HomeMy WebLinkAbout0031 SAINT CATHERINE AVE - Health �311ST CATHERINE AVE., HYANNIS
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COIKMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF E:�'VIRONbIENTAL AFFAIRS
DEPARTMENT OP ENVIRONMENTAL PROTECTION
ONE WINTER STREET. BOSTON NiA 0210E (617) 292-550v
TRUDY COME
Secretan
ARGEO PAUL CELLUCCI DAVID B. STR1:HS
Governor Commissioner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
Property Address:31 St . Catherine Ave Nameofowner Eloise McDonough
Address of Owner:
Date of Ins ��pection. �
Name of Inspector':I ease Print) E . Robinson Sr .
I am a DEP approved system!inspector rsuant to Section 15.340 of Title 5(310 CMR 15.000)
company Name: Wm. E . Robinsoneptic Service
MwingAddress: PO BOX 10b9, Centerville , MA
Telephone Number:
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate
and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewa a-disposal systems. The system:
Passes
Conditionally Passes
Needs Further Evaluation By the Local Approving Authority
_ Fails
Inspector's Signature: Date: "
The System Inspector shall submit a copy of this inspection report to the Approving Authority (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.
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NOTES AND COMMENTS
�\ RECENEQ �d
a J U N 1 8 1999
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TOWN OF BARNSiABLE
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revised 9/2/98 Pagel of11
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i� ✓ruled oe Recycird Paper. .
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
"ropertyAddr 1 St . Catherine Ave . , Hyannis , MA
Owner. oise McDonough
Date of Inspection:
INSPECTION SUMMARY: Check A, B, C, or D:
A. PASSES:
!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.
Indicat yes, no, or not determined (Y, N, or NO). 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 2ofII
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 31 S t , Catherine Ave . , Hyannis, MA
owner: Eloise McDonQUgh
Date of Inspection:O� f
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 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 of a surface water supply or
tributary to a surface water supply.
The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well.
_ The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well.
_ The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a
private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that 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) THER
revised 9/2/98 Page 3of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ,
PART A
CERTIFICATION (continued)
Property Address: 31 St . Catherine Ave . ,` Hyannis ,` MA
Owner. Eloise McDonough t
Date of Inspection: G��/<7 7
D. SYSTEM FAILS:
You mu t indicate either "Yes" or "No" to each of the following:
have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this
etermination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure.
Yes
Backup of sewage into facility-or system component due to an overloaded orclogged 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 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
<coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
E. LAR E SYSTEM FAILS:
You must indicate either "Yes" or "No" .to each of the following:
he following criteria apply to large systems in addition to the criteria above:
he 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
alth and safety and the environment because one or more of the following conditions exist:
Yes o
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 r operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional
office of th Department for further information.
revised 9/2/98 Page 4ofII
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Prop"Address: 31 St . Catherine Ave . , Hyannis , MA
owner: Eloise McDonough '
Date of Inspection: 4e, � /—�
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
1 / inspection. S
_ As built plans have been obtained and examined. Note if they are not available with NIA.
_ 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 condition of baffles
or tees, material of construction, dimensions,depth of liquid, depth of sludge, depth of scum.
The size and location of the Soil Absorption System on the site has been determined based on:
_ Existing information. For example, Plan at B.O.H.
_ Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable)
/ 115.302(3)1b))
The facility owner(and occupants,if different from owner) were provided with information on the proper maintananc."t
Subsurface Disposal Systems.
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revised 9/2/98 Page 5ofII
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
'rop"Address: 31 St. Catherine Ave . , Hyannis , MA
Owner: Elois +cDonough ,
Date of Inspection:
FLOW CONDITIONS
RESIDENTIAL:
Design flow:JIL-0 g.p.d.lbedroom.
Number of bedrooms(design):-1 Number of bedrooms(actual):3
Total DESIGN flow
Number of current residents: J
Garbage grinder(yes or no):,j6fQ
Laundry(separate system) (yes or no�(�; if yes, separate inspection required.
Laundry system inspected (yes.or no)
Seasonal use (yes or no):_4gf 6
Water meter readings, if available (last two year's usage(gpd): 1998 26, 250 gal.
Sump Pump(yes or no):A�-o 997 39, 750 gal.
Last date of occupancy:—
C MERCIAL/INDUSTRIAL:
Typi of establishment:
Des n flow: gpd 1 Based on 15.203)
Basis of design flow
Grea a trap present: (yes or no)_
Indus rial Waste Holding Tank present: (yes or no)_
Non- anitary waste discharged to the Title 5 system: (yes or no)_
Wat meter readings, if available:
Last date of occupancy:
O R:(Describe)
Las date of occupancy:
GENERAL INFORMATION
l
PUMPING RECORDS f information:
Aoour
System pumped as part of inspection: (yes or no)-,I-
If yes,.volume pumped: gallons
Reason for pumping:
TYPE OF STEM
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 Jif known) and source of information: O V-21-
Sewage odors detected when arriving at the site: (yes or no)A- {'
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revised 9/2/96 Page 6ofII
-' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION lcontirwed)
'rop"Address: 31 St . Catherine Ave . , Hyannis:, MA
OWner: Eloise McDonough
Date of Inspection:.
