HomeMy WebLinkAbout0093 UNCLE WILLIES WAY - Health 93 UNCLE WILLIES WAY, HYANNIS
A = 292 315
f
III
1
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
93 Uncle Willies Way
Property Address
Daniel Sizemore
Owner Owner's Name
information is Hyannis MA 02601 10/06/08
required for State Zip Code Date of Inspection
every page. City/Town
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 Michael Kellett
cursor-do not $ '
Name of Inspector
use the return «
key- Aardvark Environmental Inspections _ ,-
Company Name I N
c a ,
OQ - C)
P.O. Box 896 f
Company Address
East Dennis MA z 0264
Cityrrown State Zip Codr
508-385-7608 S13742
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 16.000).The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
10/07/08
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
T p Y
at that time.This inspection does not address how the system will perform to the future under
the same or different conditions of use.
I�
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
93 Uncle Willies Way
Property Address
Daniel Sizemore
Owner Owner's Name
information is H annis MA 02601 10/06/08
required for y
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:
I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
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
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
93 Uncle Willies Way
Property Address
Daniel Sizemore
Owner Owner's Name
information is Hyannis MA 02601 10/06/08
required for
every page. Cityfrown 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.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
°r 93 Uncle Willies Way
Property Address
Daniel Sizemore
Owner Owner's Name
information is Hyannis MA 02601 10/06/08
required for Y
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 %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.
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
93 Uncle Willies Way -
Property Address
Daniel Sizemore
Owner Owner's Name
information is Hy nnis MA 02601 10/06/08
required for
every page. Cityrrown 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, i
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-
10,000gpd.
❑ ® 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 11 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.
Commonwealth of Massachusetts
Title 5 official Inspec
tion Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
f
r� 93 Uncle Willies Way
Property Address
Daniel Sizemore
Owner Owner's Name
information is MA 02601 10/06/08
required for Hyannis
every page. CitylTown 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
r
❑ ® 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?
El ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined?(If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid,depth of sludge and depth of scum?
® El information
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)]
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal,System Form-Not for Voluntary Assessments
93 Uncle Willies Way
Property Address
Daniel Sizemore
Owner Owner's Name
information is Hyannis MA 02601 10/06/08
required for
every page. City/Town State Zip Code Date of Inspection
D. System Information
Residential Flow Conditions:
Number of bedrooms(design): 3 Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
1
Number of current residents:
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
Seasonaluse? ❑ Yes ® No
Water meter readings, if available(last 2 years usage(gpd)):
Sump pump? ❑ Yes ® No
Last date of occupancy: current
Date
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):
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
93 Uncle Willies Way
Property Address
Daniel Sizemore
Owner Owner's Name
information is required for y H annis MA 02601 10/06/08
every page. City/Town 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:
I
® 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)
❑ Innovative/Alternative 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:
20 Years
Were sewage odors detected when arriving at the site? ❑ Yes 0 No
commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form•Not for Voluntary Assessments
93 Uncle Willies Way
Property Address
Daniel Sizemore
Owner Owner's Name
information is Hyannis MA 02601 10/06/08
required for Y
every page. Cityrrown state Zip Code Date of Inspection
D. System Information (cont.)
Building Sewer(locate on site plan):
Depth below grade: 2.2
� g feet
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.):
Septic Tank(locate on site plan):
Depth below grade: 1.4
p g feet
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:
1000 gallons
2t,
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle
30"
2"
Scum thickness
51,
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
16"
How were dimensions determined? measured
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
93 Uncle Willies Way
Property Address
Daniel Sizemore
Owner Owner's Name
information is Hyannis MA 02601 10/06/08
required for
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.):
The tank was sound and tight with tees in place and liquid at outlet invert.
