HomeMy WebLinkAbout0026 WOLLEY ROAD - Health .20' fv®iiey ftoaa 5
Hyannis F/R
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/ TOWN OF BARNSTABLE f- C tf
LOCATION 2 b SEWAGE#
VILLAGE ASSESSOR'S MAP &-LOT,?
INSTALLER'S NAME&PHONE NO.. J/1 *
SEPTIC TANK CAPACITY
LEACHING FACILITY:(type') L` l.� (size)
NO.OF BEDROOMS
BUILDER OR OWNER
PERMITDATE: ,00' -4Z -@-e'o' COMPLIANCE DATE: 1
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the 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) ,i Feet
Furnished by
CN i
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alC7
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No. ' °` �� Fee O
s THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS
Zipprtcation for Miopont *pftem Construction Permit
Application for a Permit to Construct( . )Repair( )Upgrade( �bandon( ) Complete System ❑Individual Components
Location Address or Lot No. Owner's Name,Address and Tel.No.
Assessor's Mai
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
Type of Building:
Dwelling No.of Bedrooms_ Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow j�c gallons per day. Calculated daily flow Q gallons.
Plan Date foL t<—Ok Number of sheets Revision Date
Title
Size of Septic Tank Type of.S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable)
Date last inspected:
Agreement:
The undersigned agrees to ensure the constructfbin and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issue y this Board of Health.
Signed Date --tl x--47
Application Approved by Date
Application Disapproved for the following reasons
Permit No. O�X Y --0/ 3 Date Issued I COY
No. Fee r-
!1+. ' 4 THE COMMONWEALTH OF MASSACHUSETTS , ..;} ,. .a, Entered in computer:
a..
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLES MASSACHUSETTS Yes
Zipplicatiou for Migool bpotem Con5tructioi1 Permit
Application for a Permit to Construct( )Repair( )Upgrade( Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot NO Owner's Name,Address and Tel.No.
Assessor's Ma� ��`�y ~ �``C
arce
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
• 7>S'o>o � ..O
Type of Building:
Dwelling No.of Bedrooms " ' Lot,Size sq.fit. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow �' �' e: gallons.
Plan Date 0'— e—Ok Number of sheets ! Revision Date
Title
Size of Septic Tank Type gVS.A.S.
Description of Soil
a;
Nature of Repairs or Alterations(Answer when applicable)
Date last inspected: 5
Agreement:
The undersigned agrees to ensure the construcfa=;Band maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Envi.tonmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issue y this Board of Health.
Signed_ Date
Application Approved by Date
Application Disapproved for the following reasons
Permit No. L/ ,0/ 3 Date Issued
---------------------------------------
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS '
Certificate of Cofigltanre
THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( )Repaired( )Upgraded( )
Abandoned( )by O'' Lt 6',04 '
at 07 e, Gvo LL y &O &y,4 has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. _2 Opq-611 dated 1 I;T j
Installer Z cr8a eo 4'/c Designer
The issuance of this pemtit shall not be construed as a guarantee that the systorm_will function as designed.
Date 1 1110 Inspector 1 h f
11=
No.c ��--------------------------Fee 5 0
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS
iz ogaf *pgtem Cott5tructiott ermit
Permission is hereby granted to Construct( )Repair( )Upgrade(kd Abandon( )
System located at e?4, Y
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.
Provided:Constraction
/nust be completed within three years of the'ates a "t
Date: _� �o/`J� Approve
TOWN OF BARNSTABLE
LOCATION SEWAGE #
va.LAGE ASSESSOR'S MAP &LOTo2,'o
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) e � (size)
NO. OF BEDROOMS
BtMDER OR OWNER
PERMITDATE: i" r/� '� COMPLIANCE DATE:
Separation Distance Between :
Maximum Adjusted Groundwater Table to the 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) _i Feet
Furnished by
I
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A
8
�G 3� -
r -
' FAILED INSPECTION
COMMONWEALTH OF MASSACHUSETTS �,
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
ECEEIVED
JAN 0 6 2004
TITLE 5 TOWN OF BARNSTABLE
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY A'SSESSIVIE.NTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 26 Wolley Road
Hyannis, MA 02601
Owner's Name: Susan Hull MAP
Owner's Address:
PARCEL.
