HomeMy WebLinkAbout0180 STEVENS STREET - Health 80 STEVENS STREET, HYANNIS
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Commonwealth of Massachusetts1. RACE®
' Executive Office of Environmental Affairs
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Department of !!
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t'= Environmental Protection
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WUIIsm F.Weld
Y Trudy t oxe j1
Seer j.,y%E0A s„.. , ,•,
David B.Struhs Y
f,tj..` .t n:F.! .Arne lieeinner
' 3't1lo! t s'x; ., :SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
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CERTIFICATION
Property Address: Address of Owner:.e/ 2 j �ON
Dateyofanspe, ion: f�.Il-�ij (If different)
rw�Name of Ins ector: f a
Company Name,Address. 4 Telephone Number: T ION STATEMENT
STATEMENT
gel certJ. that 1 have.personally inspected the sewage disposal system at this address and that the information reported below is true, accurate
tz and complete+as of.the time of inspection. The inspection was performed based on my training and experience in the proper function,and ! E
Emaintenance of on-site sewage disposal systems. The system:
asses
i�, € _ Conditionally Passes
"" k Needs Further Evaluation By the Local Approving Authority
Fa11S
�r Inspector's Signature. Date: I —�� j r• `4' rt''" `'
{ 1The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(30) days of completing this, r� 5 ,,
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lf;the system is a shared system,or-has a design,flow of 10,000 gpd or greater,:the inspector and:the systetmowner®.,srll�,subm tthe;reportgto<t,,e'appropriate reE ional.,office,of the Department of:Environmental Protection. 1
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{ The,orig�nai should be sent lU the system owner and copies sent to the buyer, if applicable and the appro�ing au hon,�`! ��' fi is
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X C
ap�INSPECTION SUMMARY , � r
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A# SYSTEIN SSES:1at� rkn ra+ l9trr+ "vt',b =i't ati
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I have not found any information which indicates that the system violates any of the failure criteria as defined In 3,10 CMR 15 303H { r
t An failure criteria not evaluated are indicated below.
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Bj SYSTEM CONDITIONALLY PASSES
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k ' ' +z"4 One or-more system components need to'be,replaced or repaired. The system,;upon completion of the replacement or,repair,
r�. h ,�passes inspection. wee s t b +
� lndiwte yes, no, or not:determined'(Y,-N,,or ND).-::Describe.basis of determination in all:instances., If"not determined" explain why not) t
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The septic tank.is metal,cracked, structurally unsound, shows substantial infiltration or ex filtration, or tank failure'is ,
-,imminent''The system)will,pass,inspection if the existing septic,tank,is replaced.with a conforming septic tank
approved by.the Board of Health. . ..
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7 k�� T� 4 -�Ona Winter Street • Boston;Massachusetts 02108 • FAX(617)556-1049 • Telephone(61/)292.550
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y 440 5
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM '" 4.
PART A .... r °
CERTIFICATION (continued). ~,
r Property A`c�dress; %
Owner:. �(k94 e)(J I CS tvr,rt
Date'of Inspection:
` 'BJ SYSTEM CONDITIONALLY PASSES (continued)
Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed
pipes) 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
p
distribution box is levelled or replaced�• f e 4 E..X � >i�tatf���`^i�'sir t?���,
The system required pumping more than four times a year due to broken or obstructed pipes) The system,will pass; -
%xr; p�, R inspection.if(with approval of the Board of Health):
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a broken pipe(s) are replaced
�t + obstruction is removed gg//yggy�
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,?CJ 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 thel.
7. rr public health,safety and the environment,
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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
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Cesspool or,,privy is within 50 feet of a surface water `. . "" ' t't�
Cesspool or privy is within.50 feet of a bordering vegetated wetland or a salt marsh: ' rf "
,4 Sv�tF �: a : } wa,; t ,yadii,':.,r i w'," S� Z' ;.(�`u.l: '.i-: 'r ',;i : a •,'S-,. . ',k, .,:'.is. z:. t , ; ,"'q0,# z.-,'.tf:#gi
)`SYSTEM'WILL'FAIL:`UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IFAPPROPRIATO,DETERMINES•THAT '
"r r THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND;SAFETY AND;7HE
ENVIRONMENT 't..
fd� x .The.system nas a septic tank any soli ausorptiun system anti is withua MG fie, to a surface 'wa.ct Supjras Or tribuaars t0 a �4
surface water supply..
The system hay a septic tank and sail 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 wela �
)~v`Ez x The system has a septic tan{ 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 jhat the weIy,
free fr,pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to}or less,than�s ,
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' DJ`SYSTEM FAILS
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1 have determined that the system violates one or more of the following failure.criteria as defined in 310 CMR 15 303; The basis
Nor this determination`is identified below.``The.Board of Health should be contacted,to determine what will be necessary,to correct
the failure..
k -�«s'irrrina `si`;Backu of se e`into`facil) ors`stem coin onent due to an overloaded or,clogged,SAS.,or,cess of
., �'{v Y P ' g8 Po to � a$ 1 t'111, r0 t .
