HomeMy WebLinkAbout0636 PITCHER'S WAY - Health 636 Pitcher's Way
Hyannis P
A = 270 118
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LO('ATION 34 0`/�/i L �a'S 4v,4 y SEWAGE #
v7L,LAr,,E ASSESSOR'S MAP & LOT
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��'Pf 'NAME& PHONE NO. /7 l OW A""'
SEPTIC TANK CAPACITY -5£�7';-C- /ti S,""£c '2;-f—'L
LEACHING FACILITY: (type) (size)
NO. OF BEDROOMS
BUILDER OR OWNER lrl?w N C F-S O�t
i
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
w' 2 feet of leaching facility)
Feet
on site or within 00 g
Edge of Wetland and Leaching Facility (If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
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- TOWN OF BARNSTABLE
:,ORATION C3G � `yam ✓�%�✓ SEWAGE# FL G-��/
.VILLAG kL ..
ASSESSOR'S MAP & LOT 270
INSTALLER'S NAME&PHONE NO. 4177- O 517 - -
SEPTIC TANK CAPACITY
LEACHING FACMITY: (type) '21LM6A (size)
NO.OF BEDROOMS S
BUILDER OR OWNER -
__ PERMITDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility - Feetl_
Private Water Supply Well and Leaching Facility (If any wells exist f
`on site or within 200 feet of leaching facility) 7
Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
-
within 300 feet of leachij8 faci 'ty) Feet.
Furnished byi�
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y f
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1, - 7-1
TOWN OF BARNSTABLE
'LOCATION . C3G I.,12,01.6*257 way SEWAGE # FS, 64
VILLAGE ;_,s ASSESSOR'S MAP &`LOT L,) EIS
INSTALLER'S NAME&PHONE NO. 4'72- 03el I
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) 11rif4164 (size) e,D K y A�2"
NO.OF BEDROOMS
BUILDER OR OWNER
PERMITDATE: /,L-G - Qd COMPLIANCE DATE: 10
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 leachi faci 'ty) Feet
Furnished by �Y�. /
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Fee No.
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
ZIppYication for Mi,5pogal *paem Construction Permit
Application for a Permit to Construct(4-1'ftepair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. 6 5 is Et/q y Owner's Name,Address and Tel.No.
Assessor's Map/Parcel G/ /f'9 la qq (,�r•�✓/;y`/� S'T ��l ��S�
Installer'ps Name,Address,and Tel.No/ Y,7 y_03e1 q Designer's Mlme,Address and Tel.No.
n / 5. �<
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 gallons per day. Calculated daily flow gallons.
Plan Date 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) i%/ Y�Si/��i �'/�'�Spc70� c.r/�, 6&A�
SA<1Z _Q 57�411 &ry —15,o 7C�ii«% T/ x
r
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction 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 issued by this Board of Health.
Signed Date /0. Z ^qo'
Application Approved by Dated
Application Disapproved for theYollowiny reasons
Permit No. Date Issued
a No. ' �l�
- / Fee,
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
fication for ig oga *p!tem Construction Permit
Application for a Permit to Construct(400T Repair( )Upgrade( )Abandon( )" El Complete System ❑Individual Components
Location Address or Lot No. G�G p/if'�yI�C�� "IAlc/1 Owner's Name,Address and Tel.No.
Assessor's Map/Parcel A 1,9 99 6~11 re JOY-, 14f�r O f
Installer's Name,Address,and Tel.No. y711_034 Designer s e,Add
9 ' ress and Tel.No.
Q/ GS4Hlf?!Yi/� ��c ome-1 i ( I
Type of Building:
r Dwelling No.of Bedrooms 3 Lot Size sq. ft. Garbage Grinder( ),
Other Type of Building No. of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title.
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable)�i�1 �gT/s�i��i�$�Oo� u/ATl C1�=,Vaj
Date last inspected:
Agreement:-
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system t`
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 issued by this Board of Health.
