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Home My WebLink About0036 TANAGER ROAD - Health 36 TANAGER ROAD, HYANNIS A= 268 024 f I Q { I i i I Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �7 M 36 Tanager Road 1 Property Address r�n Valdinei& Glaucia Dangelo Owner Owner's Name information is Hyannis MA 02601 January 30 2008 required for Y rY , every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Important: A. General Information When filling out forms on the computer, use 1. Inspector: only the tab key to move your David D. Coughanowr cursor-do not Name of Inspector use the return key. Eco-Tech Environmental Company Name mn 43 Triangle Circle Company Address Sandwich MA 02563 City/Town State Zip Code 508 364-0894 1328 Telephone Number 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 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority k)04 g ). e�4, �S January 30, 2008 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. t5-2855.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 36 Tanager Road 3 Property Address Valdinei& Glaucia Dangelo Owner Owner's Name information is Hyannis MA 02601 January required for H y 30 2008 every 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: ® 1 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: Inspector's Note==> A septic system is deemed to pass this Real Estate Transfer Inspection if it does not trigger any of the failure criteria listed below. The septic system has been evaluated according to the conditions observed on the day it was inspected. No estimate or guarantee of system longevity is made or implied by a passing determination. Pumping of tank and replacement of outlet tee are recommended. B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Answer yes, no or not determined (Y, N, ND) in the ❑ for the following statements. If"not determined," please explain. ❑ The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND Explain: ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed t5-2855.doc-08/06 " Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 15 I Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �nM 36 Tanager Road Property Address Valdinei& Glaucia Dangelo Owner Owner's Name information is Hyannis MA 02601 January 30 2008 required for Y rY every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ distribution box is leveled or replaced ND Explain: ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed ND Explain: C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. t5-2855.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM 36 Tanager Road Property Address Valdinei& Glaucia Dangelo Owner Owner's Name information is Hyannis MA 02601 January 30 2008 required for Y ry , every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: *' This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/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 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. t5-2855.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 36 Tanager Road Property Address Valdinei& Glaucia Dangelo Owner Owner's Name information is Hyannis MA 02601 January 30 2008 required for Y rY , every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 1 0,000g pd. ❑ ® 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 El ❑ 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. t5-2855.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 36 Tanager Road Property Address Valdinei& Glaucia Dangelo Owner Owner's Name information is Hyannis MA 02601 January 30 2008 required for Y rY every 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? ❑ ® 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? Overflow pit also examined ® ❑ 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)] t5-2855.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15 I Commonwealth of Massachusetts W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 36 Tanager Road Property Address Valdinei& Glaucia Dangelo Owner Owner's Name information is Hyannis MA . 02601 January 30 2008 required for Y ry , every page. City/Town State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms (design): n1a Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): n/a—no plan Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d 248 gpd 9 ( Y g (gpd)): Sump pump? ❑ Yes ® No Last date of occupancy: undeterminedDate Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe): t5-2855.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ^M 36 Tanager Road Property Address Valdinei& Glaucia Dangelo Owner Owner's Name information is Hyannis MA 02601 January 30 2008 required for y rY every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, d+strib,itien-bey, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract (to be obtained from system owner) El Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: Age: 17+years. Certificate of Compliance for new leach pit issued 3120191 (Board of Health permit# N 91-97) Were sewage odors detected when arriving at the site? ❑ Yes ® No t5-2855.doc-08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 15 i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 36 Tanager Road Property Address Valdinei& Glaucia Dangelo Owner Owner's Name information is Hyannis MA 02601 Janua 30 2008 required for Y