.7�... '..... dated ............................................... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. ��p �i� _ DATE........... ........ .............. . .� ............... Ins.pector . %ram^ ..'� ....A. ........... '.rd THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TO%XN OF BARNSTABLE 30.00 No. _=5... F EE ...........-•.--... �i��rn�tt1 �r�� �utt�tritr#uan �rrtni� Permission is hereby granted..J.P.Macomber Jr . to Construct ) or Repair R an Individual Sewage Disposal System 12 S 4van Drive ��annis atNo....• --....-•--... -•---•.--. ------------------------------------------------ --------------•----------- Street _ as shown on the application for Disposal Works Construction Permit No ..Dated....`�—_.�:�_..-:���........... -----------------•-•--------d , �y Board of Health DATE ,...-�. CLl ------- . FORM 36508 HOBBS h WARREN.INC..PUBLISHERS