Signed Date /D-6 8-V
Application Approved by Date
Application Disapproved for the ollowi reasons
Permit No. �_' 6.�/ Date Issued
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS -
(Certificate of (tompliance
THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( -Repaired( )Upgraded ( )
Abandoned( )by
at nwN has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. dated
Installer ,`L rAA /3pr11�t Designer f��)
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
Date IN Inspector
No. � C - Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
Migo,oar *pgtem Construction Permit 4"
Permission is hereby granted to Construct( 4_�Repair( )Upgrade( )Abandon( ) -
' System located at - L?G 4 a 4 j rr5
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:Construction must be completed within three years of the date of this permit.
Date: f=I4_9V Approved by ,
t
ii
!0/9197
NOTICE: This Form Is To Be Used For the Repair Of Failed
Septic Systems Only:
CERTIFICATION OF SKETCH AND APPLICATION FOR A
DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT
ENGINEERED PLANS)
I, )esrpA D,ffAne2 s , hereby certify that the application for disposal works
construction pei nnit signed by me dated /0- G concerning the
property located at 1,16 �'rG4i=rs—/0#s e Ole10's meets all of the
following criteria.;;
There are no wetlands located within 100 feet of the proposed leaching facility
e/There are no private wells within 150 feet of the proposed septic system
There is no incrimse in flow and/or change in use proposed
There are no variiancm requested or needed.
• If the proposed 1+;aching facility will be located within 250 feet of any wetlands,the bottom of the
proposed leacttiltg facility will W be located less than fourteen(14)feet above the maximum adjusted
groundwater table elevation.
Please complete ithe following:
A)Top of Ground Elevation(according to the Engineering Division G.I.S.map)
B)Observed Groundwater Table Elevation(according to Health Division well map)A—
SIGNED: "L�� DATE: /0 -G'= 9�
LICENSED SEIE'T1C SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER
(Attach a sketch pllan.of the proposed system.Also if the licensed installer posesses a certified plot plan,
this plan should be:submitted).
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Commonwealth of Mossochusetts John Grad
Office of Environmental Affairs
D.E.P. Title V Septic Inspector
Department of P.O. Box 2119
.Environmental Protection Teaticket, MA 02536
1lM"m F.weld b� `<( 8.5644--66813
G"mor,.
Trudy Coxe
8rcretery.
pb
EOFJt David B.Struhs
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FO BAR F®
PART A 2 S'
CERTIFICATION 1996
Property Address: � �r -'�'-CS �nn�� Address of Owner:
Date of Inspection: 3 kZ\\G\W (If different)
Name of Inspector: 'g
Company Name, Address and 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 t me 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:
Lames
_ 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 Ihspector 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 :ne system owner and Z(Dpie, sen; w tht bu)ei; if applicable and the appro,ing authority.
INSPECTION SUMMARY:
Chec B, C, or D:
A) SYSTEM PASSES:
� 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 6/15/95) 1
One Winter street a Boston,Massachusetts 02106 a FAX(617)SM1049 0 Telephone(617)M-S600
Printed on Recycled Paper
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION.FORM
PART A
CERTIFICATION (continued)
Property Address:
Owner:
Date of Inspection:
B) SYSTEM CONDITIONALLY PASSES (continued)
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
Cl 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 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.
Z) SYSTEM "'ILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT
THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRON'�1ENT
I ne ��sten) na, a septic tank anu' su,i ibtorpkion sysien, and 6 1h;il-0, iUv fee',
surface Water supply.
_ The s�s!Pn' ha, a septic tank and soil absorption system and is within a Zone I of a public water supply well.
_ The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well.
_ The s>stem has a septic tank and soil absorption system and 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
D) SYSTEM FAILS:
I have determined that the system violates one or more of the following failure criteria as defined 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.
_ Backup of sewage into facility or system component due to an overloaded or dogged 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.
(revised 8/15/95) 2
c
I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:
Owner:
Date of Inspection:
D) SYSTEM FAILS (continued):
_ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow.