ry , every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): Depth below grade: 2feet Material of construction: ❑ cast iron ❑ 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Sewer was behind finished wall and not accessible for inspection. No evidence of leakage or backup into dwelling was observed. Septic Tank (locate on site plan): Depth below grade: 1feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 8.5 ft x 5 ft x 5 ft(1000 gallon) Sludge depth: 10 in Distance from top of sludge to bottom of outlet tee or baffle n/a—outlet tee missing Scum thickness 2 in Distance from top of scum to top of outlet tee or baffle n/a—outlet tee missing Distance from bottom of scum to bottom of outlet tee or baffle n/a—outlet tee missing How were dimensions determined? As Built Card t5-2855.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ^M 36 Tanager Road Property Address Valdinei& Glaucia Dangelo Owner Owner's Name information is Hyannis MA 02601 January 30 2008 required for y ry every 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.): Pumping is recommended at this time and maintenance pumping is recommended every 2-5 years. Tank and inlet tee appear structurally sound and functioning as intended.No evidence of leakage in or out was observed. Outlet tee is missing and should be replaced at time of pumping. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): t5-2855.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 36 Tanager Road Property Address Valdinei& Glaucia Dangelo Owner Owner's Name information is Hyannis MA 02601 January 30 2008 required for Y rY every page. CityrTown State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank (cont.) Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 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 ❑ No Alarms in working order: ❑ Yes ❑ No t5-2855.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15 i - Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;M 36 Tanager Road Property Address Valdinei& Glaucia Dangelo Owner Owner's Name information is Hyannis MA 02601 January 30 2008 required for y ry every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ® leaching pits number: 2 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Soils above leaching pits appeared unsaturated. No evidence of surface ponding, breakout, lush vegetation, or other evidence of hydraulic failure was observed. An observation hole was dug into new leaching pit stone and no effluent contact staining was observed in the stone or overlying soils. No standing effluent was observed to a depth of 2 feet below the top of the leach pit. t5-2855.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;M 36 Tanager Road Property Address Valdinei& Glaucia Dangelo Owner Owner's Name information is Hyannis MA 02601 Janua 30 2008 required for Y rY every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth —top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5-2855.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ^M 36 Tanager Road Property Address Valdinei& Glaucia Dangelo Owner Owner's Name information is Hyannis MA 02601 January 30 2008 required for Y rY , every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 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. LOCATIONS A B LEACH LEACH PIT PIT 1 37 Ft 16 Ft 0 0 2 38 Ft 20 Ft 3 66 f t 23 Ft 2 SEPTIC TANK no 1 � B EXISTING DWELLING 36 W Z J W N 3 I ~ TANAGER ROAD NOT TO SCALE t5-2855.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 15 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ^M 36 Tanager Road Property Address Valdinei& Glaucia Dangelo Owner Owner's Name information is Hyannis MA 02601 January 30 2008 required for y ry every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water fl Check cellar ❑ Shallow wells Estimated depth to ground water: 20+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: Barnstable GIS Department records You must describe how you established the high ground water elevation: Town of Barnstable GIS Department records indicate that the property is over 20 feet above groundwater table. t5-2855.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15 Town of Barnstable �pF 114E tpk y�P ti� Regulatory Services BA"STABLE Thomas F. Geiler, Director 1639. .0� - HIED MP`l a Public Health ,Division Thomas McKean,Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 This septic system inspection report was completed by a private inspector who is certified by the State of Massachusetts, Department of Environmental Protection. Although the Town of Barnstable Health Division received the original/copy of this report; this Division does not warranty the functionality of the septic system in the future nor does this Division agree with any technical observation s and interpretations contained within this report. In addition,by receiving this report the Town of Barnstable Health Division does not automatically approve the number of bedrooms listed within this report. The actual number of bedrooms approved at a particular property would-be listed on the"Disposal. Work Construction Permit". If you should have any questions regarding this report, please contact the certified Septic System Inspector who conducted the inspection. r� r, Commonwealth of Massachusetts Executive Office