HomeMy WebLinkAbout0007 BRISTOL AVENUE - Health 7 BRISTOL AVE., HYANNIS
A=
/r
o ° a
°
CONfMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
ONE WINTER STREET,BOSTON MA 02108 (617)292•6500
TRUDY COX
Secretar
ARGEO PAUL CELLUCCI Governcr DAVID B. STFtiL H
SUBSURFACE SEWAGE DISPOSAL SYSTEM IINSpECTION FORM Gorrutias:oae
PART A
7 �,r1 SAOA �i CERTIFICATION / /
Property Address: QdY60/ Nana of O "at`lleg llee, co 0./1 C!� g
Date of ,�of _ OO Address of Owner:_ �, c _ a.^e. / aayr� .41 r wl GO/
`rap ecto. y✓I l,— �o/smell%
Name of Irtspactor:(P'Iease print) O+r
I am•DEP ep{Ir system insp�Lxwsuarrt to Section 16.340 of IMe 5 1310 CMR 15.0001
Company Name: �Npl O —
Mailing Address: O o._( /et 8�' �� jyJ� a'_(,14).
Telephone Number:
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:
V YEsiea
— Conditionally Passes
— Needs Further Evaluation By the local Approving Authority
Fails
kupeeto►'s Signature: Data: a
The System Inspector shell 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
"-shelf submit the report to the appropriate regional office of the Department ofrfnvironrher"Protectlun. The original shouid'ba sent to-"
system owner and copies sent to the buyer, If applicable,and the approving authority.
NOTES AND COMMENTS
t 5
.` y
9
sf�0 \/V/
eo
i
revised 9/2/99 Pap Iof II
Pnnied on Recycled Piper
r
SUBSURFACE SEWAGE DISPOSAL SYSTVA MPECTION FOAM
PART A
CERTiF�CATIaPlleaettlmndl ,
property
Address!
Owner: cool ( C� L�.
!?ane of(nepeclfan:
00
INspECTfoN tuMMARY: Cheek A. B, C, cir D:
s. B TEM PASSES:
I hove not found any information which indicates that any of the failure conditions described in 210 CMft 16.303 exist. Any faliwe
criteria net evaluated era Indicated below.
COMMENTS:
e. SYSTIEM CONDITIONALLY PASSER:
One or more system components as described In the"Conditional Pass"&action need to be replaced or repaired. The evotem,voon
completion of the replacement or repair,se approved by tha Board of Health,will pass.
indicts yes,no, or not determined(Y.N, or NDI. Desoribe basis of determination In aft Instance&. If "not determined",explain why not,
The septic tank is metal, unless the owner or operator hoe provided the system Inspector with a copy of a Cortifleato of
Compliance(attached)Indiontfng that the tank was Installed wlthbt twenty(20)years prior to the date of the inspection;or
the septic tank, whether or not motel,Is crooked,structurally unsound,shows substantial"tration or oxfflt►ation, or tank
failure is Imminent. The system will pass Inspection If the existing septic tank is replaced with a complying septic tank is
approved by the Board of Health.
Sewage backup or breakout at high static water level observed In the distribution boa Is due to broken or obstructed ptpa(s)
or due to a broken,settled or uneven distribution box. The system will pats inspection If(with approval of the Board of
Health).
broken plpois)are replaced
obstructlen Is removed
distrib itlon box is levelled or replaced
- The syinem requited pumpbfpinoie then tourtfmee Is due to brekan of of3"ated pipetst. The t>yoni n wMtl�sa"^
Inspection If lwfth approval of the Board of Health);
broken pipes)are replaced
obstruction Is romoved
Page 2of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
/ CERTIFICATION(continued)
Property Address: ��'S l Gr✓p o.��h f ��� O,t b�/
Owner: va �, y
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 if the system is failing to protect the
public health,safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES W ACCORDANCE WITH 310 CMR 15.303 1101b)THAT THE SYSTU
IS NOT FUNCTIONING IN A MANNER WHICFLWILL.PRQTECT THE PUBLIC HEALTH AND SAFETY.AND THE ENIORONMEPLT:
Cesspool or privy is within 50 feet-of 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 R
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 of 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 I 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 tl
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 velid).
3) OTHER
revised 9/2/98 P2ge3of11
11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
/ CERTIFICATION(continued)
Property Address: LV y Owner: COO f
Date of Inspection: 1 _ O 0
D. SYSTEM FAILS: U\
Yourust indicate either"Yes"or"No" to each of the following:
1 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 iecilityer-system component-due go an overloaded orclegged SAS,ar 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.
_ U 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 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped_.
Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation.
Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
t` Any portion of a cesspool or privy is-within a Zone I of a public well.
V 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" 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-o4#4wory-o a eurfa9e44nki g.water-oupplY
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 inforq,ation.
revised 9/2/98 Page 4of11
t SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address J�j�G( �jf 1�T;7_Gr rl-1,S A,c, �,A 6 01
Owner: c o ( t
Date of Inspection: y e
3- 6�� 00
Check if the following have been done:You must indicate either "Yes" or"No" as to each of the following:
'Vee No
V _ Pumping information was provided by the owner,occupant, or Board of Health.
