Loading...
HomeMy WebLinkAbout0123 WAGON LANE - Health 123 .WAGON' LANE. " 4 Vi e 1 0 4 Y 1 Commonwealth of Massachusetts Executive Office of Environmental Affairs Department of Environmental Protection One Winter Street, Boston MA 02108 (617)292-5500 TRUDY COXE Secretary ARGEO PAUL CELLUCCI DAVID B.STRUHS Governor Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART.A - CERTIFICATION Property Address:] 123 Wagon Lane,Hyannis,MA Name of Owner: Arthur Schirch Address of Owner: Date of Inspection: March 2, 2000 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.Box 49, Ostervflle, MA 02655-0049 Map: 270 Telephone Number: (SM)862-9400 Parcel. 199 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: ✓ Passes _ Conditionally Passes Needs Further Evalua' n By the Local Approving Authority 'ls Inspector's Signature: Date: March 2, 2000 The System Inspector shall submireopy 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 flew 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 d r revised 9/2/98 Page Iof11 Printed on Recycled Paper S �q/l SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Lane antis AM Pro Address: 123 Wagon , Pe1'tY S HY Owner: Arthur Schirch Date of Inspection: ' March 2, 2000 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 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 123 Wagon Lane, Hyannis,MA Owner: Arthur Schirch Date of Inspection: March 2, 2000 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 to a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and the SAS is within a Zone 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 toe SAS is less than 100 feet but 50 feet or more from a private water supply well,unless a well water analysis for colOorm 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 revised 9/2/98 Page 3of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 123 Wagon Lane,Hyawds,MA Owner: Arthur Schirch Date of Inspection: March 2, 2000 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 1/2 day flow. Required pumping more than 4 ames 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 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic compounds,ammonia nitrogen and nitrate nitrogen. E. 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 i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B ' CHECKLIST Property Address: 123 Wagon Lane,Hyannis,MA Owner: Arthur Schirch Date of Inspection: March 2, 2000 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 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)]. ✓ _ 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: 123 Wagon Lane, Mamds,MA Owner: Arthur Schirch Date of Inspection: March 2, 2000 FLOW CONDITIONS RESIDENTIAL: Design flow: 110 g.p.d./bedroom. Number of bedrooms(design): 3 Number of bedrooms(actual): 2 Total DESIGN flow n/a Number of current residents: 3 Garbage grinder(yes or no): No Laundry(separate system)(yes or no): n/a; 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 year's usage(gpd): 1998- 75,000 gals.;1999- 75,000 gals. Sump Pump(yes or no): No Last date of occupancy: Currently occupied COMMERCLALANDUSTRIAL: Type of establishment: Design flow: eyd(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: Not pumped in 10 years-per owner. 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 components,date installed(if known)and source of information: November 1983-per as built card. 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: 123 Wagon Lane, Hyannis,MA Owner: Arthur Schirch Date of Inspection: March 2, 2000 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 plan) Depth below grade: 30" 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: 1000 gal. Sludge depth: S" Distance from top of sludge to bottom of outlet tee or baffle: 26" Scum thickness: 6" Distance from top of scum to top of outlet tee or baffle: 10" Distance from bottom of scum to bottom of outlet tee or baffle: 9" How dimensions were determined: Measuring stick 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.) The baffles were present The liquid level was even with the outlet invert. There were no signs of leakage. Recommend installing risers GREASE TRAP: None (locate on site plan) Depth below grade: Material of construction: _concrete _metal _Fiberglass Polyethylene _other(explain) I 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) Property Address: 123 Wagon Lane, Hyannis,MA Owner: Arthur Schirch Date of Inspection: March 2, 2000 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: — Comments: (note if level and distribution is equal,evidence of solids carryover,evidence of leakage.into or out of box,etc.) The box was located, but not dug up There were no signs of failure in the pit PUMP CHAMBER: None (locate on site plan) Pumps in worlQng 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 Page 8of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 123 Wagon Lane, Hyannis,MA Owner: Arthur Schirch Date of Inspection: March 2, 2000 