HomeMy WebLinkAbout0009 DACEY DRIVE - Health (2) 9 DACEY LANE, HYANNIS
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COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
TITLE 5
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION RECEIVED
Property Address: 9 Dacey Drive
Centerville, MA 02632 _ MAY 1 2 200
Owner's Name: Normand Varieur
Owner's Address: TOWN OF BARNSTABLE
HEALTH DEPT.
Date of Inspection: April 14, 2003
Name of Inspector: (Please Print) James M. Ford
Company Name: James M. Ford Map:252
Mailing Address: P.O. Box 49 Parcel: 183
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
Need&Further Evaluation by the Local Approving Authority
Fail
Inspector's Signature: Date: April 15, 2003
The system inspector shall sub racopy 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 1
Page 2 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 9 Dacey Drive
Centerville, MA
Owner: Normand Varieur
Date of Inspection: April 14, 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()(,N,ND)in the for the following statements. If"not determined",please
explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally
unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the
existing tank is replaced with a complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
Observation of sewage backup or break out or high static water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if (with
approval of Board of Health):
broken pipe(s)are replaced
obstruction is removed
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: 9 Dacey Drive
Centerville, AM
Owner: Normand Varieur
Date of Inspection: April 14, 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 CMR 15.303(1)(b)that the
system is not functioning in a manner which will protect public health,safety and the environment:
Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the
system is functioning in a manner that protects the public health,safety and environment:
_ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a
surface water supply or tributary to a surface water supply.
The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply.
The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a
private water,supply well". Method used to determine distance
"This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
failure criteria are triggered. A copy of the analysis must be attached to this form.
3. Other:
3
Page 4 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 9 Dacey Drive
Centerville, AM
Owner: Normand Yarieur
Date of Inspection: April 14, 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 '/z day flow
✓ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number
of times pumped_.
✓ Any portion of the SAS,cesspool or privy is below high ground water elevation.
✓ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
✓ Any portion of a cesspool or privy is within a Zone I of a public well.
✓ Any portion of a cesspool or privy is within 50 feet of a private water supply well.
✓ Any portion of a cesspool or privy is less 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.]
No (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
1':Pd•
You must indicate either"yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
Yes No
_ the system is within 400 feet of a surface drinking water supply .
the system is within 200 feet of a tributary to a surface drinking water supply
_ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped
Zone II of a public water supply well
If you have answered`yes"to any question in Section E the system is considered a significant threat,or answered
"yes"in Section D above the large system has failed. The owner or operator of any large system considered a
significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
15.364. The system owner should contact the appropriate regional office of the Department.
4.
Page 5 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 9 Dacey Drive
Centerville, MA
Owner: Normand Varieur
Date of Inspection: April 14, 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?
V' 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?
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: 9 Dacey Drive
Centerville, MA
Owner: Normand Varieur
Date of Inspection: April 14, 2003
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): 3 Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330
Number of current residents: 4
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)): 2002.-154,500 gals.
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): apd
Basis of design flow(seats/persons/sgft,etc.):
Grease trap present(yes or no):
Industrial waste holding tank present(yes or no)
Non-sanitary waste discharged to the Title 5 system(yes or no):
Water meter readings,if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information: Pumped 6 months aAo-per owner
Was system pumped as part of the inspection(yes or no): No
If yes,volume pumped: gallons--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:
May 7195-per as built card
Were sewage odors detected when arriving at the site(yes or no): No
6
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: 9 Dacey Drive
Centerville, MA
Owner: Normand Varieur
Date of Inspection: April 14, 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: ✓ (locate on site plan)
Depth below grade: 15"
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: 1000 gal.
Sludge depth: 1"
Distance from top of sludge to bottom of outlet tee or baffle: 31
Scum thickness: 1"
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: 13"
How were dimensions determined: Measuring stick
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.):
Tees were present The liquid level was even with the outlet invert. There were no signs of leakage.