Date of Inspection: December 12, 2003 LOT _21
Name of Inspector: (Please Print) James M. Ford
Company Name: James M. Ford
Mailing Address: P.O. Box 49
Osterville,MA 02655-0049
Telephone Number: (508) 862-9400
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:
Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
✓ Fails
Inspector's Signature: Date: December 16, 2003
The system inspector shall sub 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.
Title 5 Inspection Form 6/15/2000 page I
t i
Page 2 of 1 I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 26 Wolley Road
Hyannis, MA
Owner: Susan Hull
Date of Inspection: December 12, 2003
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 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.
s 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
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:
2
Page 3 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 26 Wolley Road
Hyannis, AM
Owner: Susan Hull
Date of Inspection: December 12, 2003
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 CNIR 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 ofa 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:
3
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Page 4 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 26 Wolley Road
Hyannis, M4
Owner: Susan Hull
Date of Inspection: December 12, 2003
D. System Failure Criteria applicable to all systems:
You must indicate either."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 '/2 day flow
✓ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number
of times pumped_.
✓ Any portion of the SAS,cesspool or privy is below high ground water elevation.
✓ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
✓ Any portion of a cesspool or privy is within a Zone 1 of a public well.
✓ Any portion of a cesspool or privy is within 50 feet of a private water supply well.
✓ Any portion of a cesspool or privy is less than 100 feet but greater than 50 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 (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 System:
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
T _ 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.
4
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Page 5 of I 1
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 26 Wolley Road
Hyannis, MA
Owner: Susan Hull
Date of Inspection: December 12, 2003
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?
✓ 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 ?
✓ _ Was the facility owner(and occupants if different from owner)provided with information on the proper
maintenance of subsurface sewage disposal systems?
1
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)].
5
Page 6 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 26 Wolley Road ,
Hyannis. MA
Owner: Susan Hull
Date of Inspection: December 12, 2003
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): n/a Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
Number of current residents: 1
Does residence have a garbage grinder(yes or no): No
Is laundry on a separate sewage 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 2 years usage(gpd)): Unavailable.
Sump Pump(yes or no): No
Last date of occupancy: Currently occupied
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): and
Basis of design flow(seats/persons/sqft,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: Pumped approximately in 1997-per owner
Was system pumped as part of the inspection(yes or no): No
If yes,volume pumped: eallons--How was quantity pumped determined?
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)
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:
Approximately 25 years plus-per owner
Were sewage odors detected when arriving at the site(yes or no): No
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Page 7 of I 1
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 26 Wolley Road
Hyannis, AM
Owner: Susan Hull
Date of Inspection: December 12, 2003
BUILDING SEWER(locate on site plan)
Depth below grade:
Materials of construction: _cast 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: None (locate on site plan)
Depth below grade:
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:
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:
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert,evidence of leakage, etc.):
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(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels
as related to outlet invert,evidence of leakage,etc.):
7
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Page 8 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 26 Wolley Road
Hyannis, MA
Owner: Susan Hull
Date of Inspection: December 12, 2003
TIGHT or HOLDING TANK:. None (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: None (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.):
PUMP CHAMBER: None (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.):
8
Page 9 of 1 1
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 26 Wolley Road
Hyannis, AM
Owner: Susan Hull
Date of Inspection: December 12, 2003
SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required)
.If SAS not located explain why:
Type
leaching pits,number:
leaching chambers,number:
leaching galleries,number:
leaching trenches,number, length:
leaching fields,number,dimensions:
✓ overflow cesspool,number: 1
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.):
The cesspool was S'W x 6'T x 9'bottom to grade and was full. Liquid was above the inlet pipe and into the cover. The cover
was 16"below grade.
CESSPOOLS: ✓ (cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration: 1 with overflow
Depth-top of liquid to inlet invert: --
Depth of solids layer: --
Depth of scum layer: 12"+
Dimensions of cesspool: S'Wx 6'T x 9'bottom to grade
Materials of construction: Cesspool block
Indication of groundwater inflow(yes or no):
Comments (note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.):
The cesspool had T of liquid on the bottom. Liquid was above the inlet and outlet pipe and up to the cover. The cover was 16"
below grade.