Required pumping more than 4 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 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. If the well has been analyzed to be acceptable, attach copy of well water analysis for
colifoim bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
E) LARGE SYSTEM FAILS:
The following criteria apply to large systems in addition to the criteria above:
The design floe of system is 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:
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 bring the system and facility into full compliance with the groundwater treatment program
requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.
(revised 8/15/95) 3
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property ,Addddrress:
Owner:
Inspection:too- 1
D Date �
31z+1a�
Check if the following have been done:
_4,eumping information was requested of the owner, occupant, and 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.
Cam\ s 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.
� he system does not'receive non-sanitary or industrial waste flow
The site was inspected for signs of breakout.
1..All system components, excluding the Soil Absorption.System, have been located on the site.
!-fte 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.
_TRe size and location of the Soil Absorption System on the site has been determined based on existing information or
approximated by non-intrusive methods
c.___
—The (2n? ^fir,nantc if diffarpw frnm o%%ner) were vrovided with information on the proper maintenance of Sub-
Surface Disposal System.
(revised 8/15/95) 4
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
t SYSTEM INFORMATION
Property Address:
Owner:
Date of Inspecti
FLOW CONDITIONS
RESIDENTIAL:
Design flow: Rallons
Number of bedrooms:
Number of current residents:
Garbage grinder (yes or no): n6
Laundry connected to system (yes or no); t'j
Seasonal use (yes or no):� -
Water meter readings, if available:
Last date of occupancy: cA )
COMMERCIAUINDUSTRIAL: CIWplr
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 R ORDS and source of information:
`nG-,� nc V)ee \ r-k u-ec r,
System pumped as pan of inspection: (yes or no)mrz)
If yes, volume pumped gallons
Reason for pumping:
TYPE OF SYSTEM
Septic tank/distribution box/soil absorption system
L---'Single cesspool
Overflow cesspool
Privy
Shared system (yes or no) (if yes, attach previous inspection records, if any)
Other (explain)
APPROXIMATE AGE of all components, date installed (if known) and source of information:
Sewage odors detected when arriving at the site: (yes or no)
(revised 8/15/95) S
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C.
SYSTEM INFORMATION (continued)
Property Address:
Owner:
Date of Insp��\c'`X'N
1\,Aeolp
SEPTIC TANK:—�:W.a
(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 baffles, depth of liquid level in relation to outlet invert, structural
integrity, evidence of leakage, etc.)
GREASE TRAP:fAFA
(locate on site plan)
Depth below grade:
Material of construction: concrete _metal „_FRP —other(explain)
Dimensions:
Scum ihickne».
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom nt cro n tM hottom of outle! tee or baffle'
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.)
x
(revised 8/15/95) 6
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: U3k��A�sw
C"A
Owner: f
Date of Inspe kWn� C4)
3lz-A��
TIGHT OR HOLDING TANK:JC\\A
(locate on site plan)
Depth below grade:
Material of construction: _concrete metal _FRP_other(explain)
Dimensions:
Capacity: gallons
Design flow: gallons/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 distriuutwi, . eyuc+i, e,idCilcG Of sulid, ca:r�o c-i, e%idence of.leakage into or out of box, e!c.)
PUMP CHAMBER:��
(locate on site plan)
Pumps in working order.(yes or no)
Comments:
(note condition of pump chamber, condition of pumps and appurtenances, etc.)
(revised 8/15/95) 7
I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:G 3u
Owner: �(\Ci
Date of Inspection: 12i,n 1
SOIL ABSORPTION SYSTEM (SAS):
(locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods)
If not determined to be present, explain:
Type
leaching pits, number:
leaching chambers, number:_
leaching galleries, number: -
leaching trenches, number,length:
leaching fields, number, dimensions:
overflow cesspool, number:
Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,etc.)
CESSPOOLS: _Ln/^-
(locate on site plan)
Number and configuration:
Depth-top of liquid to inlet invert:
Depth of solids layer: - --
Depth of scum layer: U
Dimensions of cesspool:
Materials of construction:
Indlcat,on,of ground,%a:c.-
inflow (cesspool must be pumpe as part of inspection) -
Co ents: (note condition of soil, signs.of hydraulic failure, level of ponding, ondition of vegetation, etc.)
