HomeMy WebLinkAbout0021 THIRD AVENUE (HYANNIS) - Health 21 Thir'd Avenue _ {}
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Commonwealth of Massachusetts
Executive Office of Environmental Affairs 1166T 1 Z )xe
�Department of k � ��A Environmental ProtectionVAIlGovelam F.Wetd '
Governor ..^
Argeo Paul Cellucci "Secretary
U.Governor David B. Struhs
Commissioner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
Property Address: 21 ,Third Ave, W.Hyannisport,Mass-Address of Owner. Lillian Healy
Date of Inspection: 7/28/96 (If different) 19 Weston H111 Rd .
Name of Inspector-Allan Riverside,Ct. 06878
Company Name,Address and Telephone Number.
Taylor Associates
75 Governors Way,Barnstable,Mass .02630
.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 fun-ion and
maintenance of on-site sewage disposal systems. .The system:
_ Passes
Conditionally Passes
X Needs Further Evaluation By the Local Approving Authority
Fails
Inspector's Signature: Date: .y �� V
The System Inspector s submit a coo ` of this icn re rt to the A Pecto PY po pproving A ct i thin thirty(30)days' of completing this
inspection. If the system is a shared system or 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 De artment of Environmental Protection.
The original should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority.
INSPECTION SUMMARY:
Check A, B, C, or D:
A] SYSTEM PASSES:
I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 Chip 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.
Indicate yes, no, or not determined(Y, N, or ND). Describe basis of determination in all instances.: If"not determined", explain why not) -i
The septic tank is metal, cracked, structurally unsound, shows substantial infiltration or enfiltration,.or tank fai;:re is
imminent. The system will pass inspection if the existing septic tank is replaced with a ponforming septic tank as approved
by the Board of Health.
(revised 11/03/95) 1 I,
One Winter Street • Boston, Massachusetts 02108 • FAX(617) 556 1049 • Telephone (617) 292-5500
A
io Printed on Recycled Paper
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:
Owner.
Date of Inspection:
B) SYSTEM 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(wiith 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) FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
X Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the
public health. safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A
MANNER %VHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE)
DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND
SAFETY AND THE ENVIRONMENT:
The system has a septic tank and soil absorption system and is within 100 feet to a surface water supply or tributary 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.
3) OTHER
System passes as a seasonal use;
(revised 11/03/95) 2
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address:
Owner.
Date of Inspection:
DI SYSTEM FAILS:
I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for
this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the
failure.
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.
i
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.
f
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 SYSTEM FAILS:
The following criteria apply to large systems in addition to the criteria above:
The m serves a facility with a design flow of 10,000 _system Y gn gpd or greater(Large System) and the system is a significant threat to public
health and safety and the environment because one or more of the following conditions exist:
_, the system is within 400 feet of a surface drinking water supply j
the system is within 200 feet of a tributary to a surface drinking water supply
— the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area(IWPA)or a mapped Zone II of a public
water supply well)
The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program
requirements of 314 CMR 5.00 and 6.00.'Please consult the local regional office of the Department for further information..
j
(revised 11/03/95) 3 '.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address:
Owner.
Date of Inspection:
Check if the following have been done:
y Pumping information was requested of the owner, occupant, and 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.
n/ As built plans have been obtained and examined. Note if they are not available with N/A.
The facility or dwelling was inspected for signs of sewage back-up.
X—The system does not receive non-sanitary or industrial waste flow
X_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
e 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
approsimafzd by non-intrusive methods.
The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of Sub-
Surface Disposal System.
(revised 11/03/95) 4
I�
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 21 Third Ave. , West Hyanni sport,Mass.
Owner-
Date of Inspection: 7/28/96
FLOW CONDITIONS
RESIDEN'TIAL-
Design flow:_ gallons
Number of bedrooms:
Number of current residents:_
Garbage grinder(yes or no):n r)
Laundry connected to system (yes or no):_VeS
Seasonal use(yes or ao):�e S (currently)
Water meter readings, if available:
Last date of occupancy: 1 9 a r
COMMERCIAL/INTDUSTRIAL:
Type of establishment:
Design flow:--ga]lonslday
Grease trap present: (yes or no)_
Industrial Waste Holding Tank present: `yes or no)_
Non-sanitary waste discharged to the Title 5 system: (yes or no)_
Water meter readings, if available:
Last date of occupancy:
OTHER (Describe)
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
System pumped as part of inspection: (yes or noi�1-0
If yes,volume pumped gallons
Reason for pumping:
TYPE OF SYSTEM
Septic tank/distribution box/soil absorption system
X 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: PR T 0 R To 1976,
Sewage odors detected when arriving at the site: (yes or no)ia
(revised 11/03/95) 5
r
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
Owner.