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
Page 8 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: _ 9 Dacey Drive
Centerville, MA
Owner: Normand Varieur
Date of Inspection: April 14 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: ✓ (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: Even
Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of
leakage into or out of box,etc.):
The D-box was level No solids were present
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 11
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 9 Dacey Drive
Centerville, MA
Owner: Normand Varieur
Date of Inspection: April 14, 2003
SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required)
If SAS not located explain why:
Type
✓ leaching pits,number: I-1000 gal,
leaching chambers,number:
leaching galleries,number:
leaching trenches,number, length:
leaching fields,number,dimensions:
overflow cesspool,number:
Innovative/alternative system Type/name of technology:
Comments(note condition of soil, signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.):
The pit had]'of water on the bottom The scum line was approximately 16"up from the bottom. There were no signs of
failure The bottom to grade was 7'6"
CESSPOOLS: None (cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration:
Depth-top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater inflow(yes or no):
Comments (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
PRIVY: 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: 9 Dacey Drive
Centerville, MA
Owner: Normand Varieur
Date of Inspection: - April 14, 2003
Map:252
Parcel: 183
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.
a -
3am.-7 3a.a
3o 7
I
10
Page 11 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 9 Dacey Drive
Centerville, MA
Owner: Normand Varieur
Date of Inspection: April 14, 2003
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water 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: 1195
Observed site(abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health-explain:
Checked with local excavators,installers-(attach documentation)
Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
The design plan shows no water at 12'when the system was installed
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.
11
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Commonwealth of Massachusetts
Executive Office of Environmental Affairs -7'L'A
Department of Environmental Protection
One Winter Street, Boston MA 02108 (617)292-55
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ARGEO PAUL CELLUCCI DAVID B.STRUHS
Governor Commissioner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION,FORM ^�='-T
PART A
CERTIFICATION
Property Address: 9 Dacey Lane, Hyannis, MA Name of Owner: Ann Birchhill
Address of Owner:Same
Date of Inspection: October 23, 1999
Name of Inspector: (Please Print) James M. Ford
I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000)
Company Name: James M. Ford
Mailing Address: P.O. Box 49, Osterville, MA 02655-0049 Map:
Telephone Number: (508)862-9400 Parcel.
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 Evaluaf By the Local Approving Authority
_ ils
Inspector's Signature: Date: October 27, 1999
The System Inspector shall submit py 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
Printed on Recycled Paper
• ter.
,
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address_: 9 Dacey Zane, Hyannis, MA
Owner: Ann Birchhill
Date of Inspection: October 23, 1999
INSPECTION SUMMARY: Check A, B, C, or D-.`
A. SYSTEM PASSES:
✓ I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist. Any failure
criteria not evaluated are indicated below.
COMMENTS:
B. SYSTEM CONDITIONALLY PASSES:
One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system,upon
completion of the replacement or repair,as approved by the Board of Health,will pass.
Indicate yes, no,or not determined(Y,N,or ND). Describe basis of determination in all instances. If"not determined",explain why not.
_ The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate of
Compliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection;or
the septic tank,whether or not metal, is cracked,structurally unsound,shows substantial infiltration or exfiltration,or tank
failure is imminent.. The system will pass inspection if the existing septic tank is replaced with a complying septic tank as
approved by the Board of Health.
Sewage.backup or breakout or high static.water level observed in the distribution box is due to broken or obstructed pipe(s)
or due to a broken,settled or uneven distribution box. The system will'pass inspection if(with approval of the Board of
Health)
broken pipe(s)are replaced
obstruction is removed
distribution box is levelled or replaced
_ The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass
inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
revised 9/2/98 Page 2of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 9 Dac awls MA
P Y �'�. Ny .
Owner: Ann Birchhill n`
Date of Inspection: October23, 1999 .... .. «<.r?.xz i'c::, :i
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
t
revised 9/2/98 Page 3of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 9 Dacey Lane, Hyannis, MA
Owner: Ann Birchhill
Date of Inspection: October 23, 1999
D. SYSTEM FAILS:
You must indicate either"Yes" or "No" as to each of the following:
_ I have determined that one or more of the following failure conditions exist.as described in 310 CMR 15.303. The basis for this .
determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure.
Yes No
Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool.
Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or
cesspool.
Static liquid level in the distribution:box.above outlet invert due to an overloaded.or clogged SAS or cesspool.
Liquid depth in cesspool is less than 6" below invert or available volume is less than 1h day flow.
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped_.
Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation.
Any portion of a cesspool or privy is within'100 feet of a surface water supply or tributary to a surface water supply.