.
C (� k t S 4 u
�cern �-"�t�`�j C.-e�cc�ti e.►c�� `�eea.c' M�.�c�-1e.�la �.
I
PRIVY:
(locate on site pi
Materials of construction: Dimensions:
Depth of solids:
Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc..
(revised 8/15/95) 8
f .
SUBSURFACE SEWAGE DISPOSAL SYSTEM,INSPECTION FORM -
PART C r
SYSTEM INFORMATION (continued) 5
Property Address:G
Owner:
Date of Inspection:
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100'._
4
w oue 0
DEPTH TO GROUNDWATER `
Depth to groundwater; feet
method of determination.or.approximation.
(revised 8/15/951 9
f `
' - i354
COMMONWEALTH OF MASSACHUSETTS
U F EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
d DEPARTMENT OF ENVIRONMENTAL PROTECTION
pqM SVOv
350 MAIN STREET
& WEST YARMOUTH,MA
CEN KM 508-775-2800
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
MAP 270 PAR 118
Property Address: 636 PITCHERS WAY
HYANNIS,MA 02601
Owner's Name: SORGI,FRANCES RECEIVED
Owner's Address: 314 WATER STREET-#310
QUINCY,MA 02169
Date of Inspection JUNE 23,2003 JUL 14 2003
Name of Inspector:(please print) JAMES D.SEARS TOWN OF BARNSTABLE
Company Name: A&B Canco HEALTH DEPT.
Mailing Address: 350 Main Street
West Yannouth,MA 02673
Telephone Number: 508-775-2800
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: YrJ1.Q�„�' ,t.�-- Date:
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or
DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd
or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.
The original should be sent to the system owner and copies sent tot he 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 1
Page 2 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 636 PITCHERS WAY
HYANNIS,MA 02601
Owner: SORGI,FRANCES
Date of Inspection: JUNE 23,2003
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: N/A
_ 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 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:
Title 5 Inspection Form 6/15/2000 2
Page 3 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(CONTINUED)
Property Address: 636 PITCHERS WAY
HYANNIS,MA 02601
Owner: SORGI,FRANCES
Date of Inspection: JUNE 23,2003
C. Further Evaluation is Required by the Board of Health: N/A
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 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 I of 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:
Title 5 Inspection Form 6/15/2000 3
Page 4 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(CONTINUED)
Property Address: 636 PITCHERS WAY
HYANNIS,MA 02601
Owner: SORGI,FRANCES
Date of Inspection: JUNE 23,2003
D. System Failure Criteria applicable to all systems: N/A
You must indicate"yes"or"no"to each of the following for all inspections:
Yes No
✓ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
✓ 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 field is less than 6"below invert or available volume is less than'h 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
N/A Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a
surface water supply
N/A Any portion of a cesspool or privy is within a Zone 1 of a public well
N/A Any portion of a cesspool or privy is within 50 feet of a private water supply well
N/A 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 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 Systems: N/A
To be considered a large system the system must service a facility with a design flow of 10,000 gpd to
15,000 gpd.
You must indicate either"yes"or"no to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
Yes No ,
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a
mapped Zone 11 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 is 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
systern owner should contact the appropriate regional office of the Department.
Title 5 Inspection Form 6/15/2000 4
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OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 636 PITCHERS WAY
HYANNIS,MA 02601
Owner: SORG[,FRANCES
Date of Inspection: JUNE 23,2003
Check if the following have been done. You must indicate"yes"or"no"as to each of the following
Yes No
✓ Pumping infonnation 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 nonnal glows 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?
