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Home My WebLink About0057 SEAGATE LANE - Health (2) (5;f Seagate Lane Hyannis P i f I A = 249 148 I COMMONWEALTH OF MASSACHUSETTS I 3 2005 6 E OFFICE OF ENVIRONMENTALAI.F l v E),I]R N eRF BARNSTABLE DEPARTMENT OF E NMENTAL PR0TECTI01�1 UEPT. tp 9 TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM , PART A CERTIFICATION Property Address: f Owner's Name- t AP 04ner's Address: L a a _ '-,ARCr-. . Date of Inspection: _aR-as- zt / Nacre of Inspector:(please print)�, Y1a&-4 A=�Jr� Company Name:A. . A / 1" Mailing Address. Telephone Number- - CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at tbiFs address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed rased on my training and experience in the proper f m&ion and maintenance of on site sewage disposal systems.I am a DEP Approved sysiew iuspe►forr:purauant to S ..` n 35-340 of Title S(310 CMR 25.00%. The.system: _ V paszs Conditionally Passes- Needs Further Evaluation by the Local Approving Authority .. Fails Inspector s Signature_ I}s:te: The system inspector shall submit a copy of this inspeckion report to the Approving Authority(Board of Health or DEP)within 30 clays of completing this inspection.If the system is a shared system or has a design flow of I0,OM gpcl or grcater,the mspcctvr and the system Owner shall submit the report to the appropriate regional office of the DER 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 tonditions at the time of im""n and under the conditions of use at that Unit.Tleis iospectiou does next address how the system will-perform hk file future under the same or different conditions of use. r;rto 5 inanoMi:ari&rr.,, FrI St'lMn .,�..e i �.. , Page 2 of I I OFFICIAL INSPECION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM FART A CERTIFICATION(continued) Property Address: 5 s�R1�2 Owner: Date of Itsspection: n9al-O-5— iatipe<twn Summary: Check A,B,C,D or E 1 complete all of Section D A. System Passes: 1 have not found any information whic:it indicates that any of the failure criteria described in 3110 CMR. 15.303 or in 310 ChiR 15.304 exist Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: Ono or more system compoaeats 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'B6ard of Health,will pass. Answer yes,no or not determined(Y N NTTD)in the for the following statements.If"not dewnnined"please explain. The septic tank is metal and over 20r years old*or the septic tank(whether metal or not)is structurally unsound,exhibits substantial iufi;Ttration or exfdtrat on or tank failure is irnra nt.System-will pass inspection if the existfng tank is replaced with a compiytug septic tank as appruvad by the Huard afHcaith. xA metal septic tank will pass inspection if it is structually sound,not leaking and if a Certificate of Compliance indicating that the tank is Iesa 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 distrbutioa bog.System will pass inspection if(with approval of Board of Hearth): broken pipe(s)are replaced obstruction is removed distnUtion box is leveled orreplaced ND explain: The system ioquired pumping mom than 4 tames a year due to btakea or obstructed pipe($).The system will pass inspection if(with approval of The Board of Healthy broken pipe(s)are replaced obstruction is removed N'D explain: Page 3 of i l OFFICIAL.INSPECTAON FORM,-NOT FOR VOLUNTARY ASSESSMENTS 'SUIMJRFACE SEWAGE I} ISPOSAL SYSTEMINSPEO'I'iO>t`i FORM PART A CERTMCATION,(continued) Property Address:s Z Z etc vaIE ZA. Owner. Date of Inspection: C. Further Evaluation is Required by the Board of Health: x 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 enviiofunent. ' - 1. System Will pass sinless Board of Health deierrniues in accordance with 310 CMR 15303{1)(b)that the system is not fvu; oa;ng in a mxsnner whir;will protect public heal"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 d. 8vstem will fall unless the Board of Heald:(and Public Water Suppliers if any)determines that the system is functioning in a manner that protects the public health,salety 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 a public water supply. The system has a septic tank and SAS and the SAS is within 50£ttt of a private water supply�rel2. _ The system has a septic tank and SAS and the SAS is less than 100 feet but S0 ree*or mare from a -private water supply welt**.Method used to