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: 1-6'x 6' leaching chambers,number: leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number: 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 was 314 full There were no sits of failure The bottom to grade was 11'. Reconpnend installing risers. CESSPOOLS: None (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(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 9of11 SUBSURFACE SEWAGE DISPOS AL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 123 Wagon Lane, Hyannis,MA Owner: Arthur Schirch Date of Inspection: March 2, 2000 Map:270 Parcel.199 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) 3A(,k a � Al as . ' Aa- a, 3 3a- lS C� h3- 30 y AW- 3s Qy_ 3 H revised 9/2/98 . Page 10ofll SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 123 Wagon Lane, Hyannis,MA Owner: . Arthur Schirch Date of Inspection: March 2, 2000 NRCS Report name Soil Type Typical depth to groundwater USGS Date website visited Observation Wells checked Groundwater depth:Shallow Moderate Deep SITE EXAM Slope Surface water Check Cellar Shallow wells Estimated Depth to Groundwater 30+/- Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observed Site(Abutting property,observation hole,basement sump etc.) Determined from local conditions ✓ Checked with local Board of Health Checked FEMA Maps Checked pumping records Check local excavators,installers ✓ Used USGS Data Describe how you established the High Groundwater Elevation. Must be completed) Using the Barnstable topographic and water contour maps, the maps are showing approximately 30' +/- to groundwater at this site. 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 Commonwealth of Massachusetts Executive Office of Environmental Affairs 4 Department of Environmental Protection One Winter Street, Boston MA 02108 (617)292-5500 MAR 7 2000 FA14WINSPECTION +� rOWHEDALFTHOEPTABLE TRUDY CORE w'y Secretary ARGEO PAUL CELLUCCI '' I Ft " ° DAVID B.STRUHS Governor ��/ 4 M vlc�✓ti f �j A Commissioner -� SUBSURFACE SEWAGE DISPOSAL SYSTFI INSPECTION FORM PART A CERTIFICATION / Property Address: 123 Wagon Lane, Hyannis, MA Name of Owner: Arthur Schirch Address of Owner: Date of Inspection: March 2, 2000 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. Box 49, Osterville, MA 02655-0049 Map. 270 Telephone Number: (508)862-9400 Parcel: 199 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: ✓ Passes Conditionally Passes Needs Further Evalua' n By the Local Approving Authority 'ls Inspector's Signature: Date: March 2, 2000 The System Inspector shall submit copy of this inspection report to the Approving Authority(Board of Health or DEP)within thirty(30)days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. NOTES AND COMMENTS revised 9/2/98 Page Iof11 Primed on Recycled Paper c , SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 123 Wagon Lane, Hyannis, MA Owner: )c •i • Arthur Schirch Date of Inspection: March 2, 2000 r 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 statia:water level observed in the distribution box is'due tobroken 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 ti w SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 123 Wagon Lane, Hyannis, AM Owner: Arthur Schirch Date of Inspection: March 2, 2000 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 to a;surface water.supply or tributary to_a surface water supply. The system has a septic tank and soil absorption system and the SAS is within a Zone 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 revised` 9/2/98 Page 3of11 w SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 123 Wagon Zane, Hyannis, MA Owner: Anhur Schirch Date of Inspection: March 2, 2000 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 1h day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of tines 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�l.of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. if the well has been analyzed to be acceptable,attach copy of well water analysis for. coliform bacteria,volatile organic compounds,ammonia nitrogen and nitrate nitrogen. 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 4ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 123 Wagon Lane, Hyannis, AM Owner: Arthur Schirch Date of Inspection: March 2, 2000 Check'if the following have been done: You must indicate either"Yes"of"No" as to each of the following:' r 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 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)]. ✓ _ 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 F+ SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 123 Wagon Lane, Hyannis, MA ' Owner: Arthur Schirch Date of Inspection: March 2, 2000 ,. ! FLOW CONDITIONS RESIDENTIAL• - Design flow: 110 g.p.d./bedroom. Number of bedrooms(design): 3 Number of bedrooms(actual): 2 Total DESIGN flow n/a Number of current residents: 3 Garbage grinder(yes or no): No Laundry(separate system)(yes or no): n/a; 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 year's usage(gpd): 1998- 75,000 gals.:1999- 75,000 gals. Sump Pump(yes or no): No _ Last date of occupancy: Currently occupied COMMERCIAL/INDUSTRIAL: Type of establishment: Design flow: eod(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: Not pumped in 10 years-per owner. 