of Environmental Affairs Department of Environmental Protection William F.Weld Governor Trudy Coxe Secrstery,ECEA David B.Struhs Commissioner // SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A ` J CERTIFICATION oX Property Address: a Address of Owner: . �� fGh riti/d C O Date of Inspection:.' f 1 9 (If different) Name of Inspector: W.E.. Robinson Sr Company Name, Address and Telephone Number: W.E. Robinson Septic Service P.O. Box 1089 ' Centerville MA * CERTIFICATION STATEMENT C e _ �7-7 1 certify that I have personally inspected the sewage dispos�l spsCer� t'this address and that the information reported below is true,accurate r r function an d r inin .and experience in the o w performed based ion m t a P Pe f• section. The inspection as y g .Pe and complete as of the time o sp P P , t maintenance of on-site sew a disposal systems. The system: , Passes , _ Conditionally Passes ' _ Needs Further Evaluation By the Local Approving Authority Fails r Inspector's Signature: XV Date: •-7//-_7 G r ` ? 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 I0,000,•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 Luye,t, if applicable and the approving authority. INSPECTION SUMMARY: •yY w Check A, B C, or D: A] SYSTE PASSES: f is `.. ,•; 1 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. B] SYSTEM CONDITIONALLY PASSES: ' One or more system components need to be replaced or repaired. The system, upon completion of,the replacement or repair, passes inspection. " Indicat yes, no, or not determined (Y, N, or ND). Describe basis of determination in,all instances. If"not determined", explain why no _ The septic tank is metal, 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. - k (re Lee,/-1 5/95) 1 One Winter Street • Boston,Massachusetts 0210E • FAX(617)556-1049 • Telephone(611)M-5500 `J Printed on Recycled Paper t„ i•# f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Owner: rs +7ecv�n nj Date of Inspection: B] SYST CONDITIONALLY PASSES (continued) Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health): 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 C] FURT R EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: C nditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the pu tic health, safety and the environment. 1) SY TEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER W ICH 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) YSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT T SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENV ON,MENT: _ The system has a septic tank and soil absorption system and is within 100 feel to a surface watei supp{y or tributay to a surface water supply. _ The system has a septic tank and soil absorption system and is within a Zone I of a public water supply 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 is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm• DJ SYSTEM FAI I have etermined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for thi determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the fa'ure. Backup of sewage into facility or system component due to an overloaded or dogged 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. (revised 8/15/95) 2 I , SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 3 & 7ln,4 9�r )� Owner: 7NM eS D11AA Date of Inspection: 3-1 i— 9 6 DI SYSTE AILS(continued): 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. El LARGE SY TEM FAILS: The ollowing criteria apply to large systems in addition to the criteria above: The design flow of system is 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety an the environment because one or more of the following conditions exist: 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 requiremen s f 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. ,, (revised B/is/95) 3 i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: Owner: �'{'I✓'S r7 un n�" Date of Inspection: 3- Check if the f�o lowing have been done: _ I/ PumP ing information was requested of the owner, occupant, and Board of Health. one 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 a5 part of this inspection. A 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 :/hesite was inspected for signs of breakout. _.L/AII system components, excluding the Soil Absorption System, have been located on the site. �e septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. (/The size and location of the Soil Absorption System on the site has been determined based on existing information or a proximated by non-intrusive methods. V`�The facility o�%ner (and occupants, if different from o�sner) were provided with information on the proper maintenance of Sub Surface Disposal System. (revised 8/15/95) 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION nq 7- Property Address: 3 �O Owner: �+"�3 p U 11/a i v� y Date of Inspection: FLOW CONDITIONS RESIDENTIAL: Design flow: 6 U scallons Number of bedrooms: Number of current residents: Garbage grinder (yes or no):A" Laundry connected to system (yes or no): Seasonal use (yes or no):�✓ — / _3- 9 CP Water meter readings, if available: 3� �� .Utz Last date of occupancy: COMME CIALIINDUSTRIAL: Type of es blishment: Design flowV allons/day Grease trapyes or no)_ Industrial Wing Tank present: (yes or no)_ Non-sanitaryischarged to the Title 5 system: (yes or no)_ Water mete , if available: Last date of cupancy: OTHER: (D scribe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: Al A System pumped as part of inspection: (yes or no)_ If yes, volume pumped. Qallons Reason for pumping: TYPE Y OSTEM 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) Other(explain) APPROXIMATE AGE of all components, date installed (if known) and source of information: �2— d 8 Sewage odors detected when arriving at the site: (yes or no) (revised 8/15/95) $ i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 9 Owner: ni rS O ain IN 1✓1 f Date of Inspection: 3, f l_4 ( SEPTIC TANK:_ (locate on site plan) Depth below grade: oL Material of construction: t/oncrete _metal _FRP—other(explain) Dimensions: S `t Sludge depth: Distance from top of sludge to bottom of outlet tee or baffler Scum thickness: d t y Distance from top of scum to top of outlet tee or baffle: g Distance from bottom of scum to bottom of outlet tee or baffle: Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level iin Jelation to outlet invert,,structural integrity, evidence of leakage, etc.) 4 oe�6 6 cl C,e )-ow u G % Aj a-` A 1- I 1.M 3 o +FRS ' GREAS RAP:_ (locate on .te plan) Depth below rade: Material of co struction: _concrete _metal _FRP—other(explain) Dimensions: Scum thickne S: Distance fro top of scum to top of outlet tee or baffle: Distance fr m I)ottom nt <rtim t� bottom of OLMet tee or baffie: Comments: (recommendat n for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evid nce of teal.age, etc. (revised 8/15/95) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: "?o ro d o_'n.n<< y Date of Inspection: / TIG OR HOLDING TANK:_ (locate site plan) Depth bel w grade: Material of construction: _concrete metal _FRP—other(explain) Dimensions: Capacity: allons Design flo eallons/day Alarm lev Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTt N BOX:_ (locate on site lan) Depth of liquid\l vel above outlet invert: Comments: (note if level and stributiun is equal, evidence of solids carr),ovcr, evidence of leakage into or out of box, etc.) PUMP CHAMBE _ (locate on site pl n) Pumps in worki g order.(yes or no) Comments: (note condition of ump chamber, condition of pumps and appurtenances, etc.) (revised 8/15/95) 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) 22 S or Property Address: J � �� O �- ��g n n� Owner: —M/-S a ccn h Date of Inspection: (:3- SOIL ABSORPTION SYSTEM (SAS): (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: Type: leaching pits, number: leaching chambers, number:_ leaching galleries, number: leaching trenches, number,length: leaching fields, number, dimensions: overflow cesspool, number: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,etc.) 1— C.'?6 6 r s a�— Q K A ia-E4 S !,n. t ✓! c, _� 2 cG A Sl /w5 %d// l9cil 9 / — r7 CESSPOOLS: _ (locate on site plan) � 1 Number and configuration: Depth-top of liquid to inlet invert: I b Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: /3/a K Indication of groundwater: A"o inflow (cesspool must be pumped as part of inspection) Ye$ Comments: (note condition of soil, signs of hydraulic failure, level of ponding,',condition of vegetation, etc.) PRIVY:_ (locate on sit plan) Materials of c struction: Dimensions: Depth of solid Comments: (n to condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) (revised 8/15/95) 8 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: ')M P,5 u n / i f7 Date of Inspection: / SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' �D al� /if r L._ DEPTH TO GROUNDWATER Depth to groundwater: 15 a feet / method of determination or approximation: I 8- 51 )V o 4 (revised 8/15/95) 9 C011\10\-u'£AI.TH OF MASSACHUSETTS � 2 _ ExECL TIVE OFFICE OF ExNURONMEN TAI. AFiF JR S DEPARTMENT OF ENVIRONMENTAL PRONTECTION '• O\E RT\TER STREET. BOSTOA ALA.0210c t61:j 292.550tDEC 70"OF Secretary ARGEO PALL CELLUCCI B STR-'HS Governor Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION P'roy Address: 3 6 Tanager Rd.. New of Owner pawl D A C.A n Z 0 W. Hva 7 s port , MA Address of Owner: Date of Inspection: V 6: Qj Name of Inspector:(Please Print)WM. E . Robinson Sr. 1 am a DEP approved s�rstSri inspector nt to Section 15.340 of Title 5(310 CMR 15.000) Company Name: WM E . KoInson eptic Service Mailing Address: PO BOX 0 9, Centerville-,-MA MLA Telephone Number: 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: b'Passes Conditionally Passes Needs Further Evaluation By the Local Approving Authority _ Fails Q Inspector's Signature: ltf b I� Date: The System Inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)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. -NOTES-AND COMMENTS revlSed 5/2/98 Page Ior11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A < , CERTIFICATION Icontinued) 'ropertyAddress, 36 Tanager Rd.. , W. Hyannisport -)—nor: Paul Decenzo Date of Inspection: 11-3 G^ �! INSPECTION SUMMARY: Check A, B, C, of D: A. SYSTEM PASSES: / If have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist. Any failure r•,crite,ia not evaluated are indicated below. MENTS: i B. S TEM CONDITIONALLY PASSES: ne or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system,upon ompletion of the replacement or repair,as approved by the Board of Health, will pass. Indicate y s, 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 exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipets) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health). broken pipets)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 pipets). The system will pass inspection if(with approval of the Board of Health): broken pipets) are replaced obstruction is removed revised 9/2/98 Page 2of11 f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Icontinued) Prop"Address: 36 Tanager Rd.. , W. Hyannisport Owner: Paul Decenzo Date of Inspection: C. THER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: onditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the ublic health, safety and the environment. 