detmudne distance '"'This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic c-otnpotmds kWiw-Ica that the well is free from pollution from that facility and the preseace'ofawawwja n&rogna Wd nifidw nitnagea is Nuat ec or Tess than S�r3z,provided that no other . failure criteria are triggered.A copy of the mtalysis most be attached to this form, 3. Other: ti Page 4 of I t OFFICIAL I NSPECT;ON FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTFM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: J-7 SeA q4& Owner; Bate of Inspection: A System Failure Criteria applicable to all systems.: You must indicate`y&'or"no"to each of the following for nit bspections: Yes Nv'o/ _ V✓/. ackup of sewage fur facility or system compone€at due to overloaded or clogged SAS or cesspool ✓ or poudmg of e#llve rt to the swface of the ground or surface waters due to an overloaded or /clogged SAS or cesspool — _✓ Static liquid level in the distttbution box above outlet invert due to an overloaded or clogged SAS or cesspool _ ✓4iquid depth in cesspool is less thm&'be ow invert or available volume is less than h day flow �' Required pumping move than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number /of times pumped Anv Dillon ofthe SAS,cesspool or is below high txitul water elevation. ✓ y portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface /An t/ er amply. Any portion of a cesspool or privy is within a Zone I of a public well. y portion of a cesspool or privy is within 50 feet of a private water supply well. Arty portion of a cesspool or privy is less than 100 feat but gmtcr 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 IDEP certified Iahoratory,for conform bacteria and volatile organic compounds inXC-Aies iuut the well is free stood poll,fiou Prow Mai fiscally itiW€lee presence of ammonia aUeogen and nitrate nitrogen is equal to or less than 5 p€mm,provided that no other failure criteria are triggered.A copy off the analysis must be attached to this form.j t 1eVN6)The aysfem&:ls.I heeve detach ed tiger vicar ax. ,,of the above r itue criteria exist as described in 310 CNIR 15.303,therefore the system fails.The systern ov-mer should contact the Board of Health to determine what wiII be necessary to correct the ftihae. E. Large Systems: To be considered a large system the systems must serve a facility with a"go flow of 10,080 gpd to 15,000 gpd- You must indicate either"yes°,or no to each of the#oollowing (The following criteria apply to huge systems ul 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 its a nitrogen sensitive area(Interim Wellhead protection Area—IWPA)or a mapped Zone B of a public water supply well it 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 Sectioa E or failed under Sect ou D shall upgrade the system in accordance with 310 OMR 15.304.The system owner should wtitact the approprate regional office of the Departmern. Page 5 of I I OFFICIAL INSPECT }N FORM-NOT FOR VOLUNTARY ASSESSMENT'S SU-BSlu"RFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B / . CHEC ST Property Address: s7,6ez ciTe 4� Date of lnspewula: C9— Chc-c k if the following have been done You must indicate"yes='or`'tto"as to each of the following;: _ Yes =o 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? TWere as built plans of the system obtained and examined?(If they were not available note as Nick) Was the facility or dwelling inspected for sighs of sewage back up Was the site inspected.for signs of break out? T _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 Lhe'oaMes or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scuw 7 V// 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 t6 Soil Absorption System(SAS)on the site has been determined based on: I'es�no ✓/ Existing information_For example,a plan at the Board of Health. tel Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[3I0 CMR I5.302(3)(b)] a Page 6 of l 1 OFFICIAL INSPECTVON FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM RiFORIVIATION Property Address: < Owner: _ Date c►f iB3pECtic?tt: oZ' FLOW CON"DITFONS RESIDEbiTL& . Number of bedrooms(design): 3 Number of bedrooms(actual). 3 DESIGN flow based on 310 Ch i 5.2t33(for example: }: gpd x#of beclsi,c�i }. 