Grease Trap locate on site plan):
Gre p( P )
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):
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
93 Uncle Willies Way
Property Address
Daniel Sizemore
Owner Owner's Name
information is Hyannis MA 02601 10/06/08
required for y
every page. Cityfrown 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 even
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.):
The box was level and tight with no sign of carry over.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
93 Uncle Willies Way
Property Address
Daniel Sizemore
Owner Owner's Name
information is Hyannis MA 02601 10/06/08
required for
every page. Cityrrown 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: l
® leaching pits number: 1
I
❑ 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.):
This system has 6'x6' precast pit surrounded by one foot of stone. There was 3.5' between the liquid
and the inlet invert.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
93 Uncle Willies Way
Property Address
Daniel Sizemore
Owner Owner's Name
information is Hyannis
MA 02601 10/06/08
required for
every page. Cityrrown 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
i
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.):
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
.' 93 Uncle Willies Way
Property Address
Daniel Sizemore
Owner Owners Name
information is required for Hyannis MA 02601 10/06/08
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.
3 �
v
�5
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
r
93 Uncle Willies Way
Property Address
Daniel Sizemore
Owner Owner's Name
information is required for Hyannis MA 02601 10/06/08
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
❑ Surface water
® Check cellar
❑ Shallow wells
Estimated depth to ground water: 20.0
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
property/observation hole within 150 feet of SAS
Observed site(abutting roe )
❑ ( 9 p P rtY
❑ 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:
USGS maps show an elevation of over twenty feet.
s
COMMONWEALTH OF'MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
ONE WINTER STREET, BOSTON MA 02108 (617)292-5500
k TRUDY COXE
Secretary
ARGEO PAUL CELLUCCI4 DAVID B.STRUHS
Governor
1.' •y} Commissioner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
, . PART A "
CERTIFICATION
Property Address: 93 Uncle Willies 1 4,'Hyannis, MA Name of Owner: Elliott Slade
Address of Owner' same
Date of Inspection: March 5, 1999
Name of Inspector: (Please Print) James M. Ford
I am a DEP approved system inspector pursuant to Section 15.340 of Title_5(310 CMR 15.000)
Company Name: James M. Ford
Mailing Address: .P.O. Pox 49, Osterville, MA 02655-0049 Map: 292
Telephone Numberi (508)862-9400 Parcel: 315
CERTIFICATION STATEMENT
i
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: ., +
✓ Passes x t
Conditionally Passes..,'
Needs Further Eval By the.Local Approving Authority
Nails
Inspector's Signature: Date: March 7 999
The System Inspector shall submit a copy of this insp ction report to the Approving Authority(Boar 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 \; '
Cb
revised 9/2/98 Page Iof11
Printed on Recycled Paper
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 93 Uncle Willies Way, Hyannis, MA
Owner: Elliott Slade
Date of Inspection: March 5, 1999
INSPECTION SUMMARY: Check A, B, C, or D:
A. SYSTEM PASSES:
✓ I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist. Any failure
criteria not evaluated are indicated below.
COMMENTS:
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.
Indicate yes,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 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
�?
revised 9/2/98 Page 2of11
F'
SUBSURFACE-SEWAGE DISPOSAL SYSTEM INSPECTION FORM
' PART A
CERTIFICATION (continued)
Property Address: 93 Uncle Willies Way, Hyannis, tL1A
Owner: Elliott Slade -
Date of Inspection: March 5, 1999 -
C. FURTHER EVALUATION "IS REQUIRED BY•THE BOARD OF HEALTH:
_ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the
public health, safety and the environment:
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES 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 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 AND SAFETY AND
THE ENVIRONMENT:
The system has a septic tank and soil absorption system(SAS),and the SAS is within 100 feet io a surface water supply or
tributary to a surface water supply.-
-7 The system has a septic tank and soil absorption system and the SAS is within a Zone 1 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) OTHER
J
revised 9/2/98 Page 3oftt
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 93 Uncle Willies Way, Hyannis, MA
Owner: Elliott Slade
Date of Inspection: March 5, 1999
D. SYSTEM FAILS:
You must indicate either "Yes" or "No" as 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'/z 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 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 1.00 feet but greater than 50 feet from a private water supply well with no
acceptable water quality analysis. If the well has been analyzed to be acceptable,attach copy of well water analysis for
coliform bacteria, volatile organic compounds,ammonia nitrogen and nitrate nitrogen.