Any portion of a cesspool or privy is.withina Zone 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
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 9 Dacey Lane, Hyannis, MA
Owner: Ann Birchhill
Date of Inspection: October 23, 1999
Check if the following have been done:-You must indicate either"Yes" or "No" as.to each.of the following: _
Yes No
✓ _ Pumping information was provided by the owner,occupant,or Board of Health.
✓ _ None of the system components have been pumped for at least two weeks and the system has been receiving normal flow
rates during that period. Large volumes of water have not been introduced into the system recently or as part of this
inspection.
✓ _ As built plans have been obtained and examined. Note if they are not available with N/A.
✓ _ The facility or dwelling was inspected for signs of sewage back-up.
✓ _ The system does not receive non-sanitary or industrial waste flow.
✓ The site was inspected for signs of breakout.
✓ _ All system components,excluding the Soil Absorption System,have been located on the site.
✓ _ The septic tank manholes were uncovered,opened,and the interior of the septic tank was inspected for conditions of baffles
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.
t • ,
revised 9/2/98 Page 5of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 9 Dacey Lane, Hyannis, MA
Owner: Ann Birchhill
Date of Inspection: October 23, 1999 >r
FLOW CONDITIONS
RESIDENTIAL•
Design flow: 110 g.p.d./bedroom.
Number of bedrooms(design): 3 Number of bedrooms(actual): 3
Total DESIGN flow. 548
Number of current residents: 2
Garbage grinder(yes or no): No
Laundry(separate system)(yes or no): No; If yes, separate inspection required
Laundry system inspected(yes or no): No
Seasonal use(yes or no): No
Water meter readings,if available(last two year's usage(gpd): 1998-111,750 gals.:1997-146,250 gals.
Sump Pump(yes or no): No `
Last date of occupancy: Currently occupied.
COMMERCIAL/INDUSTRIAL:
Type of establishment:
Design flow: apd(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:
Never pumped-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:._ May 7195-per as built card.
Sewage odors detected when arriving at the site: (yes or no) No _
revised 9/2/98 Page 6of11
i.N
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 9 Dacey Lane, Hyannis, MA _. ._
Owner: Ann Birchhill
Date of Inspection: October 23, 1999
BUILDING SEWER: _
(Locate on site plan)
Depth below grade:
Material of construction: _cast iron 40 PVC _other(explain)
Distance from private water supply well or suction line
Diameter
Comments: (condition of joints, venting,evidence of leakage,etc.)
SEPTIC TANK: ✓
(locate on site plan)
Depth below grade: 15"
Material of construction: ✓concrete _metal _Fiberglass _Polyethylene _other(explain)
If tank is metal, list age_ Is age confirmed by Certificate of Compliance_(Yes/No)
Dimensions: 8'6"x 4'10"x 5'(1000 gal.)
Sludge depth: 5"
Distance from top of sludge to bottom of outlet tee or baffle: 27"
Scum thickness: 10" _
Distance from top of scum to top of outlet tee or baffle: 6"
Distance from bottom of scum to bottom of outlet tee or baffle: 8"
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.) Both tees were present. The liquid level was even with the outlet invert. Recommend punning.
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 Pap 7oflt
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 9 Dacey Lane, Hyannis, MA
Owner: Ann Birchhill
Date of Inspection: October 23, 1999
TIGHT OR HOLDING TANK: None (Tank must be.pumped prior to;or at time,of inspection): t
(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 was
not dux up. There were no sixes of failure in the nit
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.)
revised 9/2/98 Page 8of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 9 Dacey Lane, Hyannis, MA
Owner: Ann Birchhill
Date of Inspection: October 23,, 1999
SOIL ABSORPTION SYSTEM(SAS): ✓
(locate on site plan, if possible;excavation not required,.location may be.approximated.by,non-intrusive methods)
If not located,explain:
Type:
leaching pits, number: 1-1000 gal.
leaching chambers,number:
leaching galleries,number:
leaching trenches,number, length:
Teaching fields,number,dimensions: 4
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 had 16"of water on the bottom. There were no signs of failure. The bottom to grade was 76".
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:
k (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: 9 Dacey Lane, Hyannis, MA
Owner: Ann Birchhill
Date of Inspection: October 23, 1999
Map:
Parcel.-
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)
GAGA c
r
l
QA
a
Al �5Cl. _
3 ,�, , as
G gL - a
y
A3 a
l33
- 3aa
Ay _ 30,
/3y - 418
revised 9/2/98 Page 10ofII
J `
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 9 Dacey Lane, Hyannis, MA
Owner: Ann Birchhill _.