The size and location of the Soil Absorption System(SAS)has been determined based on:
Yes No
✓ Existing infonnation. 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)]
Title 5 Inspection Form 6/15/2000 5
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OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 636 PITCHERS WAY
HYANNIS,MA 02601
Owner: SORGI,FRANCES
Date of Inspection: JUNE 23,2003
FLOW CONDITIONS
RESIDENTIAL
Number of Bedrooms(design): 3 Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203(for example: 1 10 gpd x#of bedrooms: 330
Number of current residents: 8
Does residence have a garbage grinder(yes or no): NON
Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required]
Laundry system inspected(yes or no): YES
Seasonal use(yes or no): NO
Water meter readings,if available(last 2 years usage(gpd)): N/A
Sump pump(yes or no) NO
Last date of occupancy: PRESENT
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203):
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: N/A
Was system pumped as part of the inspection(yes or no): NO
If yes,volume pumped: gallons—How was quantity pumped detennined?
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 copy of the DEP approval
Other(describe):
Approximate age of all components,date installed(if known)and source of information:
1998 PERMIT#98-651
Were sewage odors detected when arriving at the site(yes or no): NO
Title 5 Inspection Form 6/15/2000 6
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 636 PITCHERS WAY
HYANNIS,MA 02601
Owner: SORGI,FRANCES
Date of Inspection: JUNE 23,2003
BUILDING SEWER(locate on site plan): ✓
Depth below grade: 10"
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 onsite plan): ✓
Depth below grade: 19"
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: 1,500 GALLON
Sludge depth: 2" .
Distance from top of sludge to the bottom of outlet tee or baffle: 28"
Scum thickness: 1"
Distance from top of scum to top of outlet tee or baffle: 12"
Distance from bottom of scum to bottom of outlet tee or baffle: 17
How were dimensions detennined: ASBUILT AND TAPE
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as
related to outlet invert,evidence of leakage,etc.):
TANK AT WORKING LEVEL.TANK 19"BELOW GRADE.INLET COVER AT 6".TWO INLET TEES,
OUTLET BAFFLE.NO SIGN OF OVERLOADING OR SOLID CARRYOVER.
GREASE TRAP(located on site plan) N/A
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.):
Title 5 Inspection Form 6/15/2000
Page 8 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 636 PITCHERS WAY
HYANNIS,MA 02601
Owner: SORGI,FRANCES
Date of Inspection: JUNE 23,2003
TIGHT or HOLDING TANK: N/A (tank must be pumped at time of inspection)(]ocate 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: 0
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.,):
DISTRIBUTION BOX IS 16"x16",2' BELOW GRADE.ONE LINE IN,ONE LINE OUT.BOX IS CLEAN AND
SOLID.NO SIGN OF OVERLOADING OR SOLID CARRYOVER.
PUMP CHAMBER: N/A (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.):
Title 5 Inspection Form 6/15/2000 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: 636 PITCHERS WAY
HYANNIS,MA 02601
Owner: SORGI,FRANCES
Date of Inspection: JUNE 23,2003
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: 60'x4'x2'
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.)
LEACHING IS A ONE PIPE FIELD 60'x4'x2'. DID TEST HOLE ABOVE AND BESIDE.PUT CAMERA UP
LINE,CLEAN.NO SIGN OF OVERLOADING OR SOLID CARRYOVER.
CESSPOOLS: N/A (cesspool must be pumped as part of inspection)(]ocate on site plan)
Number and configuration:
Depth—top of liquid to inlet invert:
Depth of solids layer:
Depth of scu n 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: N/A (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.)
Title 5 Inspection Form 6/15/2000 9
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OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 636 PITCHERS WAY
HYANNIS,MA 02601
Owner: SORGI,FRANCES
Date of Inspection: JUNE 23,2003
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two pennanent reference landmarks or
benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building.
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Title 5 Inspection Form 6/15/2000 10
Page 1 1 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 636 PITCHERS WAY
HYANNIS.MA 02601
Owner: SORGI,FRANCES
Date of Inspection: JUNE 23,2003
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to no groundwater 10 feet
Please indicate(check)all methods used to detennine the high ground water elevation:
Obtained from system design plans on record-If checked,date of design plan reviewed:
./ Observation 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:
TEST HOLE 10'NO WATER. TEST HOLE 5' BELOW BOTTOM OF FIELD.
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Title 5 Inspection Form 6/15/2000 11