E. LARGE SYSTEM FAILS:
You must indicate either "Yes" or"No" as to each of the following:
The following criteria apply to large systems in addition to the criteria above:
The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public
health and safety and the environment because one or more of the following conditions exist:
Yes No
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone II of a public
water supply well
The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional
office of the Department for further information.
revised 9/2/98 Page 4of11
-- i
SUBSURFACE SEWAGE DISPOSAL'SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 93 Uncle Willies Way, Hyannis, MA'
Owner: Elliott Slade ri
Date of Inspection: March S, 1999 _
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 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.
✓ _ 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 conditions of baffles
4 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)
[15.302(3)(b)l
_ The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of
SubSurface Disposal Systems..
revised 9/2/98 Page 5of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 93 Uncle Willies Way, Hyannis, MA
Owner: Elliott Slade
Date of Inspection: March 5, 1999
FLOW CONDITIONS
RESIDENTIAL:
Design flow: 110 g.p.d./bedroom.
Number of bedrooms(design): n/a Number of bedrooms(actual): 2
Total DESIGN flow n/a
Number of current residents: n/a
Garbage grinder(yes or no): No
Laundry(separate system)(yes or no): No ; If yes, separate inspection required
Laundry system inspected(yes or no): No
Seasonal use(yes or no): No
Water meter readings,if available(last two yearg;usage(gpd): Wa
Sump Pump(yes or no): No
Last date of occupancy: Currently occupied.
COMMERCIAL/INDUSTRIAL:
Type of establishment:
Design flow: Qpd(Based on 15.203)
Basis of design flow
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:
Pwnped on Oct 5194 and Oct 8197-per treatment plant
System pumped as part of inspection(yes or no): No
If yes,volume pumped: gallons
Reason for pumping:
TYPE OF 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
APPROXIMATE AGE of all c ents,date installed(if known)and source of information: November 1985-per as built card.
r
Sewage odors detected when arriving at the site: (yes or no) No
revised 9/2/98 Page 6of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM`INFORMATION (continued)
Property Address: 93 Uncle Willies Way, Hyannis;MA t
Owner: Elliou Slade
Date of Inspection: March S, 1999 -
BUILDING SEWER
(Locate on site plan)
Depth below grade:
Material of construction: cast iron _40 PVC _other(explain)
Distance from private water supply well or suction line "
Diameter
Comments: (condition of joints, venting,evidence of leakage, etc.)
SEPTIC TANK: ✓ ,. ,. .t4_
(locate on site plan) `
Depth below grade: 10" '
Material of construction: ✓concrete _metal _Fiberglass ®Polyethylene =other(explain) ,
If tank is metal,list age Is age confirmed by Certificate of Compliance_(Yes/No)
Dimensions: 8' x S' x 4'6 (1000 gal.)
Sludge depth: 1
Distance from top of sludge to bottom of outlet tee or baffle: 30
Scum thickness: ' 2"
Distance from top of scum to top of outlet tee or baffle: 8"
Distance from bottom of scum to bottom of outlet tee or baffle: 11
How dimensions were determined: Measurinit stick t ,,
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.) 3The system needs an inlet tee the outlet tee was present. The liquid level was even with the outlet invert.