1) S STEM 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 THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2► STEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER,IF ANY)DETERMINES THAT THE SYSTEM IS NCTIONING 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 of 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 for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less -than 5 ppm. Method used to determine distance (approximation not valid). 3) O HER f revises 9/2/98 P2gv3of11 k SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 36 Tanager Rd_ , W. Hyannisport Owner: Paul Decenzo Date of Inspection: //:3 d--L D. SYSTEM FAILS: You ust indicate either"Yes" or "No" to each of the following: I have determined that one or more of the following failure conditions exist as described 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. F 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. LAR E SYSTEM FAILS: You mus indicate either "Yes" or "No" to each of the following: he following criteria apply to large systems in addition to the criteria above: he 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 ealth 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 11 of a public water supply well) The ow er or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional office o the Department for further information. revised 9/2/98 Page 4ofII f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM, PART B CHECKLIST Property Address: 36 Tanager Rd.. , W. Hyannisport Owner: Paul Decenzo Date of Inspection: Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Yes No 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 NIA. v _ The facility or dwelling was inspected for signs of sewage back-up. _ The system does not receive non-sanitary or industrial waste flow. Y _ 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 condition of baffles or tees, material of construction, dimensions,depth of liquid, depth of sludge, depth of scum. The size and location of the Soil Absorption System on the site has been determined based on: _ Existing information. For example, 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) / 115.302(3)(b)] 6✓ _ The facility owner(and occupants,if different from owner) were provided with information on the propermaintenaac."I Subsurface Disposal Systems. revised 9j 2/98 page 5oril SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION 4op"Address: 36 Tanager Rd.. , W. Hyannisport Owner: Paul Decenzo Date of Inspection: FLOW CONDITIONS RESIDENTIAL: Design flow:.G d g.p.d./bedroom. Number of bedrooms Idesign►:-I Number of bedrooms (actual): Total DESIGN flow .3 G e Number of current residents:/L./A Garbage grinder(yes or no): 4 Laundry(separate system) (yes or no) ; If yes, separate inspection required Laundry system inspected (yes or no) Seasonal use (yes or no):Zt-0 Water meter readings, if available (last two year's usage(gpd): 1998 78 , 750 gal. Sump Pump(yes or no):�d 1997 79, 500 gad- Last date of occupancy:11-36—g COMMERCIAL/INDUSTRIAL: Type o establishment: Design ow: ypd ( Based on 15.203) Basis of esign flow Grease t ap present: (yes or no)_ Industri Waste Holding Tank present: (yes or no)_ Non-san tart'waste discharged to the Title 5 system: (yes or no)_ Water eter readings, if available: Last d e of occupancy: OTHER (Describe) Last to f occupancy: GENERAL INFORMATION PUMPING RECORDS and so�ce of information: 5—.� System pumped as part of inspection: (yes or no)AA If yes, volume pumped: gallons Reason for pumping: TYPE O 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) I/A Technology etc. Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other p/►� APPROXIMATE AGE of all components, date installed lif known) and source of information: I q 6V Sewage odors detected when arriving at the site: (yes or no) revised Page 6of11 SUBSURFACE'SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(eoetinued) ►ropertyAddress: 36 Tanager Rd.. , W. H,yannisport owner: Paul Decenzo Date of Inspection: BOIL G SEWER: (Locate n site plan) Depth b low grade:_ Materi of construction:_cast iron_40 PVC_other(explain) Dista ce from private water supply well or suction line Dia eter Com ents: (condition of joints, venting, evidence of leakage,etc.) SEPTIC TANK:_ (locate on site plan) Depth below grade: Material of construction: 44oncrete_metal_Fiberglass _Polyethylene_otherlexplain) If tank is metal,list age_ Is.age confirmed by Certificate of Compliance_(Yes/No) Dimensions:1 �c, "' �✓ Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle:_ 