HomeMy WebLinkAbout0042 VINEYARD AVENUE - Health 42 Vineyard Ave
Hyannis
' A=291 - 202
TOWN OF BARNSTABLE Y
LCKATIO-N y'ot'.)tid SEWAGE #
S.-VILLAGE l��trvr�\S ASSESSOR'S MAP & LOT
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type 73::l N-,\mokr l,C (size) 3 x�
NO.OF BEDROOMS J __
BUILDER OR OWNER 4zkN^ .
DATE: tRA11-5\0c1 'COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility r Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or.within 200 feet of leaching facility)
Edge of Wetland and Leaching Facility(If any wetlands exist G,
within 300 feet of leaching facility) 1 v Feet
Furnished by_ r\' -CD
1
1 ) 1 1
suN � �
� N
CONIMONWEALTH OF NLksSACHliSETTS
-
r, EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIR`��, fl
- =_= DEPARTMENT OF ENVIRONMENTAL PROTECTION'
ONE X'INTER STREET. BOSTON \L4 02106 (617) 292•:50o
o
2 q9 TRU+4CO
1 99 '&cre;a
.- t0�ofe i
ARGEO PAUL CELLUCCI G H Np�%AVIDy�S�TK i
Governor C0msiuss::
�c SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
c.�
_ CERTIFICATION P�
Property Address: `'i 2 �i�i��t"��'�'�'� �V�y a Name of Owner � �
1� 1�„a-a IAb�C Address of Owner: T'
Date of Inspection:• ` \` /C'�f//11vr,U JT �/ i�10►v Cr,
Name of Inspector:(Please PriAd•c a ry C lF'JEt: KU W`�� - C)U` ij l �.
I am a DEP approved system inspector pursuant to Section 15.[340 of Tide 5(310 CMR 15.0001
Company Name: - 2 � r..r k r.��'r�, a... C t,.+CA F
Mailing Address:- Q! d.,. 2 -7:g4-. y d:5:iy f2 ME tf
Telephone Number: SGo� ,1 L f 9 ;z. /4- • ,1 co
CERTIFICATION STATEMENT
1 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 peviormed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems. The system:
t
Passes
Conditionally Passes
Needs Furth Ev u ion y e Local Approving Authority
Fails c\
1 I
Inspector's Signature ' � Date: G
The System Inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within thirty(30)days of
completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner
shaft 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
revised 9/2/98 of11 -
4i Printed on Raytkd Paper
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
l ` / CERTIFICATION (corrtirwedl
%roperty.Address:
Jwner:
Date of Inspection:
INSPECTION SUMMARY: Check A, B, C, or D:
A. SYSTEM PASSES:
1 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
as installed within twenty(20)years prior to the date of the inspection; or
Compliance (attached) indicating that the tank w
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($)
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
,t<07"A
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:
Owner:
Date of Inspection:
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' the system is failing to protect the
public health, safety and the environment.
11 SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WIT 310 CMR 15.303(1)(b)THAT.THE SYSTEM.
IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH A SAFETY AND THE ENVIRONMENTc
_ Cesspool or privy is within 50 feet of surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or salt marsh.
• x
r
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND UBLIC WATER SUPPLIER,IF ANY)DETERMINES THAT THE SYSTEM IS
FUNCTIONING IN A MANNER THAT PROTECTS THE PUBL HEALTH AND SAFETY AND THE ENVIRONMENT:
a,
_ The system has a septic tank and soil absorpt n system(SAS)and the SAS is within 100 feet of a surface water supply or
tributary to a surface water supply. r.
_ The system has a septic tank and soil abs ption system and the SAS is within a Zone I of a public water supply well.
_ The system has a septic tank and.soil ob orption system and the SAS is within 50 feet of a private water supply well.
_ The system has a septic tank and soil sorption system and the SAS is less than 100 feet but 50 feet or more from a
private water supply well,unless a w I water analysis for eoliform bacteria and volatile organic compounds indicates that the
well is free from pollution from that acility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less
than 5 ppm. Method used to dete ine distance (approximation not valid).