33o Number of current residents:W Dees residence have a garbage grinder(yes or no): D Is laiurdry an a separate sewage system�c,Y or no}: [if yes separate inspection repaired] Laundry system inspected) or no):1 A Seasonal.use:(yes or no): Water teeter readings,if a le(last 2 years usage(gpd)): a Q Sump pump(yes or no):,&Q Last date of occupancy: 9-0'j COMMERC]EALff NDUSIMAL Type of establishment: Desiga flow(based on Sit}CtIVM 35.203): gpd Basis of design flow(seats/pmons/sgft etc.): Grease trap present(yes or no): industrial waste holding tank present(yes or no): Nan-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings,if ava€iabic: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: 4 uJAe,' 1 AM-0 r O 0✓rep,. l Wa3 system pumped 83 part Of Pile inspection(yes or 3fi ): APO" If yes,volume pumped:--_-gallons—How was quantity pumped determined? Reason for purnpiug: Typkl'or 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/Alteroative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight tank _,__Attaco a copy of the DEP approval _Other(describe): App7)ilaato as of ail couggmlents,&aw imtallcd(ifknowu)and Nuumv of information: Were sewage odors detected when arriving at the site(yes or no):�� Page 7 of 11 ([/gy'�p �Q(��y-�I��® INS yy}}��..n�6 �� =nnl•4hh - -}:=4If FU- '. 31L 1 4L � U554� VIVilLs�El.4Y/16R�L; -5.� �`cs�liY�"`.,i'vj i+V'R _f'.kJr'$r'. aiaa4.-i .- aJ`'..'+-7:.3i4Rir-�4£ . PY C Property G Ln . - .s BUILDING + tfa+Pr«,g{}ra=rsrt Prfi((lt3n.,��„f ergii' dfl AV{' -tht'C eXlalaiiij: µ » '.wa u#Stiakn a+tt G': +arm. n.. y.. _ cate on site plan) 'viateiia?of rQa2s"ttt _,• ✓ .= Y ri �ti�_ ,�, __ . _�o ePexia�i< z �_ --_............_..... ..�r++. �nyyy or no):_-_�s3-TacU a VQDV O Sludge dW!: s ^ ' + r n-+of rv. +F';>„`:,L'..,'.tr;.Q�ori} Me: Distance ftoms I OW were dimk ,_.. 4g:''y,liquid level- / 1 Dimensions: Scum thicimess; Distance fk-fffy IN- - et-): Page S of 11 OFFICIAL INSPECWON FORM—NOT FOR VOLUNTARY ASSESSMENT'S SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: eva fe I A. Owner: Date of Inspection: TIGHT or HOLDING TANK: (tank must be pumped at time of inspectionXiocate on site plan) Depth below grade: Material of construction: concrete metal fiberglass---Polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gallonsiday 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:._ Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover;any evidence of leakage' o ��b or out o �ox,etc.) ,f : CcMd•�Jvi.. 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.): Page 9 of I 1 OFFICIAL INSPECT N FORM--NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Addrest: 5"7 5 e4.Ga 4e L t Owner: Date of Inspection: SOIL ABSORPTION SYSTEM(SAS}.�(locate on site plaA,excavation not required) If SAS not located explaint why: Type V leaching pits,number leaching chambers,number. 'teaching galleries,mmibsc _leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number: _iattovative/alterastive system Type/name of technology, Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): 400d stae bh e .'«t ay,, w,-I- sa• ' ree S ce. _ CESSPOOLS: (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:._,y(locate on site plan) r Materials of construction: Dimensions: Depth of solids: .- 4 Comments(note condition of sod,signs of hydraulic failure,level of poniiing,condition of vegetation;etc.): r Page 10 of I I OFFICIAL INSPEC f bN FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:_s 7 cS _ V��tn.S Owner: Date of inspection: oZ Q SKETCH OF SEWAGE DISPOSAL SYSTEIM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.Loeare all wells within 100 feet.Locate where public water supply enters the building. 0 ' a r\ � a A 'WS77 Q o 0 O t D G � F A-& 3a" 9-C- 13' A-0- 3g' B-O- 0,0' A-F- y3'6" a-L 21'6'' A-F- SV' 8-F 36 6" Page I I of 1 I OFFICIAL INSPECWON FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C . SYSTEM INFORMATION(continued) Property Address' Se co s. L Q3wuer. Date of inspection: SATE EXAMT Slope Surface water Check cellar Shallow wells , Estimated depth to ground water 15-0 feet Picase indicate(check)all methods used to determine the high ground water elevation: �brained from system design plans on record-If checked,daze of design plan reviewed bserved site(abutting property/observation hole within 150 feet of SAS) ✓checked with local Board of Health-explain: V ecked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must descnbe how you established the high ground wa er elevation: rAnt ar0Ie_ r'• /�'cl GtS'�"�w� `'I - J 3� Title 5 Inspection Form 6/15/2000 11 - ea ft 4t `