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:Ids How dimensions were determined: n �f_'YiL ��w lL 'omments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to youtlet invert, structural integrity, evidence of leaka e, etc.) l D y /mob en Y��l-e rvya l3 e/d C, oe � C ".J � T Yw6 .0+ T GR E TRAP: (locate n site plan) Depth b low grade:_ Material of construction:_concrete metal_Fiberglass _Polyethylene_othe►(explain) Dimensi ns: Scum t ickness: Distanc from top of scum to top of outlet tee or baffle: Distan a from bottom of scum to bottom of outlet tee or baffle: Date o last pumping: Com ents: (rec mmendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evi nce of leakage, etc.) revised 9/2/98 Page 7of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Icontinued) ,'ropertyAddress: 36 Tanager Rd.. , W. Hyannisport Owner: Paul Decenzo Date of Inspection:`'/3 6� 5 TIG R HOLDING TANK: (Tank must be pumped prior to, or at time of, inspection) (locate o site plan) Depth bel w grade:_ Material o construction:_concrete_metal_Fiberglass_Polyethylene_other(explain) Dimension Capacity: gallons Design flo gallons/day Alarm pre ent Alarm lev I: Alarm in working order: Yes_ No Date of revious pumping: Comme ts: (condiY n of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX: (locate on site plan) Depth of liquid level above outlet invert: Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) PUMP CH MBER:_ (locate on ite plan) Pumps in orking order: (Yes or No) Alarms in orking order(Yes or No) Comment (note con ition of pump chamber, condition of pumps and appurtenances,etc.) reviSei, 5/2/98 Page 8or11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 'rop"Address: 36 Tanager Rd.. , W. Hyannisport ° Owner: Paul Decenzo Date of Inspection: SOIL ABSORPTION SYSTEM(SAS):_ (locate on site plan, if possible;excavation not required,location may be approximated by non-intrusive methods) If not located, explain: " Type: leaching pits, number:L leaching chambers,number:_ leaching galleries, number:_ leaching trenches, number, length: leaching fields, number, dimensions: overflow cesspool, number:_ Alternative system: Comments: Name of Technology: i (note con�)jion of soil, signs of h draulic failure, level of ponding, damp soil, condition of vegetation, etc.) { 1 )c h-b b aG) — csr 6•6-T Z_ 2 o nT .t. s CES9 00LS:_ (locate n site plan) Number nd configuration: Depth-to of liquid to inlet invert: Depth of olids layer: )epth of cum layer: Dimension of cesspool: Materials of construction: Indication Df groundwater: i iflow (cesspool must be pumped as part of inspection) Commen (note co dition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY._ (locate n site plan) Material of construction: Dimensions: Depth o solids: Comme ts: (note c ndition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) revi Page 9 of 11 . SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM g4 PART C „ SYSTEM INFORMATION(continued) -roperty Address3 6 Tanager R d.,W. Hyannis port )wrw: Paul Decenzo Jate of Inspection: a1 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) i . revised 9;2/98 Page 10of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART C SYSTEM INFORMATION Icontinued) rop"Address: 36 Tanager Rd.. , W. Hyannisport Owner: Paul Decenzo Date of Inspection: 6/I-3 d--q NRCS Report name Soil Type_ Typical depth to groundwater USGS Date website visited Observation Wells checked Groundwater depth: Shallow Moderate Deep SITE EXAM Slope Surface water Check Cellar Shallow wells Estimated Depth to Groundwater Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observed Site (Abutting property, observation hole, basement sump etc.) Determined from local conditions V Checked with local Board of health Checked FEMA Maps Checked pumping records Checked local excavators, installers Used USGS Data Describe how you established the High Groundwater Elevation. (Must be completed) J„q, G bio � �� -z '2j revised 9/2/95 Page 11 of 11 r ' TOWN OF BARNSTABLE - LOCATION I-c � z�2 SEWAGE # " VILLAGE /7 /,. 6 r 1 _ ASSESSOR'S MAP & LOT INSTALLER'S NAME & PHONE NO. jy SEPTIC TANK CAPACITY /u o 0 LEACHING FACILITY:(type) % a n- C (size) NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER T c�. �- BUILDER OR OWNER J`� _ �c� x- 1,,-1. A. DATE PERMIT,ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No -_•?_` \C 4 No.. it------ Ar THE COMMONWEALTH OF MASSACHUSETTS " BOAR® OF HEALTH TOWN OF BARNSTABLE Appliratiun for Disposal Works Tonstrnrtiun jJamit Application is hereby made for a Permit to Construct) or Repair (/`' an Individual Sewage Disposal stem at: .3 Sys . .... � �- y of?�......... .................................................................................................. Location-Address / or Lot No. nn1n-- -----------•--•------•--.....•-----......--•---•--------.. ------------------------------------------- =.....-----------------...._........._- W fl /2S o A�/'U7 Cat Installer Address Type of Building Size Lot----------------------------Sq. feet U Dwelling_No. of Bedrooms................................ .....Expansion Attic ( ) Garbage Grinder ( ) U 'q Other—T e of Building No. of persons............................ Showers — Cafeteria a' Other fixtures . --------------- - d W Design Flow.............................................gallons per person per day. Total daily flow_...._......