3) OTHER
revised 9/2/.98 Page 3orIII
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION Iconrtinued)
property Address:
Owner:
Date of Inspection:
D. SYSTEM FAILS:
You must indicate either " s" or "No" to each of the following:
have determined at one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this
determination is ide ified below. The Board of Health should be contacted to determine what will be necessary to correct the failure.
Yes No
Backup of sew ge into facility or system component due to an overloaded or clogged SAS or cesspool.
_ Discharge or pon ng of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or
cesspool.
Static liquid level in t distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
Liquid depth in cesspool less than 6" below invert or available volume is less than 1/2 day flow.
Required pumping more tha 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped
_ Any portion of the Soil Absorpt n 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 ithin 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- an 100 feet but greater than 50 feet from a private water supply well with no
acceptable water quality analysis. If the w� II has been analyzed to be acceptable, attach copy of well water analysis for
coliform bacteria, volatile organic compound ammonia nitrogen and nitrate nitrogen.
E. LARGE SYSTEM FAILS:
You must indicate either "Yes" or "No" to each of the following:
The following criteria apply to large systems in addition to th criteria above:
The system serves a facility with a design flow of 10,000 gpd hr greater(Large System) and the system is a significant threat to pub!
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 su,ply
the system is within 200 feet of a tributary to a surface drinkin water supply
the system Is located in a nitrogen sensitive area(Interim Wellhea 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 Paige 4of11 `.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: �Z IV, J 1 W�
Owner:
Date of Inspection:
Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following:
Yes No
Pumping information was provided by the owner, occupant, or Board of Health.
None of the system components have been pumped for at least two weeks and-the system has been receiving normal flow
rates during that period. Large volumes of water have not been introduced into the system recently or as part of this
inspection.
_ As built plans have been obtained and examined. Note if they are not available with NIA.
"f r
The facility or dwelling was inspected for signs of sewage back-up.
The system does not receive non-sanitary or industrial waste flow.
4 _ 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
y` or tees, material of construction, dimensions,depth of liquid, depth of sludge, depth of scum.
The size and location of the Soil Absorption System on the site has been determined based on:
Existing information. For example, Plan at B.O.H.
_ Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable)
115.302(3)(b))
The facility owner (and occupants,if different from owner) were provided with information on the propermaintenanca-0f
SubSurface Disposal Systems.
revised 9/2/98 Page 5of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM..
PART C
SYSTEM INFORMATION
'rope" Address:
Owner:
Date of Inspection:
FLOW CONDITIONS
RESIDENTIAL:
Design flow:. IL g•p d./bedroom
Number of bedrooms (design):J, Number of bedrooms (actualE L
Total DESIGN flow
Number of current residents:
Garbage grinder(yes or no):
Laundry(separate system) (ye.�,; or no): : If yes, separate inspection required
Laundry system inspected• yes or no)
Seasonal use (yes or no): M1!
Water meter readings, if available (last two year's usage (gpd): v1 n
Sump Pump (yes or no):
Last date of occupancy:—t ��j—)- („
COMMERCIALANDUSTRIAL:
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:
System pumped as part of inspection: (yes or 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 operati3n and maintenance contract
Tight Tank Copy of DEP Approval
Other _
jr
c c `
APPROXIMATE AGE of all components, date installed(if known) and source of information: ` ��`;VAN —
Sewage odors detected when arriving at the site: (yes or no) f�
revised 9/2/98 P21ge6(if II
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
'roperty Address:
Owner: 1
Date of Inspection:
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:�_
(locate on site ple'n)�
Depth below grade:
Material of construction: 1 concrete_metal_Fiberglass _Polyethylene_other explain)
If tank is metal,list age— Is age confirmed by Certificate of Compliance_(Yes/No)
Dimensions:-
Sludge depth: .' t�
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 toe or baffle:."Li
How dimensions were determined:
'omments:
( endation for pumping, condition of inlet.1nd outlet tees or baffles, depth of liquid level in relation to outlet inve t, structural'"Uegrity,
recorecomm VvT-o-,c
nce f leakage,etc.) 11J6 �i — _'i
Ir,
GREASE TRAP:
(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 pumping:
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 9/2/98 Page 7of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
'roperty Address:)
Owner:
Date of Inspection:
TIGHT OR HOLDING TANK:!` (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: 1 <.1�w' L'�'1 —► ✓r
Comments:
( ote if level #nd distrkyuti n is qual, evi ence of solids carryover, egidence of leak ge i to Ar out of box, etc.) -
v
1 •r
PUMP CHAMBER:�i'"��
(locate on site plan)
Pumps in working order:(Yes or No)
Alarms in working order(Yes or No)
Comments:
(note condition of pump chamber..condition of pumps and appurtenances, etc.)