Date of Inspection:
SEPTIC TANK_
(locate on site plan)
Depth below grade: _
Material of construction:_concrete_metal_FRP _other(explain)
Dimensions:
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:
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert.; structural integrity,
evidence of leakage, etc.)'
GREASE TRAP._
Gxate'on site plan)
Depth below grade:
Material of construction: _concrete_metal_FRP_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:
Comments: - --
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity,
evidence of leakage, etc.)
(revised 11/03/95) 6
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
Owner.
Date of Inspection:
TIGHT OR HOLDING TANK_
(locate on site plan)
Depth below grade:
Material of construction: _concrete_metal_FRP_other(eaplain)
Dimensions:
Capacity:_ gallons
Design floe: gallons/day
Alarm level:
Comments:
(condition of inlet tee. condition of alarm and float switches, etc.)
DISTRIBUTION BOX:_
(locate on site plan)
Depth of liquid level above outlet invem:
Comments:
(note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.)
� 1
PUMP CHAMBER
(locate oa site plan)
Pumps in working order:(yes or no)
Comments:
(note condition of pump chamber, condition of pumps and appurtenances, etc.)
I
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(revised 11/03/95) 7
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
Owner.
Date of Inspection:
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.)
CESSPOOLS:
(locate on site plan)
Number and configuration: c)nP
Depth-top of liquid to inlet invert: empty
Depth of solids layer: six.. i-nab e S
Depth of scum layer:_ 0
Dimensions of cesspool:_ 3 ' —fl"x 6 -0"
Materials of construction: h 1 n r k
Indication of groundwater: none
inflow (cesspool must be pumped as part of inspection) empty
Y
Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
no_ failurP dilato seasonal use system need upgrade to -•sustain
l•oar rQuad nr+cupanr+v
PRdVY:_
(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.
(revised 11/03/95) 8
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
Owner.
Date of Inspection:
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100'
tA o -)
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Sl.u�
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DEPTH TO GROUNDWATER
'Depth to groundwater: feet
method of determination or approximation: Gz-- L Pc ]-+-
(revised 11/03/95) 9
TOWN OF BARNSTABLE
IATION �iV °�d &, SEWAGE #
vi LAGE&Jr 5 r 10oR T ASSESSOR'S MAP&LOTI_?J2 l'�
INSTALLER'S NAME&PHONE NO. AaZZrd tis 7 7 J I3 C a
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) 5-7- P1 % (size)
NO.OF BEDROOMS -�
R OWNER -71s
PERMITDATE /-���� S COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table an&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 1 achiingJacilit Feet
Furnished by �� 'L �
1p
W G _
r - L
�-, ASSESSORS MAP NO:
No. ..:°J-:.`.�. '. I PARCEL NO: FEB .-•...............
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
TOWN OF BARNSTABLE
Applirativit for Dig niittl Workii Tomitrurtion Frrmit
Application is hereby made for a Permit to Construct ( ) or Repair ( x) an Individual Sewage Disposal
System at:
........................ 1•-•THIRD-•AVE--•-•---•-••--_-•••---••---•--.WEST HYANISPORT
Location-Address or Lot No.
TIM HEALY SAME
......................-..............................................................••---•-••-- -------------------•-----••••---••••••-----------•••••••.._..--•-••--•---•.......--------...••-•--
Owner Address
W ARCH CONST CO HYANNIS
Installer Address
UType of Building Size Lot............................Sq. feet
Dwelling— No. of Bedrooms-_____a-----------------------------------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 capacit,�.0Q0---gallons Length---------......_ Width---------------I Diameter................ Depth................
Disposal Trench—No. .................... Width.................... Total Length-------------------- Total leaching area....................sq. ft.
Seepage Pit No-------1------------ Diameter---------6......... Depth below inlet-----4............. Total leaching area..................sq. ft.
Z Other Distribution box (x ) Dosing tank ( )
0.4 Percolation Test Results Performed bY-------- ---------------------------------------------------------------- Date.........................................
a Test Pit No. I................minutes per inch Depth of Test Pit__-_--.-____________ Depth to ground water........................
(% Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
W --------------------------------------------------------------------------------•----•••••.......
•--•-•--------------------
•••-•••••••--.._.............
.._.
0 Description of Soil........................................................................................................................................................................
x
U ........................••-•----•----••••-•-•••-•••-••-•••-••--•-•-••-•--••--•---•---••••••••-••---•-•-•-••••••--•-•-•---••••...••-•••••----------•-•----•••••••••••-•••--•••••-•••--•-•----•---••-•••---
W
VNature of Repairs or Alterations—Answer when applicable.___-_-___UP--- RADE---TO.-TITLE--V-•--•_•--________•••---•---••--
_••••---•--1000-_-TANK_--Dbox•••••--(_Z_�_•_•••4x5_--leach•-•fit-•---_3- feet 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 Comph nce has been issued y t e b Hof health.