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.):
9
Page 10 of 11
OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 26 Wolley Road
Hyannis, MA
Owner: Susan Hull
Date of Inspection: December 12, 2003
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.
8ACk
D
A .8
31 36
a
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Page 11 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 26 Wolley Road
Hyannis, M4
Owner: Susan Hull
Date of Inspection: December 12, 2003
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water 25 +/- feet
Please indicate (check) all methods used to determine the high ground water elevation:
Obtained from system design plans on record- If checked, date of design plan reviewed:
Observed site(abutting property/observation hole within 150 feet of SAS)
✓ Checked with local Board of Health-explain: topographic and water contours maps
Checked with local excavators, installers-(attach documentation)
Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Using the Barnstable topographic map and the Cape Cod Commission water contours map,the maps were showing approximately
25'+/-to ground water at this site.
This report has been prepared and the system inspected and failed 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/6r this report.
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11
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFF
DEPARTMENT OF ENVIRONMENTAL PROTEC ! N
ONE WINTER STREET,BOSTON MA 02108 (617)29275500 •;
RE��f0
�g
WU,LIAM F.WELD DEC TRUDY CORE
Governor 6 1 Q/- Secretary
ARGEO PAUL CELLUCCI �� �VID B.STRUHS
Lt. Governor C.nissioner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION q
Property Address:�-�L' ICII��`� �'� g' Address of Owner:GAS p►v P�v
Date of Inspection: kzi� (If different) 7-7
Name of Inspector: J l
Company Name, Address and Telep or� Number:
yv�S u
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 Evaluation By the-Local Approving Authority
_ Fails
Inspector's Signature: Date:
The System Inspector shall submit a copy of this inspection report to the Approving Authority 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.
INSPECTION SUMMARY:
Check A, B, C, or D:
A] SYSTEM PASSES:
I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303.
Any failure criteria not evaluated are indicated below.
B] SYSTEM CONDITIONALLY PASSES:
One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair,
passes inspection.
Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain why not.
The septic tank is metal, 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 conforming septic tank as
approved by the Board of Health.
(revised 11/03/95) 1
i�Printed on Recycled Paper
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property'Addre,s:
Owner.%'t-t , I
Date of Inspection:
B] SYSTEM CONDITIONALLY PASSES (continued)
_ Sewage backup or breakout or high static w/aced
ery in the distribution box is due to broken or obstructed
pipe(s) or due to a broken, settled or uneve b The system will pass inspection if(with approval of the
Board of Health):
broken pipe(s) are replac
obstruction is removed
distribution box is levellThe system required pumping more than foar due to broken or obstructed pipe(s). The system will pass
inspection if(with approval of the Board of
broken pipe(s) are replac
obstruction is removed
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 THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER
WHICH WILL PROTECT THE PUBL HEALTH AND SAFETY AND THE ENVIRONMENT:
_ Cesspool or privy is wit in 50 feet of a surface water
_ Cesspool or privy is w' in 50 feet of a bordering vegetated wetland or a salt marsh.
2) SYSTEM WILL FAIL UNLESS HE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT
THE SYSTEM IS FUNCTIO NG IN A MANNER THAT PROTECTs THE PUBLIC HEALTH:AND SAFETY AND THE
ENVIRONMENT:
The system h a septic tank and soil absorption system and is within 100 feet to a surface water supply or tributary to a
surface wate supply.
_ The system as a septic tank and soil absorption system and is within a Zone I of a public water supply well.
_ The syste has a septic tank and soil absorption system and is within 50 feet of a private water supply well.
_ The syst m has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water
supply ell, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is
free f om pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5
pp
3) OTHER
( evised 11/03/95) 2
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property A dre(ss: �� �
Owner: 401 l I
Date of Inspection: 1?�, 6�
Check if the following have been done:
U/Pumping information was requested of the owner, occupant, and Board of Health.
_VeNone 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.
t/ As built plans have been obtained and examined. Note if they are not available with N/A.
he 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.
�AII ystem components, excluding the Soil Absorption System, have been located on the site.
The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or
tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum.
The size and location of the Soil Absorption System on the site has been determined based on existing information or
appr ximated by non-intrusive methods.
The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of Sub-
Surface Disposal System.