°.Vd�lt;f'1 f;a :�lSC,i'ia Fif tt +t.r"t,,,, -t• ^f e, F. S' :de>,i ;� r # •.;': '3' S s: ' ,{v 1 r.... !' e
ti :1�FiF1 1,fr?e7�S $",'.'+,s,Ti '3iFMa'' ;' ta �e,
za era * + Discharge"orponding of effluent'to the surface of the ground or surface waters due.to an overloaded{or clogged SAS ors01
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iaed'B/15/95) 2 rt tas� r� )'K
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
�l CERTIFICATION (continued)
Property Address: 5 e n SUI S
Owner: �e.�1 (I� ,
Date of Inspection:12 i ' )4s'
D)SYSTEM FAILS(continued):
44 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 112 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] LARGE SYSTEM FAILS:
The following criteria apply to large systems in addition to the criteria above:
The design flow 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 Address: (XJ (4e u-en"
0
Owner: '_Tlo ,
Date of Ins ection:
12 � 1) )qS -
Check if the/following have been done:
V Pumping 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
,,�y�- /�during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection.
+ � (`1"�As built plans have been obtained and examined. Note if they are not available with N/A.
The facilityor dwelling was ins
pected ected for signs of sewage back-up.
g�The system does not receive non-sanitary or industrial waste flow
_✓The site was inspected for signs of breakout.
ZAII 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 or
rproximated by nun-intrusive methods.
he facili, o,,r„ ;J;• .,., occupants, if di'rere^1 from ovme-) were provided with information on the proper maintenance of Sub-
Surface Disposal System.
(revised 8/15/95) 4
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Ad ess:
Owner: �.�1
Date of Inspection:
z� 1-11as
FLOW CONDITIONS
RESIDENTIAL:
Design flow:'-z7)V allons
Number of bedrooms:
Number.of current residents:
Garbage grinder (yes or no):-E
Laundry connected to system (yes or no):
Seasonal use (yes or no):t
Water meter readings, if available:
Last date of occupancy: I�K�w�
COMMERCIAUINDUSTRIAL:
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 occupants:
GENERAL INFORMATION
PUMPING RECORDS and source of information: n
N y t�ecc�ao5
System pumped as pan of inspection: (yes or no)_
If yes, volume pLimned gallons
Reason for pumping:
TYPE OF SYSTEM
tic tank/distribution box/soil absorption system
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: 30
Sewage odors detected when arriving at the site: (yes or no)
(revised 8/15/95) $
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Ad ress:r
Owner: �� �,
Date of Inspection: n
L2j jq
SEPTIC TANK:1.
(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:
(locate on site plan)
Depth below grade:
Material of construction: _concrete _metal _FRP—other(explain)
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
rlictance from botto- M cro— in hnvorn of owlet tee o, battle'
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 8i.5/95) 6
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION.FORM
PART C
of r c! SY E INFORMATION (continued)
Property ess: 1� c eU v
Owner:
y �1�I �C�'��-�,Q
Date of Inspection:
TIGHT OR HOLDING TANK:I
(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 ievei and distributic,i: eyua , evidence of solid carr�o,er, evidence of leakage into or out of box, etc.)
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 B/15/95) 7
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM „
PART C
SYSTEM INFORMATION (continued)
Property Ad ess: '
Owner: ' do
Date of Inspecti n:)
SOIL ABSORPTION SYSTEM (SAS):
•v methods)
required,,but may be approximated b non-intrusive e )
locate on site Ian if possible; excavation not eq y pp Y
( plan,
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.)
kffi
CESSPOOLS: V
(locate on site plan)
Number and configuration: to
D t
Depth-top of liquid to inlet.invert:
Depth of solids layer: D"
Depth of scum layer: c
Dimensions of cesspool:
Materials of construction: :::G(.oeA
Indication of groundN�ate--. A.10�--
inflow (cesspool must be pumped as part of inspection) geWL a L—
f vegetation, etc.
v f ponding, condition o e )
failure, level o ,
Comments: (note condition of soil, signs of hydraulic fa p g, g
N0
PRIVY:
(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.)
(revised 8/15/95) 8
I
4
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SY TEM INFORMATION (continued)
Property Add ss•. I � ���t '
P Y
Owner: !'Z
Date of Inspe ion: �nk c
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100'
qq Q� i
DEPTH TO GROUNDWATER
WAVe— ( `^
Depth to groundwater:�feet ,yv I-c57' Oov-e—(p 0'5 xCeS-�&v`- /Vo �,Ig7Gr �f
method of determination or approximation:
(revised 8/15/95) 9