Date of Inspection: October 23, 1999
MRCS 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 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)
A perc test was done on Jan. 26195, showing no water at 12'.
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 9/2/9 8 Page 11 of 11
dTOWN OF �` AL.E
LOCATION �T �/ cv SEWAGE# 1/94AX
��- kU
VILLAGE � �/ /(/` � ASSESSOR'S MAP&LOT "'
INSTALLER'S NAME&PHONE NO. � � - f ?I/ � d
SEPTIC TANK CAPACITY /'*,ff
LEACHING FACILITY: (type) I ' (size) `7 4
NO.OF BEDROOMS
BUILDER OR OWNER
PERMTTDATE: 3"23 COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by �
Q
V
NIf, 3 �.
TOWN OF BARNSTABLE
LOCATION L� �r• SEWAGE #
VILLAGE /CT c a ASSESSOR'S MAP & LOT! C /9-3
INSTALLER'S NAME&PHONE NO. y+ 36
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) pl-r /140 Cht• (size)
NO. OF BEDROOMS
BUILDER OR OWNER
PERMITDATE: COMPLIANCE DATE:
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) � Feet
Furnished by TI? Sly L l o�. .� • f'd�
jb r
W o
O J �
91 o0
p - E 3 70 a�'v_ ls" j P s�
No.... .,tom: �?.�' FE.........job.......
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Appliration for Bi_nVo,!3Fa1 Evrkg Toaaotrur#ion ramit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at
.. .................... ..... «.� �-. ...... _........ -- .........._............................---
-_-. o lion-Ad rc or Lot No.
.... • ....................................... ....................................
'-•.- -------------'-•----..........._..._........--------
Owner ..............................•---•-•-'-----Address
Installer Address 901,
G1 f,
Type of Building Size Lot............................Sq. feet
Dwelling—No. of Bedrooms---,_,___.-f3rp ______________Expansion Attic ( ) Garbage Grinder ( )
cl, Other—Type of Building )°K... S.` No. of persons___________________________ Showers ( ) — Cafeteria ( )
Q' Other fixtures ---------------- -------------- --
d _tZ ... .
W Design Flow--------------------- ................gallons per person per day. Total daily flow-------333G..........................gallons.
WSeptic Tank—Liquid capacity_M qQ-gallons Length________________ Width---------------- Diameter-............... Depth................
x Disposal Trench—No- -------------------- Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No---------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tar
'~ Percolation Test Results _ Performed by--------- r- ---------------•- Date----....-°.:�. �_�_...._..
a
Test Pit No. 1--- _ ----minutes per inch Depth of Test Pit_-___---_---_-___ Depth to ground water_PjQA,4 _----.
LZ4 Test Pit No. 2----------------minutes per inch Depth of Test Pit.................... Depth to ground water........................
O
Description of Soil-- -------- -------•--------------------------------•-----•-------------------------------------------------
V --••--•--•------•......••••----------•-••...................•--••••••-••--•'-•---••----'------'-------------------•------'-••-•--
-------- - ----------
-----------
W ---------------------------------------------------------------------------------------------------------------------------------------------- -,------`7--�-- ---------------
U Nature.of Repairs or Alterations—Answer when applicable---------------------------.....................................................................
-----•---•-•-------------------------••-•---------•----------------------------------•••-----••---•-----•--------------------•-------.......•-----------.....------•-•-•---••-••-•-•-•••....._•--''-----
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees;16
to place the
system in operation until a Certificate of Co been iseued the board of health.
Signed .. Zs
....... .... .............
[e.
Application.Approved By ----------01)1�..�. e�1-------
Application Disapproved for the following reafons: ...................... ........................ ... ....... ...............
----------------------------------------------- ----- -------------------------------------------------------- ------------------ --------------------------------------
! S-v 6o `, Dare
Permit No. ......................... .. ...... Issued ----------------S:. - "
Dare i
p
No.-_I Fss........1no........