Si -------- --3/2-/95--..-..
g --
Application,Approved Bj
Dare
Application Disapproved for the following reasons- ------------------------------------------------...............
-- ---------- ----------------------------------------------------------
---------------------------------------------------------------------------------------------.._.....-.-------------------------------------------------------------
Date
Permit No. ...- `'�`. '.... Issued ..... -___ C ....--� ......
Dare
1 Fps.....3 0..................
u THE COMMONWEALTH OF MASSACHUSETTS -
BOARD OF, HEALTH
TOWN OF BARNSTABLE
Alip iration for Dhip t ml Works Tomitrnrtinn 11amit
Application is hereby made for a Permit to Construct ( ) or Repair ( X) an Individual Sewage Disposal
System at:
21__THIRD_AVE-..________•___________________WEST HYAPIIS_P,0RT__'r-7 .
•------------------------ - - - ----------•-------------------------------------...------•--
Location-Address or Lot No.
>"TIM HEALY SAME
......................-.......................................................................... ------•-•------•----•--------•-------------------•-•.-._...-------...-------------------------_...
Owner Address
a ARCH CONST CO__-_•.-- HYANNIS
---...................................... -•-••--•--•---------------•-•----•---•._...-------•-•--•------•---•-•--••--•--------------------•.
Installer Address
d Type of Building Size Lot............................Sq. feet
V Dwelling—No. of Bedrooms------#-------------------------------_..Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building ---------------------------- No. of persons-..-_--------..-.--..-.-.--- Showers ( ) — Cafeteria ( )
Otherfixtures .........------------------------------------------------------------I.. ... ...M - .
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
Disposal Trench No. ..P-....•.-ooOWidth................ -. Total Length.................... Total leaching area_...._.P.-._•.....sq. ft.
Septic Tank—Liquid ca acrt ....-....... allons Length---------------- Width...--.-_-.--_ Diameter............... Depth----------------
Seepage Pit No------- ..: --.- Diameter.........6--------- Depth below inlet-----4•............ Total leaching area..................sq. ft.
Z Other Distribution box (X j `" `" -Dosing tank ( )
aPercolation 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.....-......-....-......
9 ............................... ...•--....-•----•-•----•----...-..-•--•-----••--••--.._.-....---------------•--.-..•-....---•---------•-•-------------•------
ODescription of Soil........................................................................................................................................................................
U ---•-•-----••--••------••-••-••-------------• --••-•.-...---------•--•--••--•••---•--••-------------•--•---••----------------------•------•----- .......................................................
W
U Nature of Repairs or Alterations—Answer when applicable....----..UP_-GRADE......
TO-_TITLE_-V.
...............................
1000_ TANK Dbox____ _(1_�______4x6___leach_ oit____•_3__ fee_t___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
ehhas ybeen issued by t e b of health.
Signed jj - 3 .2.9 .93.:..
Date
Application.Approved By ............... ....... .. / '...�� . ,� � �-
��7
Application Disapproved for the following reason - ------------------------------------------ ---------------------------------- ..................
------------------ ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ ........................................
v Date
Permit No. - ............. 1�.. .... Issued ------ C' �. .....
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
t1T Ertifiratr of Q110myliance
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
by ----------------------------AR.C-HCC.ON.ST----C.O----------------------- ------------------------------------..-------------------------------------------------------------........._._.............. .......
Instauer
21 THIRD AVE WEST HYANNISPORT - --------------------------------------------------------
hasat ............. -......-------------------------------------------------------------
been installed in accordance with the provisions of TITLE of TheSt to Environmental Code as described in
the application for Disposal Works Construction Permit No. .._ .------. 1�... ._.... dated - --------
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTOORRRY.
DATE.
.. ... .. - / - Inspector - .�
�%
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
No.l-. .............. FEE........M
�t��n�nt nr�� ��un.�tr�r#i.�n �rrntit
ARCH CONST CO
Permission is hereby granted --------------------------------------------------------------------------
to Construct,( ) o Re)air (X ) an Individual Sewage Disposal System
G1 THIID ACE WEST HYANNISPORT TIM HEALY
atNo...................................---••-•--••-••-•-••---•----•--. --•--------••-------------.----------------
Str
as shown on the application for Disposal Works Construction Perm� ��'--{�-.-- Dated•._r ��._ <
....................... ......................................... ---------•-—
G Board of Health
DATE............. ..•---
FORM 36508 HOBBS♦!WARREN,INC..PUBLISHERS