HomeMy WebLinkAbout0239 TOBEY WAY - Health 239 T6bey Way -.
Hyannis P
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TOWN OF BARNSTABLE �/ 0
LOCATION SEWAGE# -
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VUELL-AGE-1/ ASSESSOR'S MAP &L T
INSTALLER'S N &PHONE
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) l (size)
NO.OF BEDROOMS
BUILDER Oft-eW1qRt / z/
PERMTTDATE: �qr�COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and 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 hingffacility) Feet
Furnished by
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Nam..
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�� F �y p�"� A38ESSOR$UAPAI z
No. '• .— PARCEL
THE COMMONWEALTH O MASSA
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
01pptication for Migpont 6rwm Cougtrurtiou 3permit
Application is hereby made for a Permit to Construct(X�or Repair( )an On-site Sewage Disposal System at:
Location Address or Lot No.,c .�, � /� Own l
s me,A, rey��n�,Tel.No. q
Cal S Tok3�, s..tr+-✓ L � J,ev(�
In s e, td and Tel.No. �� Designer's Name,Address and Tel.No.
P� G�� �i44e-E 3v /�.
''ww 9Z 3 Pov3'::- GA,
0 1 Sob 3e2 913-..
Type of Building:
Dwelling No.of Bedrooms Garbage Grinder @-XJ)
Other Type of Building No. of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets f Revision Date ---
Title .5�;r>c 5�5��-/ D�Sy •c' �x- �c-1�,��cQsaol� �e�a--v
Description of Soil
Nature of Repairs or Alterations(Answer when applicable)
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issu d y s and of Health.
Signed Date
Application Approved by _
Application Disapproved for the following reasons
Permit No. Date Issued �'�
.7iL�.� � X' '. r .a. `.+a...r'•' w r .. ,�`+. N' w, 2 - . ♦. G.a �.'�..;. �.' vV,. Y..� V . ...f-.° � 9 �.y �s�. C...-tt f'•s•rIW"�M" '�... __;
Ewa
No. �"-..!ia - `w s�� ?,.� Fee! '..
THE COMMONWEALTH O MASSACHUSETTS
PUBLIC HEALTH DIVISION-TOWN OF BARNSTABLE., MASSACHUSETTS .
112[."p1tcatton for Migoml *pgtem Comaructton 3permtt
T Application is hereby made for a Permit to Construct(,Y)or Repair{ )an On-site Sewage Disposal System at:
Location Address or Lot No. ame,A dreg�and-Tel.No.
L e7 8 Tom yr' s._•,+Y' /
7V
Insfllor's e, d Fess,and Tel.No. Designer's Name,Address and Tel.No.
Soe 3evz 6i3Z
Type of Building:
Dwelling No.of Bedrooms 3 Garbage Grinder$Jo)
Other Type of Building . No. of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow 3 30 gallons.
Plan Date 5/7 T Sro Number of sheets / Revision Date �^
Title 5c777-o c Ae,&x C-0-0--op
Description of Soil
Nature of Repairs or Alterations(Answer when applicable)
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 the Environmental'Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued y s and of Health.
Signed Date
- Application Approved by
Application Disapproved for the following reasons
Permit No.
Date Issued
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BAR NSTABLE;'MASSACHUSETTS
r
Certtftcate of Cornpftance
THIS IS TO CjqZTTFY,th the On-site Sewage Disposal System installed(V)or repaire&replaced( )on b �
by /✓dc !/, 4", A 1610t9 for tf1 r�r
as / has been constructe e in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. — dated
Use of this system is conditioned on compliance with the provisions set forth below:
7,}}
No. �'� Fee/� "elf)
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
i
ltgoml *p6tem con5tructton vermtt
Permission is hereby granted to f
to construct( repair( an On-site Sewage System located.a
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.
All construction must be completed within two years of the date below
Date: 44" Approve 'y. '�
Page 2 of I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 239 Tobey Way
W. Hyannisport .
Owner. Carol Wells
Date of Inspection;
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:
B. tem Conditionally Passes:
e or more system components as described in the"Conditional Pass"section need to be replaced or
repaired. he 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 se tic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally
unsound,exhi its substantial infiltration or exfiltration or tank failure is imminent.System will pass inspection if the
existing tank i replaced with a complying septic tank as approved by the Board of Health.
•A metal septi tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicating that a tank is less than 20 years old is available.