(revised 11/03/95) 4
n
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:
Owner:
Date of Inspection:
D] SYSTEM FAILS:
I have determined that the system violates one or more of the followi failure criteria as defined in 310 CMR 15.303. The basis
for this determination is identified below. The Board of Health sho d be contacted to determine what will be necessary to correct
the failure.
Backup of sewage into facility or system component d e to an overloaded or clogged SAS or cesspool.
Discharge.or ponding of effluent to the surface of t e ground or surface waters due to an overloaded or clogged SAS or
cesspool.
Static liquid level in the distribution box abov outlet invert due to an overloaded or clogged SAS or cesspool.
Liquid depth in cesspool is less than 6" bel w invert or available volume is less than 1/2 day flow.
Required pumping more than 4 times in he last year NOT due to clogged or obstructed pipe(s).
Number of times pumped_.
Any portion of the Soil Absorption stem, cesspool or privy is below the high groundwater elevation.
Any portion of a cesspool or pri is within 100 feet of a surface water supply or tributary to a surface water supply.
Any portion of a cesspool or p ivy is within a Zone I of a public well.
Any portion of a cesspool o privy is within 50 feet of a private water supply well.
Any portion of a cesspoo 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, vola le organic compounds, ammonia nitrogen and nitrate nitrogen.
E] LARGE SYSTEM FAILS:
The following criteria ap y to large systems in addition to the criteria above:
The system serves a fa lity with a design flow of 10,000 gpd or greater (Large System) and the system is a significant threat to
public health and safe and the environment because one or more of the following conditions exist:
the syste is within 400 feet of a surface drinking water supply
the sys m is within 200 feet of a tributary to a surface drinking water supply
the s stem is located in a nitrogen sensitive area (Interim Wellhead Protection Area(IWPA) or a mapped Zone II of a
pu is water supply well)
The owner or oper or of any such system shall bring the system and facility into full compliance with the groundwater treatment program
requirements of 3 4 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.
(revised 11/03/95) 3
•
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
Owner:
Date of Inspection:
SEPTIC TANK:_
(locate on site plan)
Depth below grade:
Material of construction: _concrete _metal _FRP —other(explain)
Dimensions:
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Comments:
(recommendation for pumping, condition of inlet and outlet tees or affles, depth of liquid level in relation to outlet invert, structural
integrity, evidence of leakage, etc.)
GREASE TRAP:_
(locate on site plan)
Depth below grade:
Material of construction: _concrete _metal _F _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 utlet tee or baffle:
Comments:
(recommendation for pumping, conditio of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
integrity, evidence of leakage, etc.)
(revised 11/03/95) 6
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
PropertyAddress:
Owner: H-01 L
Date of Inspection: ►z�t���
FLOW CONDITIONS
RESIDENTIAL:
Design flow:-5'6Q gallons
Number of bedrooms:_77
Number of current residents:
Garbage grinder(yes or no):_
Laundry connected to system (yes or no): �f
Seasonal use (yes or n0 wel
Water meter readings, if available:
Last date of occupancy:
COMMERCIAUI N D USTRIAL:
Type of establishment:
Design flow:_gallons/day
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 RE OR S and source of information:
K&at5 eQdQL4
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)
Other (explain) 't--t nr=4 yco OSLIE�.0--.l CAS lS,
APPROXIMATE AGE of all components, date installed (if known) and source of information: + ��
Sewage odors detected when arriving at the site: (yes or no)4AD
(revised 11/03/95) 5
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
Owner:
Date of Inspection:
TIGHT OR HOLDING TANK:_
(locate on site plan)
Depth below grade:
Material of construction: _concrete _metal _FRP —other(explain)
Dimensions:
Capacity: gallons
Design flow: Aallons/day
Alarm level:
Comments:
(condition of inlet tee, condition of alarm and float switches, etc.)
DISTRIBUTION BOX:_
(locate on site plan)
Depth of liquid level above outlet invert:
Comments:
(note if level and distribution is equal, evidence of solids c/over, ence of leakage into or out of box, etc.)
PUMP CHAMBER:_
(locate on site plan) -
Pumps in working order:(yes or no)
Comments:
(note condition of pump chamber, condition f pumps and appurtenances, etc.)