revised 9/2/98 rage aof11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
'roperty Address: l4
Owner:
Date of Inspection:
SOIL ABSORPTION SYSTEM(SAS): r
(locate on site plan, if possible: excaJ tion not required, location may be approximated by non-intrusive methods)
If not located, explain:
Type:
leaching pits, number:_ _
leaching chambers, number: A.
< <t 14-1���-'�
leaching galleries, number:_
leaching trenches. number, length:
leaching fields, number, dimensions:
overflow cesspool, number:_ v
Alternative system:
Name of Technology:
Comments:
(node condition of soil, signs of hydraulic failure, level of ponding, d�mp soil, condi n of vegetation, etc.)
CESSPOOLS:
(locate on site plan)
Number and configuration:
Depth-top of liquid.to inlet invert:
9epth of solids layer:
)epth 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.)
r
PRIVY: k 6 ,
(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 9of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
'roperty Address: 14
lwner:
Date of Inspection:
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent reference landmarks cr benchmarks
locate all wells within 100' (Locate where public water supply comes into house)
\Y\.
1
_5
revised 9/2/98 Page 10of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (contirwed)
roperty Address:
Owner:
Date of Inspection:
NRCS Report name ---
Soil Type_ ---- -
Typical depth to groundwater____._ _ _-_
USGS Date website visited e,tj
Observation Wells checked
Groundwater depth: Shallow Moderate Deep
SITE EXAM Slope '�V'Q
Surface water{-�"�>
• Check Cellar 1iL
Shallow wellsi'-
Estimated Depth to Groundwater�� Feet
i
Please indicate all the methods used to determine High Groundwater Elevation: \
Obtained from Design Plans on record
Observed Site(Abutting property, observation hole, basement sump etc.)
Determined from local conditions
Checked with local Board of health
Checked FEMA Maps
Checked pumping records
Checked local excavators, installers
Used USGS Data
Describe how you established th-- High Groundwater Elevation. (Must be completed)
revised 9/2/98 Page 11 of11
TITLE 5
OFFICIAL INSPECTION FORM •NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A 4�
CERTIFICATION91
A,P
Property Address:_ V 1 A Ac A� -1�gnni S ,t�RCEI. Z-®2
Owner's Name:_ �l)ZA6P� P1,9L) e
OT
Owner's Address:_
Date of Inspection:_ _Q S—
Name.of Inspector: (please rint) PA V,d �� ��'� JA.N 1 8 2005
Company Name: 3v f*`*-
_
Mailin Address: y�ar���4 Ua6 46 Town OF BARNST.ABLE
g 3 {fie,,y f ,jjAy G - HEALTH DEPT,
Telephone Number: 7ggo
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: /
V Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: Date: �QS
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.
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.
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
_PART-A
CERTIFICATION(continued)
Property Address:
L41 ylr%A a,,d s
Owner:_�� zia FL4*M--9 5
Date of Inspection:_
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 15.304 exists.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 repai
will pass. r,as approved by the Board of Health, .
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
ND explain: Distribution box is leveled or replaced
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: -
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
V
PART A
CERTIFICATION(continued)
Property Address•_ I `/)n q� Ave) H YAnro 5
Owner:_�1t"61 'pF►-AUM RS
Date of Inspection:_
� -U5
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.
_ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more
from a private water supply well".Method used to determine distance
"This system passes if the well water analysis,performed at a DEP certified laboratory,for
coliform bacteria and volatile organic compounds indicates that the well is free from pollution from
that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5
ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to
this form.
3. Other:
.OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
T
PART A
_CERTIFICATION(continued)
Property Address:
- pia -
y� � A�1c i-iyo�� s
Owner:_ELl' 4',\ 'P�;]A\jn.�fL$
Date of Inspection:_
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
1/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 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.
-Z 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 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.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.
You must indicate either`yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
Yes no
_The system is within 400 feet of a surface drinking water supply
The system is within 200 feet of a tributary to a surface drinking water supply
The system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a
mapped Zone II of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,or
answered"yes"in Section D above the large system has failed.The owner or operator of any large system
considered a significant threat under Section E or failed under Section D shall upgrade the system in
accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the
Department.
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE.DISPOSAL_SYSTEM WSPECTION FORM
PART B
CHECKLIST
Property Address:
y a �i i+Ly qr,� NV t
Owner:_�\j Zl�le,�j ?=IAu r^ 0.S
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
✓ 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?
Has large volume 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 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?
P _ Were all system components g the SAS,located on site?
_V_ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the
ndi cotion 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 diffeient 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 C is at issue approximation of
distance is unacceptable)[310 CMR 15.302(3)(b)J
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C.
SYSTEM INFORMATION
Property Address: l
- �Ia �,� Aft A4, H � S
Owner:— e1•q_tAkj� , lPi-�IAW`tlks
Date of Inspection:_ j_ �..D 5
_ FLOW CONDITIONS _` \
RESIDENTIAL,0d'/' /Y'0r'e ,AGE-1t*0z' 1c &-z
Number of bedrooms(design):<r,.'. Number of bedrooms(actual): O /Ylf9 y ' &460-'
DESIGN flow based on 310 CM 15.203(for example: 110 gpd x#of bedrooms): a a
Number of current residents: vt- �/
Does residence have a garbage grinder(yes or no):L
Is laundry on a separate sewage system(yes or no):Iv,'[if yes separate inspection required]
Laundry system inspected(yes or no):Y
Seasonal use(yes or no):_AL
Water meter readings,if available(last 2 years usage(gpd)): ' — j q 3•? O y 7/19
Sump pump(yes or no)://
Last date of occupancy:E!!Z'W N14 d4__
COMMERCIALIINDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): gpd
Basis of design flow(seats/persons/sgft,etc.):
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/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information: /`�' ��� /��lh 41 9-3_cl _ _7-g 1
Was system pumped as part of the inspection(yes or no):
If yes,volume pumped: gallons--How was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM
-,LAeptic 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 a components,date installed(if known)and source of information:
Were sewage odors detected wbetrarriving at the site(yes or no): A//
I
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C_
SYSTEM INFORMATION(continued)
Property Address: Vfr\ Ay 14yA),0) s
Owner:_ EIVZA1,,Ith FLq\)mCr-k S
Date of Inspection:_
BUILDING SEWER(locate on site plan)
Depth below grade:� "_
Materials of construction:— iron ✓40 PVC_other(explain):
Distance from private water supply well or suction line:
Comments(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK:4(locate on site plan)
Depth below grade: 13-„
Material of construction: ,/concrete_metal_fiberglass_polyethylene_other(explain)
If tank is metal list age:_ is age confirmed by a Certificate of Compliance(yes or no):—(attach a
copy of certificate)
Dimensions:
Sludge depth: r;2-K
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:
How were dimensions determined: a'g/oAenfs -W-
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid•
levels as related to outleett/�invert,Jevidence of leakage,etc.):
GREASE TRAP:_(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 pumping:
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity,liquid
levels as related to outlet invert,evidence of leakage,etc.):
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTA
RY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:_ LA VirA twd q,'` I-1yA1Rr':S
Owner:_F-1124 4a k Av rM t S
Date of Inspection:
TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:
Material of construction: concrete metal fiberglass_polyethylene other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons/day
Alarm present(yes or no):
Alarm level: Alarm in working order(yes or no):
Date of last pumping:
Comments(condition of alarm and float switches,etc.):
DISTRIBUTION BOX: (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert:
Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any
evidence of leakage into or out of box,etc.):
x . iS in 4nod LEA /Vv CArr)&21
30k ,S a2/ &/;cfeA GrA Ae
PUMP CHAMBER: (locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no):
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
"V t
4
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:_ ,L�a v 1 ivt y Qd Av f
Owner:_ F—L;C.q L,.r►. P-I�TaVm��2S
Date of Inspection:_
SOIL ABSORPTION SYSTEM(SAS):,_/ (locate on site plan,excavation not required)
If SAS not located explain why:
Type
Leaching pits,number:_
Leaching chambers,number. 3 pa9
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.):
1' S>r1 c2f2w
CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration:
Depth-top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater inflow(yes or 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.):
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE.DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:_ L'1 �►„�Y��J A,�c f-�y�n 1�
Owner:_61?'Zgl.-Fk P1=lq✓m�2S
Date of Inspection:_
SITE EXM
Slope R111 0,4-
Surface water / -0 1/
Check cellar �� r
Shallow wells Arl m ,4 G�
�' leg,
Estimated depth to ground water"10 feet1
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 des c 'be how ou established the high ground water elevation:
Qj�
?e
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
Owner:_ El. C pyy 7��AV M4R S
Date of Inspection:_
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.
JZEA IZ
A yy (3 -
' D�ZiveW:�Y
- C- a6 ' po - - -
D - 2 a,
G. ,
TOWN OF BARNSTABLE
LOCATION 42 VINYARD AVENUE", SEWAGE #
95-1789.
VILLAGE HYANN I S ASSESSOR'S MAP& LOTA?A-40a
'INSTALLER'S NAME&PHONE NO. ELLIS BROTHERS CONST CO. 362-6237
SEPTIC TANK CAPACITY j ro O 65-/
LEACHING FACILITY: (type) A s7/c C gt (size) -s k X
NO.OF BEDROOMS
BUILDER OR OWNER1n
PERMITDATE: 6',- 74;�—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 leaching facility) Feet
Furnished by
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� ��
1
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.,i .n
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e '
T�
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No. / Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS
ZIpptication for Migpogar *pgtem ongtruction Vermit
Application is hereby made for a Permit to Construct( )or Repair( )an On-site Sewage Disposal System at:
Location Address or Lot No. Owner's Name,Address and Tel.No.
Installer's Name,Address, d Tel.No. Designer's Name,Address and Tel.No.
Type of Building:
Dwelling No.of Bedrooms �� Garbage Grinder(/tIv
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 Revision Date
Title
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) STQ f J, 0<zaG
Date last inspected:
Agreement:
The undersigned agrees to ensure constru ion and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions itle 5 o e Environmental and not to place the system in operation until a Certifi-
cate of Compliance has be sued s Board of Health.
Signed DateVr
"�
Application Approved by �
Application Disapproved for the f0vowingYas4ns
Permit No. ��— -7 Date Issued 7 /��`
No. / Fee
THE COMMONWEALTH OF MASSACHUSETTS
I'
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS
Ztpprfcation for .Mioaal *pgtem Conttruction Vermit
Application is hereby made.for a Permit to Construct(. )or Repair, )an On-site
ey Sewage'•Disposal System at:
Location Address or Lot No. 61 e s Name%'Address and Tel.No.41,6
— 2
` '" �///� ��f ,�ram- r G✓ ,f z
Installer's Name,Address, d Tel.No. j 6 Z _ 3 Designer s*ame,Address and Tel.No.
s. Type of Building:
Dwelling No.of Bedrooms Garbage Grinder
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 Revision Date
Title
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) y�
Date last inspected:
Agreement-!' .
The undersigned agrees to ensure constru ion and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions itle 5 o e Environmental a and not to place the system in operation untilpa Certifi-
cate of Compliance has be ued s Board of Health.