ND explain:
Observatio of sewage backup or break out or high static water level in the distribution box due to-broken or
obstructed pipe(s) r due to a broken,settled or uneven distribution box.System will pass inspection if(with
approval of Board o Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
The system req fired pumping more than 4 times a year due to broken or obstr uxicd pipe(s).The system will
pass inspection if(with a roval of the Board of Health):
broken pipe(s)are replaced
obstruction is T =vw
ND explain:
-\ COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS .
DEPARTMENT OF ENVIRONMENTAL RT EIVED
PROTECTION
MAP
24
PARCEL, , �I pQ� AUG o 9 Z004
ILOT
TOWN OF BARNSTABLE
HEALTH DE
PT
5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 239 Tobey Way
W. Hyannisport
Owner's Name: Carol Wells
Owner's Address: '`
l
Date of Inspection: c�+
;o
Name of Inspector:(please print) Wi 11 i am E_ . Robinson Sr. o
Company Name: William E. Robinson Septic Service
Mailing Address: P O Box 1089 Go v3
Centerville, MA w
Telephone Number:- (5 0 8) 7 7 5-8 7 7 6 cQ
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my
training and experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system:
yI Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: /U y Date:
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of HeaRh*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 scnt to the buyer,if applicable,and the approving
authority.
Notes and Comments
•••*This report only describes conditions at the time of inspection and under the conditions of use at that
time-This inspection does not address how the system will perform in the future under the same or different
conditions of use.
Title 5 Inspection Form 6/15/2000 page 1
Page 4 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 239 Tobey—WayW.
Owner: _
Date of Inspection:
D. S lem Failure Criteria applicable to all systems:
You m st indicate"Yes"or"no"to each of the following for all inspections:
Yes o
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%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.
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 f et from a private Katrr
supply well with no acceptable water quality analysis.(This system passes if(lie 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.]
(Yes/No)The system fails.1 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 onsidered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000
gpd-
You mu t indicate either"yes"or"no"to each of the following:
(The fol wing criteria apply to large systems in addition to the criteria above)
yes no
e system is within 400 feet of a surface drinking water supply
_ — the ystem is within 200 feet of a tributary to a surface drinking water supply
the s stem is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped
Zone 1 of a public water supply well
1f you have ans Bred"yes"to any question in Section E the system is considered a significant threat,or answered
"yes"in Section above the large system has failed.The ovtnu or operator of arty large system considered a
significant threat rider Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
15.304.The syste o%,.-ner should contact the appropriate regional office of the Department.
4
Page 3 of 11
OFFICIAL INSPECTION FORM=NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address:239 Tobev Wav
W. Hyannisport
Owner:Carol Wells
Date of Inspection: —G
C. urther 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 fail' to protect public health,safety or the environment.
1. stem will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the
s stem 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. S tem will fail unless the Board of Health(and Public Water Supplier,if any)determines that the
syste 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
s rface water supply or tributary to a surface water supply.
The system has a septic tank and SAS and the SAS is within a Zone i of a public water supply.
_ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply.well.
The system has aseptic tank and SAS and the SAS is less than 100 feet but 50 feet or more front 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
acteria and volatile organic compounds indicates that the well is Gee from pollution from that facility and
e presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
ilure criteria are triggered.A copy of the analysis must be attached to this form.
3. (her:
3
Page 6 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 239 Tobey Way
W. Hyannisport
Owner: Carol WElls
Date of Inspection: 7-Xq,6f'l
FLOW CONDITIONSs
RESIDENTIAL
Number of bedrooms(design):. Number of bedrooms(actual):_
DESIGN flow based on 310 CMR 5203(for example: 110 gpd x#of bedrooms): 36 a
Number of current residents: ��,
Does residence have a garbage ' der(yes or no):,.
Is laundry on a separate sewage system(yes or no):-&plif yes separate inspection required)
Laundry system inspected(yes or no):�v
Seasonal use:(yes or no):&V
Water meter readings,if available(last 2 years usage(gpd)): 2003 148, 500
Sump pump(yes or no):,Lc) 2002 — 125, 250
Last date of occupancy: 7:;�1
CO ME IJINDUSTRIAL
Type of establis ent:
Design flow(b ed on 310 CMR 15.203): gpd
Basis of design ow(seats/persons/sqft,etc.):
Grease trap pre ent(yes or no):_
Industrial wast holding tank present(yes or no):_
Non-sanitary aste discharged to the Title 5 system(yes or no):
Water meter adings,if available:
Last date of ccupancy/use:
OTHER( scribe):
GENERAL INFORMATION
Pumping Records
Source of information: NZA
Was system pumped asp of the inspection(yes or no): It,0
If yes,volume pumped:_gallons--How was quantity pumped determined?