(revised 11/03/95) / 7
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Aodress: P o
Owner: `L.,.
Date of Inspection: L-4`\CA
SOIL ABSORPTION SYSTEM (SAS): S -
'v methods)
.� be a approximated b non intrust e
(locate on site plan, if possible; excavation not required, but may pp y
If not determined to be present, explain:
Type:
leaching pits, number:_1�,C(o
leaching chambers, number:_
leaching galleries, number:
leaching trenches, number,length:
leaching fields, number, dimensions:
overflow cesspool, number:
Comm nts: (note condition of soil, signs of hydraulic failure, level of ding, condition of vegetation,etc.)
CESSPOOLS: S
(locate on site pl )
Number and configuration: v
Depth-top of liquid to inlet evert: t,,2.4
Depth of solids layer:
Depth of scum layer: y
Dimensions of cesspool: [ak Q--
Materials of construction: Cesy--rA
Indication of groundwater: Yt=k
inflow (cesspool must be pumped as part of inspection)
Commen s: ( ote condition of soil, signs f hydraulic fail re, level of ponding, nd' ' n of vegeta' n, 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.)
(revised 11/03/95) B
I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 2Lp Lkzok�5
Owner:
Date of Inspection' t\�f
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100'
DEPTH TO GROUNDWATER
Depth to groundwater: 4 n feet
method of determination or approximation: f(z)bCAtCL-&QXA-tA
(revised 11/03/95) 9
-
ASSESSORS MAP
e70
TEST HOLE LOGS
PARCEL: 77
NOTES:.._. , .
F LOOD ZONE: A-107- � 5- -- SOIL Ey ALUATOR
WITNESS-
DATE.-
REFERENCE: 1:Ce:P _ Jd
__ _ AL�-�UU�+2
__. _..__._._ _.w._._._T.._ 1) The installation.shall comply with Title V and Town of Barnstable Board of
,l7-1104 5 PERCOLAT ON RATE: L- li l R 4 ' Health Regulations.
__. 2) The installer shall verify the location of utilities, sewer inverts and septic
TH- I TH-2
components prior to installation.
3) All septic piping to be 4 inch Sch 40 PVC at 1/8"per foot.
j 4) This plan is not to be utilized for property line determination nor any other
/ '� _ purpose other than the proposed system installation,
ryb'M7 w /, 5) All septic components must meet Title V specifications.
/t7 Q7 �,,, 6) Parking shall not be constructed over H10 septic components.
LOCATION MA PC ,� 7) The property is bounded by property comers and property lines as depicted.
8) The property owner shall reviewdesign
p peaty considerations to approve of total
number of bedrooms to be considered for design. Receipt of payment for the
plan and installation based on the plan shall be deemed approval of the
number of bedrooms.
,9j The existing cesspools shall be pumped and backfilled per Title V
Abandonment Procedures.
10
j )Pro o p sed leaching is to be within 36 inches of grade or provide venting or cut
grade as,permitted by the Board of Health.
11)System components to be 10 feet from water line.
V .
SEPT I (4� SYSTEM DESIGN
FLOW ESTIMATE
I 2 BEDROOMS AT GAL/DAY/BEDROOM f.�?,'OGAL/DAY
S7EPTIC TANK
lD Ee ; Za GAL/DAY x 2 DAYS • L�6 GAL
USE/61006ALLON SEPTIC TANK
SOIL ABSORPTION SYSTEM
000
-' �Y
3 w
UAS
** 14
�P IDE AREA: ►x / �( i. a 1'L7 2 ? i t)IC
:a
117BOTTOM AREA: Zia '2 C� = , f3
, t
!► ,
0\ °' s :,,
TIC SYSTEM SECT ION ( T.
V4
AI
SEPTIC TANK � V �"I I��J '' I
„ .. 76
31 TE AND SEWAGE PLAN
.�.---- LOCAT ION : A2.1(:7 L-'r t-0tA D
�.
PREPARED FOR �"t a 4157T'4c
P
SCALE: r�
DAV I D B . MASON `S DATE:
Z DBC ENVIRONMENYAL DESIGNS
W EAST SANDWICH . MA,
W DATE HEALTH AGENT ( j0$ ) $33- 2177
z