GREASE TRAP: None
(locate on site plan)
Depth below grade: ^ ^'
Material of construction: -®concrete —metal,—Fiberglass ®Polyethylene _other(explain)
Dimensions: ,
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle: -
Date of last P>mPmg " -
Comments: s- '
,4 w(recomn=dation 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 9/2/98 Page 7ofII
N
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 93 Uncle Willies Way, Hyannis, MA
Owner: Elliott Slade
Date of Inspection: March S, 1999
TIGHT OR HOLDING TANK: None (Tank must be pumped prior to, or at time, of inspection)
(locate on site plan)
Depth below grade:
Material of construction: _concrete _metal _Fiberglass _Polyethylene _other(explain)
Dimensions:
Capacity: gallons
Design flow: gallons/day
Alarm present:
Alarm level: Alarm in working order: Yes_ No_
Date of previous pumping:
Comments:
(condition of inlet tee, condition of alarm and float switches, etc.)
DISTRIBUTION BOX: ✓
(locate on site plan)
Depth of liquid level above outlet invert: 0" (even)
Comments:
(note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.) The box was level and there
were no siltns of solids
PUMP CHAMBER: None
(locate on site plan)
Pumps in working order: (Yes or No)
Alarms in working order: (Yes or No)
Coma-Bents:
(note condition of pump chamber, condition of pumps and appurtenances, etc.)
revised 9/2/98 Page 8of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 93 Uncle Willies Way, Hyannis, MA '
Owner: Elliott Slade
Date of Inspection. March 5, 1999
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: I-6'x 6'
leaching chambers,number: _
leachinggalleries,number:
g `
leaching trenches,•number,length:
leaching fields,number, dimensions:
overflow cesspool,number: r y
Alternative system:
Name of Technology:
Comments:
(note condition of soil, signs of hydraulic failure,level of ponding, damp soil,condition of vegetation,etc.) `
The pit had 6"of water on the bottom There were no si1?ns of failure. The bottom to tirade was 8'6".
CESSPOOLS: None `
(locate on site plan)
Number and configuration:
Depth-top of liquid to inlet invert:
rt.
Depth of solids layer: µ-
Depth of scum layer:
Dimensions of cesspool:
Materials of construction: "
Indication of groundwater: `
inflow(cesspool must be pumped as part of inspection)
Comments: (note condition of soil, signs of hydraulic failure,level of ponding,condition of vegetation,etc.)
•
PRIVY: None .
(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 9/2/98 Page 9of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 93 Uncle Willies Way, Hyannis, MA
Owner: Elliott Slade
Date of Inspection: March 5, 1999
Map: 292
Parcel: 315
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)
Uj'1111fS WA`I
t
Dec'.
!9
aq' 3
3a ag
y5
revised 9/2/98 Page 10of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
t
Property Address: 93 Uncle Willies Way; Hyannis,MA e
Owner: Elliott Slade
Date of Inspection: March 5, 1999 - -
NRCS Report name
Soil Type
Typical depth to groundwater
r
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 .
s
Please indicate all the methods used to determine High Groundwater Elevation: ,
Obtained from Design Plans on record'
Observed Site,(Abutting property,observation hole,f basement sump etc.)
Determined from local conditions
✓ Checked with local Board of Health -
Checked FEMA Maps
Checked pumping records
Check local excavators,installers 4
✓ Used USGS Data
Describe how you established the High Groundwater Elevation. ( Must be completed) '
Using the Barnstable water table and topographic maps, the maps were showing approximately 23'to groundwater at this
site.. The bottom of the pit to grade was 8'6".
This report has been prepared and the system"inspected and passed as of the date of inspection. This report is not a warranty
or guarantee that the system will function properly in the future. There have been no warranties or guarantees, either expressed,
written or implied relating to the system, the inspection and/or this report.
revised 9/2/98 Page 11of11
T� tDIF gA�NSTABLE
LOC 'I'tON ' 3 �l e w rl I j 5 SWAGE
VIL,GA�E �✓l `{ ASS�.SSCTt'S 1vIAP A L4x ,
xN5TA�3.1.Ett'S N�iRtI��1�gY41dE I+IO ',
0�zrU
i SEP'IC TAIVT�CAI'�CSTX, / S� .�.
LSAC
EM, .r)F a okL O�Iz
ARMITM
SapaM on Atata�Gu'Eetv�eett k�a jai.