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 components,date installed(if known)and source of information: November 1983-per as built card. 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: 123 Wagon Lane, Hyannis, MA Owner: Arthur Schirch Date of Inspection: March 2, 2000 ? s BUILDING SEWER: ,...' (Locate on site plan) k 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 plan) Depth below grade: 30" 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: 1000 gal. Sludge depth: S" Distance from top of sludge to bottom of outlet tee or baffle: 26" Scum thickness: 6" , .A Distance from top of scum to top of outlet tee or baffle: 10" Distance from bottom of scum to bottom of outlet tee or baffle: 9" How dimensions were determined: Measuring stick 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.) The baffles were present. The liquid level was even with the outlet invert. There were no signs of leakage. Recommend installing risers. 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 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) Property Address: 123 Wagon Lane, Hyannis, MA Owner: Arthur Schirch Date of Inspection: March 2, 2000 TIGHT OR HOLDING TANK:1,Wone;(Ta&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: Comments: (note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.) The box was located, but not dug up. There were no signs of failure in the nit. PUMP CHAMBER: None (locate on site plan) w 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 Page 8oftl SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 123 Wagon Lane, Hyannis, MA Owner: Arthur Schirch 0 Date of Inspection: March 2, 2000 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan, if possible;excavation not required, location may be approximated by non-intrusive methods) 4 `. i If not located,explain: Type: leaching pits, number: 1-6'x 6' leaching chambers,number: leaching galleries, number: leaching trenches,number, length: leaching fields,number,dimensions: overflow cesspool,number: 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 was 314 full. There were no signs of failure. The bottom to grade was 11'. Recommend installing risers. CESSPOOLS: None (locate on site plan) , Number and configuration: Depth-top of liquid to inlet invert: x. Depth of solids layer: 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 9of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 123 Wagon Lane, Hyannis, MA ' Owner: Arthur Schirch Date of Inspection: March 2, 2000 Map.270 Parcel: 199 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) 3Ak A - 3 3a- 1S (o /A3 30 3-' C� 0 i y 13 Aq 36 , revised 9/2/98 Page 10ofII 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 123 Wagon Lane, Hyannis, MA Owner: Arthur Schirch Date of Inspection: March 2, 2000 , NRCS Report name Soil Type Typical depth to groundwater USGS Date website visited Observation Wells checked Groundwater depth: Shallow Moderate Deep SITE EXAM Slope Surface water Check Cellar Shallow wells Estimated Depth to Groundwater 30+/- Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observed Site(Abutting property,observation hole,basement sump etc.) Determined from local conditions ✓ Checked with local Board of Health Checked FEMA Maps V Checked pumping records Check local excavators, installers ✓ Used USGS Data Describe how you established the High Groundwater Elevation. (Must be completed) Using the Barnstable topographic and water contour maps, the maps are showing approximately 30' +/- to groundwater at this site. 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 TOW1V OF BARNSTABLE IcT LOCATION �a3 w�G�� �'+✓a� SEWAGE # � �oZ( VII:LAGE IAN✓AAL'S . ASSESSOR'S MAP &LOIa70 I INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY UO'O LEACHING FACMITY: (type) (size) �OX NO.OF BEDROOMS BUILDER OR OWNER r V Sck r C. PERMITDATE: COMPLIANCE DATE: I Fj3 i Separation Distance Between the: Maximtim 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 i �-M - r -� •a o �n M C6 M � � � � k � C M I� LOCATION SEWAGE PERMIT NO. o`i 1 Lk Li vk6o)J VA) VILLAGE INSTALLER'S NAME i ADDRESS ® U I L.D E R OR OWNER DATE PERMIT ISSUED - OAT E COMPLIANCE ISSUED .4 i � � �9-�� li �� �q, � r-- v �'a ©e � sC 0 � 21 .� � � o � . �r � v � 1` J Fizs........`.' .Q............ --� THE COMMONWEALTH OF MASSACHUSETTS BOA OF HEALTH Allp iration for Bigpnsal World Tumitrnrtiun Prrmit Application is hereby made for a Permit to Construct (L-)or Repair .( ) an Individual Sewage Disposal System at: . � .... '?�.- •-- -... ....... ............... ................. a ddress or t No �r4.�:...- .....- ------------------- yyl �_- -----------...