Reason for pumping:
ptic
F SYSTEM
tank,distribution box,soil absorption system
Single cesspool
Overflow cesspool
—_Privy
_Shared system(yes or no)(if yes,attach previous inspection records,if any)
_Innovative/Altergative technology.Attach a copy of the current operation and maintenance contract(to be
obtained from system owner)
Tight tank .—Attach a copy of the DEP approval
_Other(describe): '
Approximate age of all components,date installed(if known)and source of information:
4/ 9 / 130�
Were sewage odors detected when arriving at the site(yes or no): U
6
Page S of I]
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 239 T.obey Way
W. Hvannisport
Owner: Carol Wells
Date of Inspection:
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
V 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?
—vl�aave large volumes of water been introduced to the system recently or as part of this inspection?.,
L/— 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?
l/ — 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 no/
;/ Existing information.For example,a plan at the Board of Health.
_ Determined in the field(if any of the failure criteria related to Part Cis at issue approximation of distance..
is unacceptable)[310 CMR 15.302(3)(b)]
S
Page 8 of I I
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 239 Tobey Way
W. Hyannisport
Owner: Carol Wells
Date of Inspection:
TIGHT or HOLD TANK: (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:
Material of construct n: concrete metal fiberglass_polyethylene other(explain):
Dimensions:
Capacity: gallons
Design Flow: allons/day
Alarm present(yes or no):
Alarm level: Alarm in working order(yes or no):
Date of last pump g:
Comments(con tion of alarm and float switches,etc.):
DISTRIBUTION /(if
IIOh. present must be opened)(locate on site plan)
Depth of liquid level above outlet invert:d
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.):
- bIle-
PUMP CHAMBER: ocate on site plan)
Pumps in working order(y s or no):
Alarms in working order cs or no):
Comments(note conditi of pump chamber,condition of pumps and appurtenances,etc.):
8
Page 7 of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 239 Tobey Way
W. Hyannisport
Owner: Carol WElls
Date of Inspection:
IIUIL7bow
G SEWER(locate on site plan)
Depth grade:
Materof construction:_cast iron 40 PVC_other(explain):
Distanom private water supply well or suction line:
Comm (on condition of jousts,venting,evidence of leakage,etc.):
SEPTIC TANK: V(Iocate on site plan)
9;
Depth below grade: 1
Material of construction: concrete metal fiberglass_polyethylene
_other(explain)
If tank is metal list age:_ Is age confumc&by a Certificate of Compliance(yes or no):_(attach a copy of
certificate) j
Dimensions: 6 4
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle: s,
Scum thickness: —y ' ' ,
Distance from top of scum to top of outlet tee or baffle:.
Distance from bottom of scum to bottom of outlet tee or baffle
How were dimensions determined:
Comments(on pumping recommendations,inlet and outlet tee or battle conditicn,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.):
`� 0.
TM,nensions:
SE TRAP: (locate on site plan)
elow grade:
l of eonstru ion:_concrete metal fiberglass____polyethylene_other
): — —
ions:hickness:e from to 0
f scum.to top of outlet tee or baffle:
e from bo tom of scum to bottom of out et
1 tee or baffle:
last um,inP gnts(on nsping recontmeodations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to ou et invest,evidence of leakage,etc.):
7
Page 10 of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 239 Tobey Way
W. Hvannisport
Owner: Carol Wells
Date of Inspection:.:2•-2�
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.
p;
a�
10
Page 9 of I l
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 239 Tobey Way
W. Hyannisport
Owner: Carol WElls
Date of Inspection:
SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,ezcavation'not required)
If SAS not located explain why:
Type/ ,
eaching pits,number:_
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.):
6 0 6 c, L— 12/z
CESSPOOLS: (cess of must be pumped as part of inspection)(locate on site plan)
Number and configuratio
Depth—top of liquid to let invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cessp 1:
Materials of cons tty tion:
Indication of groun water inflow.(yes or no):
Comments(note c ndition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
PRIVY: (locate n site plan)
Materials o cons tion:
Dimension
Depth of solids:
Comments(not condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
9
Pagel 1 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: _ 239 Tobey Way
W. Hyannisport
Owner. Carol Wells
Date:of Inspection: L/
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(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:
G1 aa2
I1
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