Maxi�ruml�}ust�tl Gtauttcf Awe llatmilet6tt6m�afl.aac;higFacil ty
patvat4`d'Jatcr Sapp y UJ�;91:a�icl L,eac6�teg��ciiaty a�iy��el9s cx4st �aai
city eltcs oc;wltl7ab a0Q feat of le�actuttg fgcbty) �--�--�—r-"'""""'"
ciuc cy�W,_ an (W-d 1.eacl tntt i-Wllty( i oy wEtlancls exist
iustlaict:300. ty.)
ucid3hod by ra Y
� �
� � �
W
� � � �
\ � s �,
S �
c1'. 1
�l.J �
� '
� � �1 � - �
� � � �� � �
w
t'�
' LOCAll No
�� SEWAGE PERMIT .
PILLAGE
INST LLER'S NAME i ADDRESS
Z0 es
c -
8 WIL E R OR OWNER
C i /ate/-�•�
DATE PERMIT ISSUED
T�
DATE COMPLIANCE ISSUED 11_ 37as
tt f
` �
tft Cam. I
�.{J I
j�.
` � \ _ i
f
�'_
n 1 �I,
r
am
9 No.... �........... FEis...... ...............
THE COMMONWEALTH OF MASSACHUSETfS
BOARD OF HA ELTH
4er 3 / <* QW.......-0 F-6.�n ..............................
Appliration for Di-opaiial Works Tomitrurtion Prrutit
Application is hereby made for a Permit to Construct (.<) or Repair an Individual Sewage Disposal
System at:
Y
.0.6A...... ......... .......... ...................
Locad A)d, or Lot No.
.......... S77fu V ..00 ..................................................................................................
Owner Address
................................ ...... ........................................ ..................................................................................................
Installer Address
Type of Building Size Lot--/10.,-!Y5....Sq. feet
Dwelling—No. of Bedrooms...............3........................Expansion Attic Garbage Grinder
Other—Type of Building ............................ No. of persons...._..._._.____..__.__._... Showers Cafeteria
Otherfixtures ................................................................................................................
el ' ---------------------*------------Design Flow............./-/0---------------------gallons per person per day. Total daily flow..............3..:.3...�2.............gallons.
Septic Tank—Liquid capacity. gallons Length.,6..'C..... Width.-9.(..-Z0 - Diameter................ Depth....
Disposal Trench—No..................... Width.................... Total Length___......_........_. Total leaching area......................sq. ft.
Seepage Pit No---------1---------- Diameter......40---1--- Depth below inlet____________________ Total leaching area.?,.-..fo.-7...sq. f t.
Other Distribution box (>4) Dosing tank ( ) -
Percolation Test Results Performed by------- Date.......................................
Test Pit No. I...15��----minutes per inch Depth of Test Pit........6-1..... Depth to ground water_-_____---.......__.
Test Pit No. 2................minutes per inch Depth of Test Pit___.........___..__. Depth to ground water._____.__.._........_.._
............11 ... ......................Y,........
. .... - -/ -11..........*-----------------
0 Description of Soil...... --------/ts....... . .......
............... .......... .........................................................................................................
--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------0........................
U Nature of Repairs or Alterations—Answer when applicable................................................................................................
....................................................................................................................................................................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TL I Ti!L- 5 of the State Co
de ode— The undersigned further agrees not to place the system in
-y--
operation until a Certificate of Compliance has issued y the b rrd of health......... /o
......... . ... ... .................. ......................... ....I.............
-D`te
ApplicationApproved By_ ......................... ......... ..... .. .... .. -------------------- ........V------
Date
Application Disapproved for the following . .............................................................�............................................
......................................................................................................................................................... ............................................
Date
PermitNo.......................................................... Issued-...................I....................................
bate
----------
NO. ) r .5... f U FEE...... ...............