_.._.._...._.•..................gallons. 1:4 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. 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........................ a ••--••-•--•------------------------------•---------------•-•-•-••-•---------------•------------..•--•-----------•--•---......------------..... .... ------••-- ODescription of Soil..-.!� ll-iQ----------------------•-----•-------------•-----------------------------. U ----------------------------------------- ------------------------------ •------------ ----------- --•----------------------------------------------- W VNature of Repairs or Alterations—Answer when appli�pble_./_/J_�Sf�1`.. <� d71 L':� ' �111 1'-. 11�tr z/----------------------------------------------------------------------------------------------- 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 issu by 4e�oar Ith� r Signed ... � ... , Date Application Approved By ...... r��.- .--jE c r✓s tip:•= -'- C1 ^�/...... .. ...... Dace Application Disapproved for the ollowing reasons- -------------------------------------------------------------------------------------------- ------------.......................... 11 - - -------------------------.............................------------------------- ----- ---------------------------- -------------------- ------- .................................. Q Date PermitNo. 1---- ----------------............. Issued ............................................................ ------ Date No....a_. .. �A r Fss ....o 0.... ` THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Appliration for Disposal Works Cnnnstrnrtinn Frrmi# Application is hereby,made for a Permit to Construct 45 or Repair ( an Individual Sewage Disposal System at: n .Location-Address ........._.-or Lot No. •..................................•---------- J. Owner p /1 Address F 1�fj/, b✓/ �!,_!r. �v l - v //lC r_ /T _n_�UR.r. C /? � ��t - ................... ............ _ ... .. -- Installer Address d Type of Building Size Lot............................Sq. feet V Dwelling—No. of Bedrooms............................................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........................ a --•-•-----•--••---------•-•----------------•--•--•---•••-------•...•-------------••---------•---•---......................................................... 0 Description of Soil..... -•--•--------••------••---•-=-------•---•- x W ...............-..........-.............................................................................................................................................................................. U Nature of Repairs or Alterations—Answer when applicable___ ✓f.: t��_____:_ _: �_ ___________________ •---•-------------------------------------------------------------------•/?7/.o-i-`-- 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 issue y t�,� Ifth.`:;�- ---- - ------ ------------------------ Dace q. .. Application Approved By .....- ..n�1 .. .:r.t � ------------------.................... ------------- ---- .----------- --------- -c �. . / .....„. .�. - -Y Date Application Disapproved for the ollowing reasons: ....................................................... .........-----------------------------.....----------------------- ------------------------------------------- --------------------------------------.........................................---------------------------------------------------------- ------ .........................------------- Date PermitNo. .. . �--�------------------------ - Issued -------------........----------------------------...------------. Date THE COMMONWEALTH OF MASSACHUSETTS �'. BOARD OF HEALTH TOWN•OF BARNSTABLE V61-ex#ifi ate of CfumyXianre THIS IS TO CERTIFY, That the Individual Sewage*Disposal System constructed ( ) or Repaired v. 1. o , /� ------------------------------------------------------------- -------------------------- I taller at ..:?.r ' . t ... f "r' ....................... 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. ....... .--...,C�..7....... dated ----------------------------------------------. THE ISSUANCE OF THIS CERTIFICATE SHA�L`NOT,BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE... �z.t C h .._.-�-� 9..°,/.......... . ................. Inspector ....................... ^�... ............................---------------- THE COMMONWEALTH OF MASSACHUSETTS l� BOARD OF HEALTH No..........� �7 TOWN OF BARNSTABLE 3D d .... FEs......___.......... Disposal Works 'W"Uns idion V�mit Permission is hereby granted...........9__---------• m C.?.�p------•------•-------•--••---U t-9......................................... to Construct ( ) or Repair ( ) an Individual Sewage Hisposal System atNo............................................................................................................................................................................................... Street q as shown on the application for Disposal Works Construction Permit No..,_........... .. Dated.......................................... ............................. _..•---•--•--•-•-•-•-••---............•-•.....__..._....---••-•- --• Board of Health FORM 36508 HOBBS&WARREN.INC..PUBLISHERS