BUILDINTitean),
(Locate )
Depth bMaterialtion: cast iron 40 PVC other(explain)
Distancee water supply well or suction line
DiameteCommeon of joints, venting, evidence of leakage,-etc.)
SEPTIC TANK:_
(locate on site plan)
t
Depth below grade:,
Material of construction: concrete_metal_Fiberglass _Polyethylene_other(explain)
If tank is metal,list age_ Wage confirmed by Certificate of Compliance_ (Yes/No)
Dimensions:
Sludge depth:_
Distance from top of sludge to bottom of outlet tee or baffle:
Scum thickness:_ Vt
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom oJ outlet tee or baffle:
How dimensions were determined:
'omments:
(recommendation for pumping, condition of inlet and outlet tees or baffles depth liquid I in relation to outlet i ert, structural integrity,
evidence of leakage, etc.) 16 O Q'd ;26a J� /1/� ���� >�"' r�Z :L
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�iL�GrrU ��� Q!► vw ft '
GREAS P:
(locate on sit plan)
Depth below rade:_
Material of c nstruction:_concrete_metal_Fiberglass _Polyethylene_other(explain)
Dimensions:
Scum thickn ss:
Distance fro top of scum to top of outlet tee or baffle:
Distance fro bottom of scum to bottom of outlet tee or baffle:
Date of las pumping:
Comment
(recomm ndation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity,
evidenc of leakage,etc.)
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revised 9/2/98 Page 7of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
'roperty Address: 31 St . Catherine Ave . , Hyannis:, MA
Owner: Eloise McDonough
Date of Inspection: / �� f cr
TIGH OR HOLDING`TANK: (Tank must be pumped prior to, or at time of, inspection)
(locate n site plan)
Depth bel w grade:_
Material o construction:_concrete_metal_Fiberglass_Polyethylene_other(explain)
Dimension
Capacity: gallons
Design flo gallons/day
Alarm pre ent
Alarm le Alarm in working order: Yes_ No
Date of p vious pumping:
Commen
(conditio of inlet tee, condition of alarm and float switches,etc.)
DISTRIBUTION BOX
(locate on site plan)
Depth of liquid level above outlet invert: 0
Comments:
(note if level and distribution is equal, evi'_eof solids carryover, evidence of leakage into or out of box, etc.) -
PUMP CHA BER:_
(locate on si a plan)
Pumps in w rking order: (Yes or No)
Alarms in orking order(Yes or No)
Comments
(note con ition 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)
'roperty Address: 31 S t . Catherine Ave . , Hyannis ,. MA
Owe: Eloise McDonough
Date of Inspection: G- g
SOIL ABSORPTION SYSTEM(SAS):t/
(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:
leaching chambers,number:_
leaching galleries, number:_
leaching trenches, number, length:
leaching fields, number, dimensions:
overflow cesspool, number:_
Alternative system:
Name of Technology:
Comments:
(note condition of soil, signs of hydraulic fail e, level of ponding, damp soil, condition of veget ion, etc.)
CESS OLS:_
(locate site plan)
Number a d configuration:
Depth-top f liquid to inlet invert:
Depth of so ids layer:
)epth of sc m layer: °
Dimensions f cesspool:
Materials of onstruction:
Indication of roundwater: ;
infl w (cesspool must be pumped as part of inspection)
Comments:
(note condi ion of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
I
PRIVY:_
(locate on sit plan)
Materials of c nstruction: Dimensions:
Depth of solid °
Comments:
(note conditio of soil, signs of hydraulic failure, level;of ponding, condition of vegetation, etc.)
revised 9/2;98 Pagr9of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
"rop"Address: 31 S t . Catherine Ave -,, Hyannis , . MA
)caner: Eloise McDonough
Jate of Inspection:
Lchk
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent reference landmarks or locate-all wells within 100' (Locate where public water supply e)
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revised 9/2/98 Page 10of11
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
rop"Address: 31 St . Catherine Ave . , Hyannis ,, MA
Owner: Elo s cDonough
Date of Inspection: C j
NRCS 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 L Fe t
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from Design Plans on record
Observed Site(Abutting property, observation hole, basement sump etc.)
Determined from local conditions
Checked with local Board of health
Checked FEMA Maps
Checked pumping records
Checked local excavators, installers
Used USGS Data
DescriVe how you esta lished the High Groundwater Elevation. (Must be completed)
revised 912198 Page 11of11
TOWN OF BARNSTABLE
LOCATION SEWAGE #
VILLAGE C.�` ASSESSOR'S MAP & LOT �$
INSTALLER'S NAME & PHONE NO. a ►'K... , A,
SEPTIC TANK CAPACITY /Q!IQ•
LEACHING FACILITY:(type) 1, ,� (size) /0�". Al-S
NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER
BUILDER OR WNE 'Mloji
DATE PERMIT ISSUED: ,
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No
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