None of the system composent haw bsen poa4pad4or-aKJeast two wee"and the system hasbaaaaacsiriogaws•al Aow
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.
V _ 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.
]f _ 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. 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)I
The facility owner(and.occupaats.if different lrom�yvrJer).vitere prnvided.with iafntrnatioann thn���o.�y�pp-0f
SubSurface Disposal Systems.
revised 9/2/98 Page 5of11
! SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address:
Owner:
Date of Inspection:
FLOW CONDITIONS
RESIDENTIAL- /�
Design flow: 10 g.p.d./bedr
Number of bedrooms(design): Number of bedrooms(actual):
Total DESIGN flow_��
Number of current residents: O
Garbage grinder(yes or no):-"
Laundry(separate system) (yes or no): If yes,sepaWe inspection required _
Laundry system inspected yes o
Seasonal use(yes or no):_U
Water meter readings,if available(last two year's usage(gpd): /+
Sump Pump(yes or no):*0
Lest date of occupancy:. ,2ko0
COMMERCIALIINDUSTRIAL:
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:(Describel
Lest date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of in rmation:
V.4•-IV - 2 f;� 4min —®(i o-e(/t
System pumped as part of inspection: (yes or no)_
If yes, volume pumped: gallons
Reason for pumping:
TYP FSYSTEM
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)
1/A Technology etc. Attach copy of up to date operation and maintenance contract
Tight Tank Copy of DEP Approval
Other APPROXIMATE rrt
AGE of all components, date installedlif known)-and source of4wfetation: TU^n do#
Sewege odors detected when arriving at the site:(yes or no)NO
revised 9/2/98 Page 6ofII
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: �f>`lo,l o o //
e l 4 4 n 6,0
Owner: Ccb( 1 i e
Date of Irsspection:.
00
BUILDING SEWER:
(Locate on site plan)
�/ fo
Depth below grade:30 /
Material of construction:_cast iron 40 PVC_other(explain)
Distance from private water supply well or suction line
Diameter
Comments: (condition of joints,venting,Avide e of Iga}cage,-etc.) -•-
(r.Wn j-(P�✓ /ems V A-i
SEPTIC TANK:_
(locate on site plan)
Depth below grade:t
Material of construction:_concrete_metal_Fiberglass _Polyethylene_other(explain)
If tank is metal,list age_I Is.age confirmed by Certificate of Compliance_(Yes/No)
Dimensions: l 0 X
Sludge depth:
:Distance from top of sludge to bottom of outlet tee or baffle -
Scum thickness: 9-/.,
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom pf outle tee orb If le:
i How dimensions were determined:�c I e- e Vic.�,
Comments:
(recommendation for pumping, condition of inlet and outlet tees or-►Baffles, depth of liquio level in relatio?to outlet invert, tructur tegrity,
evidence of leakage, etc.) 0,0 ✓jQ(%G+>✓ a. !� refs po
o W S•
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 7ofII
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
/ r
SYSTEM INFORMATION(continued)
Property Address: 2Jr r/S 7 v R G Gi ti✓1 rl ���t ��6 0
Owner: �0/r is
Date at Inspection:
3,2A -o0
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(ezplain)
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.)
I
DISTRIBUTION BOX:_
(locate on site plan) /(�
Depth of liquid level above outlet invert:/r orme, '
Comments:
(note if level and disyibution is equal,evidenee of solids carryover, id nce of leak @a into or out of box, etc.) — - —
ve-
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.)
revised 9/2/98 page 8orn
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
/ SYSTEM INFORMATION(continued)
elfProperty Address: 1S/.40( cp1f� 1�0?N y<s /d1c; ' 0,4601
Owner: Cod l' C
Date of Inspection: 3 a�-0
SOIL ABSORPTION SYSTEM(SAS):_
(locate on site plan,if possible;excavation not required,location maybe approximated by non-intrusive methods)
If not located,explain:
Type:
leeching pits,number:
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.)
9- O re rJICI
CESSPOOLS:
(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)
i o
Comments:
(note condition of soil,signs of hydraulic failure,level of pending,condition of-vegetation, etc.)
PRIVY:_
(locate on site plan)
Materjals 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 9or11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
J/ YSTEM INFORMATION(continued)
Property Address: / �tS10 Of<L �N✓1'S i Qe[6(� /
Owner: C c7c�t, 5
Date of Inspection:
0 —�
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)
i
f
i
I
I
-d3 6 � 39 �
revised 9/2/98 page loorii
t SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)Property Address: ` /�'�c1
Owner: !, 1W
Date of hspectiorl: !
J-"�-j-o
NRCS Report name
Soil Type_
Typicaldepth 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 L 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
Checked local excavators, installers
V Used USGS Data
Describe how you established the High Groundwater Elevation. (Must be completed)
/ Q 0 Jr
be/DW ti'rutG�l A10 l�00 P"I's Gi✓2
uJd-3 0 -
��1!h lTr ov�.r'�kr: 3�✓, G} Jl J
J �d
revised 9/2/98 Page 11of11