THE COMMONWEALTH OF MASSACHUSETfS
,�" • BOARD OF HEALTH
Appliration for Disposal Works Tonstrurtiun Prrmit
Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal
System at:
..........U L.46....... !1_ j -4(-) ly----- -=----- . .-#� ---------------------------------------------- --=---
Location-Addre,,7- or Lot No. r
Owner Address
W
Installer Address
Type of Building Size Lot__ _,.: ___: ____._Sq. feet
aDwelling—No. of Bedrooms-__.t......... .........................Expansion Attic ( ) Garbage Grinder ( )
p-I Other—Type of Building .E.................. No. of persons............................ Showers ( ) — Cafeteria ( )
QI Other fixtures ............................ .
W Design Flow.............//0.....................gallons per person per day. Total daily flow____-__--__..-a—_ __.C.?......._..._..gallons.
WSeptic Tank—Liquid capacity _gallons Length._';..._._... Width__`..lr.. Diameter________________ Depth.... _+�...
x Disposal Trench—No..................... Width____________________ Total Length.....................Total leaching area--------------------sq. ft.
Seepage Pit No.--_____------------ Diameter------ _r___ Depth below inlet.................... Total leaching area _._....:_.7...sq. ft.
z Other Distribution box ( Dosing tank
Percolation Test Results Performed by------- ._..~).° �i' . Date........................................
Test Pit No. 1...4.Z:_._minutes per inch Depth of Test Pit........ _...._... Depth to ground water--------m-_____________
Test Pit No. 2..............:.minutes per inch Depth of Test Pit:''::_____•--_____-•-- Depth to ground water........................
x ................--------------- -...................................
0
Description of Soil /� cs r' l�/�4L .... ()... �• / -----•-•-----'�'' f = -- �
(� '---•--•------- }• -......--'�-1+! f.-{ 1��....� v . .................--- ......... ...............
-•------------------------------------------------------------------•-.....__._.._._........._.....'-------------•.._.._......------..........-------•••-------•.............._..............__..._.....
U Nature of Repairs or Alterations—Answer when applicable._........................................:.....................................................
Agreement:
The undersigned agrees to install,the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITHE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has issued he the b rd�of health.
---dig .-•--•---- .. ^...y....
-, D to y
Application Approved By------------- --•--------- ------------•:.... ' J I.... -- -•-/........-......-......1------.
4 I Date
Application Disapproved for the following .t:..w...............................................................................................................
---------------------------------------------------------•--•----------------------------....----------...---•-----------------------------------------------------------------------------••------------
Date
PermitNo......................................................... Issued.......................................................
µ Date
r' THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
:.....................................OF.....................................................................................
fit
THIS ERIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
by....................... -?
,r Installer
has been installed in accordance with the provisions of TITLE 5 of Tb State Sanitary Code as described in the
application for Disposal Works Construction Permit No.___f -.. - .P................ dazed_.:.::.___._.___.___._______.____...__._........
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE--•..............,._._ .... ......a5.................................. inspector.............
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
�^ V
FEE.......1.- ...
Disposal Tor Tonstr ion rrmit
-
Perm> s10 is ereby granted--�'.!..- --- - ... .....p --a--�.r ----------------------------------------•---•--..........---------.........-•---....
to Construct rVor Repair ( an Individual Sewage Disposal,$ystern } A
atNo.............. _ L............. `_ ........ s. ................ =��--............................................
Street
as shown on the application for Disposal Works Construction PermitNo..................... Dated.......... ............................
"^ ( L-_'er [ Board of Health
DATE....... - ="----------------------- �►--------
FORM 1255 HOBBS & WARREN. INC., PUBLISHERS �+
,ems Z -3 4s-
L0CA Nc��� SEWAGE PERMIT NY.
VILLAGE
.y
I N S T I LER'S NAME a ADDRESS
c - ZZA
S i L ER 0R OWNER
C l �
so DATE PERMIT ISSUED
DATE COMPLIANCE ISSUED 1I- 7 - 35
I � 4r