Signed \ 'Date
Application Approved by
S
Application Disapproved for the fo owing a ons ..,
Permit No.
1 �� l Date Issued
ate.----•
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
i
Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal/System installed( )or r paired/replaced on
by ��_ �����R S for
as has Srn constructed in accordance
` with the provisions of Title 5 and the for Disposal System Construction Permit No. 1799 dated
Use of this system is conditioned on compliance with the provisions set orth below:
let—
..,, J r°'
No. / Fee
I
I` THE COMMONWEALTH OF MASSACHUSETTS
.PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
migPogal *potent Congtruction Vermit
Permission is hereby,granted t S�
to construct )repair( an On-site Sewage System located at d ,
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 midst be completed within two years of the date below.
Date: / '� "�t Approved by
r,
'C '
D '
„
CON ST. CO. °
P.O. SOX 59
23 ENTERPRISE ROAD
YARMOUTHPORT, MA 02675
DATE /'(-9 14UMBER
NAME A�m���,. LATE PROPOSAL NEED
ADDRESS ,�/
` ��'` yam- DATE LOOKED AT
> � i0� 'RICE :
C ��
BOX NUMBER
PHONE NUMBER ( )72s- y t� �
JOB SITE ADDRESS -o4/
DIRECT N TO JOB SITE �� ��
iba-
WORK TO BE COMPLETED :
a>
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eI
�v
J'
�S
NOTE: 19
V Y j
1
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CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL
WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANS)
f
I
1, /� , hereby certify that the application for disposal works '
r
f ,
construction permit signed by me dated , concerning the
property located at meets all of the
following criteria:
• There are no wetlands within 300 feet of the proposed septic system
• There are nor private wells within 150 feet of the proposed septic system
• The observed groundwater table is 14 feet or greater below the bottom of the leaching facility
• There is no increase in flow and/or change in use proposed
l
• There are no variances requested or needed.
SIGNED : DATE:
LICENSED SEPTIC SYSTEM INSTALLER;IN THE TOWN UP BARNSTABLE NUMBER
[Attach a sketch plan of the proposed system. Also if the licensed installer posesses a certified plot plan,
this plan should be submitted].
G Is-�
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`A k-t. Real Estate System General Property inquiry H.:::`.,.1.!
a „_,a
Parcel 1,f�� .t:.J`.G c:h7 '.... .... Account
... r,., E r. .�. Its' 200696 Parents
1_,..?ti::•...\t ,_t..7C1 a U•;::: VINEYARD ;••rVi" N'c?3.s'.:j!if.?orRr€(::7od_ 62B :1.("'4::? Dist! H?
Devel Lots 42,! Lot Size: 22 Acres
t..t_u"`I^'..-?n':: Owns WHITE, W[:::NDE:::L_L P ,; LIL..;;.1':i-, t...l ! S'l.a'l::.o Class: 101
42 VINEYARD N o. B l t_,t.7::s` ?, Areas M.':'
Year Addedg
Deed Date, ReferenceN C5970,
' (' - r st„ WHITE,i E Ina•N IE I i•- .l,L./ O .,H Y Deed lylj"f?,D r [Jl,�',_,t 7 Deed i=ie` C59746,
♦..!ismment°.if;'
Values: l...ia,it., g 15200 Buildings: 3"9503 E. a FPsat1_l!.•'f::?.,a..
t:rdad System: 34 I:I"1 :,l,•axt 1764 %V.t.Ni'`'!l••ES•1D A`JI`,.NUE , Fr nt:g•-'- 195
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a i '_ - . 3
Contra! Info= Last Auto Up _ : 050695
5 i S _1 su v - d3C �A �S _F : at?n r{ „ ix
Land - ? tIeUFd By "ate 0000 Sid __ Rfd : _ +td By: tL L% e ' rWf I
Tax Title; Account.- Taken.'' Account Status: Hold Statuss
Cancel
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Owners Name
Road Index Road Name
Parcel Number 291
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