---- _ E wner Address a •--•................. ..� ._ :_ ... .......................... L?. _ .. .... ... Installer Address V �/ Type of Bu i g Size Loti___�b f. 28...Sq. feet 13 Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) Other-Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( ) a Other fixtures -----•-•---•-------------------- . W Design Flow......1__�_��_............................gallons per person per day. Total daily flow..____���.........................gallons. WSeptic Tank—Liquid capacity---%.04gallons Length...... ....... Width..... Diameter________________ Depth__ =.-/" . Disposal Trench—No_____________________ Width.................... Total Length...... _.J...... Total leaching area....................sq. ft. 0 Seepage Pit No.....11 "0---- Diameter........)...__.._. Depth below inlet_..... ........... Total leaching area_2.4?�q_..__sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ ,4 Test Pit No. i... per inch Depth of Test Pit...... _L'..___ Depth to ground water....)V-N ?'--=-._. Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ ,_.._... Description of Soil-------�•-='--�--�-------• �•- -�'°'a--��• •-----�-0-------------- ---------- --------- -----------------------�- �- •- W --•----••-------------------------------••--•---•--------------------------------------•-=-----•--•------•---•------...-----•--•----•-•--------•--------------•------•-•------•--•-----------------..._. V 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 TITLE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been 'ssued by the board of health. Signed..... ... ._ ................. y = ✓n=�3 Date ApplicationApproved By...................................... - •------- -•----------------------------- ------ Date Application Disapproved for the following reasons-----------------------------•--•-----------------------•-------------------------------=-----------------_----•- Date PermitNo......................................................... Issued_....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .....................:....................OF..................................................................................... Tntifiratr of TuntpliFanrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired by.................................................................................................................................................................................................... Installer at...................................................................................................................................................................................................... has been installed in accordance with the provisions of TITLE j of The State Sanitary Code as described in the application for Disposal Works Construction Permit No......................................... dated_...._-._-.-..--__-__----__-.______________-__-_ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE AS A GUARANTEE THAT THE SYSTEM WILL �CTION SATISFACTORY. DATE_ /.;L'.-�---t.1 .................................................... Inspector--•--- ----• •----------...--••--••••-••--•-•-------...-----------•--...._._....•- No......................... Fx$.............................. + THE COMMONWEALTH OF MASSACHUSETTS BOAS OF HEALTH F_CW' _05;.:.�-...........OF..... ---- Appliration far Bi-gnoal 10orkii Tonotrurtion retain Application is hereby made for a Permit to Construct ( 4-7 or Repair ( ) an Individual Sewage Disposal System at _73 14A.11m, ... .1 `Y:3 ddress or t No W caner r� .................... ..... �P. Installer Address d Type of Building Size Lot----- __�_� __...Sq. feet U Dwelling—No. of Bedrooms......1::...................................Expansion Attic ( ) Garbage Grinder ( ) `P1414 Other—T e of Building No. of persons............................ Showers — Cafeteria Q'I Other fixtures -------------------------------- . W Design Flow...._..j__�.0...........................gallons per person p day. Total da•1Wflow..._.....`�...� _....................__gallons. f. WSeptic Tank—Liquid capacity..._�t allons Length................ Width__.._......._ Diameter__.____..___--_- Depth.... f...._. Disposal Trench—No. .................... Width. _.----------- Total Length..................... Total leaching area....................sq. ft. Seepage Pit No......1.€'uvia_. Diameter......... Depth below inlet...... .......... Total leaching area..A. ....sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.............................................. -----------.... Date.------•-----------•------------------- ,al Test Pit No. 1....j— .minutes per inch Depth of Test Pit------- ' '_...__ Depth to ground water--__: _d (i, Test Pit No. 2................minutes per inch Depth of Test Pit................. Depth to ground water-___-______--___--.____. P4 .........� ... � Description of Soil------. .. � U ••-------------------•-•---•-----•--•------------••-----------------------------............ W UNature 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 TITI1% 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Signed...................................................................................... ------------•------•---•------ Date ApplicationApproved�By........................................................................................... Date Application Disapproved for the following reasons:----•-------•-••-•-----•------------------------------------------------------------------------------•......--- --•--•-•------•------------------•••--------..........-----=------•---•--•--••----------•-.....--•------•._......_....--•------------------------------------------•----•------•------------••--•-------- Date PermitNo......................................................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................OF............................... 1:-------......--•....-------•...,-------...--•----• (grriifirate of Toll pliaure THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) by----•----•---------------•--•-•--••---•---••••--•-•--••----•••---•--•-------------------------------•------•--------•--------•-----------------•-•------••-•---•••-__---------------•--------•------ Installer at...................................................................................................................................................................................................... has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the application for Disposal Works Construction,Permit No......................................... dated------------------------------------------------- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTR E® AS A GUARANTEE THAT THE SYSTEM WIL/4 CTION SATISFACTORY. !�DATE....b ..� .. :ft__---------•--------------------------------•-------- Inspector.... .... ...........................................:.-•---•-----.....----•----• THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...........................................OF...................................................................................... No......................... FEE........................ Difistinal Workii Tongt cation eriiti Permissionis hereby granted............................................................................................................................................... to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at No Street w as shown on the applicatio i for Disposal Works Construction Permit No ,-wo? d......................................... f P� •--------•-------•--•----•---- ------ --------------------------------------•--•- th '. DATE........ . ------------------•--.......... FORM 1255 HOBBS & WARREN, INC., PUBLISHERS IJN rn 4 In —47 AA dD o D myo Dv 7 -j .4 (b G1 { M A 0 is w 0 ' Z1 n U4 o Z m SOW D II-i co rj N � JO r : W��6 �• w W GN 0 �o o a d z � I V1 `i Z �a � •� D J D Ct :T a v _ •. �� r .0 C < O y n m �1 1-4 CP W 70 cm N b m m U� Na p� SirKI _pATA ;� <>t►JGLG- FAMII-Y - � BcoRooM N uo tZl1.1AF 2 ' V ,i GAIzeA6E G Z3 I. DNIL. -.FLOW ^ 110 x 3 = �I jEPT\G' TAQK = 33ox15o'/. i) use ►000 GAL. _ Sys , I o15Po5AL PtT ' v5E to00 GAL. 5oTT0M n2EA= 0 6.F._ i 5o II 7 TA " G II -TOTAL. DAILY FLOV( � �30 G PD, ^� ZY, V D I, PEIZC0LATIo1J GZATE IiN 2MIn1 0P-LE55 � T @9 II 526.OF y �" o j AL.AN WHARO A J()NE$ Pia 24M Izz c�IP/ v STQ 5 U M� k 1 Top FuU= 100•0 � O�3/� � G. G• = �� Y Ioov lw\/. i I Sv<35oic__ DIST. PT IC, -rA, ( 1000 I NV• TANK Lcncu PIT ,NV. ,NV. WITU II VJA�NGD /f'fE7 6 Tv N rc � CoveSE s ,ya Ct=RTIFIGD PLOT PLAID yo ��C PRUFIL� L0ZQ-T ►0IJ BG NO 5CALE �jG,t> La /'_ 70 VATrc q�G/�j-`r R E E 2E N G>= CE RT�FY -THAT -TNE �5 NSESNo�rYN 1 ►AEREoN COMPLY5 WITH -T N6 S I of LttJ T/ A►Jt� 51rT5e,GK fZ6QuIQ-EMEN7"!�, =(OWN O� �jpPr•1STAF�L.r ANC t!, �lcfT' ,QK �7���. Z9 t LOC, .T D WITNI T Gl OOD LL�.11�1 pATE G g AxT,Gv-e IJ`{E INC. R.EGtS�6Q6•�'�.ANDSuMvEYoe�... �' Tlll''j PL�r.I 15 NJOrT C3 ��n p►d AIJ v3TGP-VILLE - MASS• IuSTRuM6NT 5v2��E`( E 'rNEie"'j r.Sk7 5uouLD /.✓G• /AILIL 1 AT i ,�1 F`, "�� APP LICA►�T-� `•:�+�.s'S r- �SS—�'•"l C O v t o` ..� •� '�sv $ u� 'u a a� I-E E}I ...-__._.._........... _ III ! L I` D o Ip ' f � r Ih I xit I I a a � 1 �I I , I Q 2 rO:::PlSF'T.c_PS 03 a - 6 _tie1 11 • s.eLxsc c,� 1 - � � 2 ,c ins_ 'pl I I I I �1�, ` _2 v Pr s,>_c, or.�at_cc:e E � rs�•�• 'F"'a sue.'., : s„-2: :'`iee 2.x ��.-,�..-1_s�_-- 1 D Oa btuGtc,r�{} Ztl Q - ; �r=c-nc•}��_��7,N) i� I l I 4 6. :; 12SUr rG�::2" ..... 3 rp �i i A $ j . RAM i 0 � XMIC sra. rc:'ra'�+eexzne�._ rFR --rE6191 xQ sydl `----_—__-- 2004 - _ G .SE�tjBSY�.;}7vt � � ,I I �/ •® � .�i� .j � Reserved It 1 4/_ 1 f, —— - — 3 ` Preliminary p7n.k,a-nd 6)yOuts by DC.D.are for the use of tne'ir CusromerS only.Any.other use is Strictly Prom Bite o g C1 C E <� u1 �a 2 T J O T Q I T C p E 0 Q 0 - T I U O r T iC 1' Ip .n T E, y a' 4 t I I I i I ! I , I I j — i jj I - li , I i.. I i _ I I: it �