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
App rtt#ion for Diti-pooal lVark.6 Tomitrns#ion ratuff
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at
.............................................................
o lion-Ad ..................... Lot No:
/a owner Address�----------------------------------Installer----------------------------------------- --•-•...................••--•------•-•------Address------------------------------•--•--
�
as 7/0
d Type of Building Size Lot............................s q. feet
Dwelling— No. of Bedrooms..,....,_/�----------------------------Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building Wt°�(._-----:''^�No. of persons---------------------_-_.- Showers ( ) — Cafeteria ( )
Q' Other fixtures ..... ......................... . .
d ► 7Z
w Design Flow---------------------_0----------------gallons per person per day. Total daily flow.--.... 3 o............._......._..__gallons.
WSeptic Tank—Liquid capacity 1.(-)-�-U-_gallons Length________________ Width---------------- Diameter.--------------- Depth__-_-__--___---.
x Disposal Trench—No. .................... Width.................... Total Length-------------------- Total leaching area....................sq. ft.
Seepage Pit No--------._--_-__-..+Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
z Other Distribution box (K +) Dosing to ( ) _
Percolation Test Results ' Performed by..__.._-- � _..r �---------------_ Date....._ °�� � 7
Test Pit No. I.. ._ _-minutes per inch Depth of Test Pit-------------------- Depth to ground water.y .aN .....--.
44 Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water........................
P4 ^ ------------------------------------------------------------
'...
•-•----
-----
•------
•-----------
•.............
..•-•----
-.....
•-•-
D Description of Soil.............� C'^
- - -- --------------
x
-••••-••••-•---------------••-•••••••-•---------------------••-•-•---••-•••-----•••-•----------•---••-•••••-•-----------------••-----------------•--...••-------•--•---•- ----- ....................
__ ___ .............
-......
Fr ^? -�
x Nature of Repairs or Alterations—Answer when applicable.-___------- - ---------------__.----F ---- ----- ------
Agreement.
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code —The undersigned further agrees not to place the
system in operation until a Certificate.of Cornpli-ance--has been issued
by the board of health.
Signed '.�--...41 t/ `)16/,e?lt7------
---------
Application.Approved B A r Y� �, -._..... - .."?...---.G,t........
PP PP Y .......- - ^^ - mate
Application Disapproved for the following reasons: ----------------------------------------------------------- ---...._........-....-.--......----------------------------
_------ --------------------- -- ---------- --- -------..........--------------- ----------- --- ------ ..._..... ...... ...................._........._ ----------------------------------------
Date
Permit No. ------- ..��.......-..60 � 9 _
. ............................ Issued `.x.,i--............
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
C�er#ifi a e of Cnnmplianee
,THIS IS TO CERTIFY, That the ividu l-Sewage Dis , sal System constructed ( V/) or Repaired ( )
bye - '4 .`D ... ..._..���---- �:. �i------�--------......._--------- -------------------------------- -....------------------------- ---------
Q nsr.Jler
Ck,
at ......: -'.(.......3.��......_..... ....... - N ' - - -- ------------------------------------ -------------------------------------------------------------
has been installed in accordance the provision of TI'II.E 5 of The State Environmental Code as described in
the application for Disposal Works Construction Permit No. _.-. ... ---- dated ....i2..:- ?_ ._— .
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SAT1ISFACTORY.b i� '-"��
- ...... - Ins ector - -- --•_ -.•-..�. ...
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
orko Sono#rion �rrnti#
Permission 's hereby granted --------------------------- ------- ""
to Construct (�)�or Repair ( )-an Individual Sewage Disposal System
at No..,tK_ ----n ` = 1 /�'''v"t'` ° --
Street
as shown on the application for Disposal Works Construction Permit No ,
Dated____... ��_..- �... ,....—�,�..�
--------••-----------------------------•-------------------.............................................
Board of Health
DATE.................................................................................
FORM 36508 HOBBS&WARREN.INC.,PUBLISHERS
L
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VOTTOM. = -16 sr'. +� ss• I��� 28"
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1%C1 604-ATI oN •QA7E lool
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MAP ZSZ/SI 253 /19
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OTA
TorAL DA►L"I = 330 I•�- / • lk'r
Tc��GiOC�ATI ON : SZA7G c �i�l u UIV�LES�i / ;z
tH OF OF
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of . PMR
SULLIVAN �c� 81d.tY}3Ta � f
F6' No: 29733 �,
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MAP 252/51 253 /19
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