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Home My WebLink About0110 THIRD AVENUE (HYANNIS) - Health J 110 Third Avenue Hyannis A= 266 - 015 I .. y r+ COMMONWEALTH OF MASSACHUSETTS z EXEC.UTIVE OFFICE OF ENVIRONMENTAL AFFAIRS. a DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5. OFFICIAL INSPECTION.FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address:.. Owner's Nam .Owner's Address: OleRECE►� ® Date of Inspection: pPR 1 2pp� Name of Inspector: (please rint) ! 6 gTAB�E Company Name . T0\00F�NDEPT: Mailing Address; U• Oyk Telephone Number: O - 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 ection 15.340 of Title 5(310 CMR 15.000). The system: Passes Conditionally Passes Ne As.Further Evaluation by the Local Approving Authority is inspector's Signature: / Date: �V .wu A 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 afthe 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 I Page 2 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: P/!L ILIA Owner. Date of Inspection: 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 br 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*br 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 pipes)or due.to a broken;settled or uneven distribution:box. System willpass 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 re'uired um 'in more than�4 times a year due t q o broke P P g Y . n 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 . r Page 3 of l'l OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY'ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION.(continued) Property Address: VA Owne Date of Inspection: 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.wili protect public health,safety andthe 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 10.0 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.l 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 aseptic 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,providedthat no,other failure criteria.are triggered. A•copy of the analysis must be attached to this form. 3. Other: 3 Page 4 of I I OFFICIAL.INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE'SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: / Owne . 20, Date of Inspection. D. System Failure Criteria applicable to all systems: You'mast 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 groundor 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 groundwater 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 1 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 A are triggered.A copy of the analysis must be attached to this form.] (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: .To be considered a large'system_the system must serve 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.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 15.304.Thesystem 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: IC14.. Owner. Date of Inspection: 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? . — 1/ Have large.volumes of water been introduced to the system recently or as part of this inspection? A— 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 hee 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 Cis at issue approximation of distance is unacceptable) [310 CMR 15,302(3)(b)] 5 Page 6 of l l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTIONFORM PART C SYSTEM'INFORMATION Property Address: (/ , / >q , OwnlhkL Date of Inspection: D / FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):-.a . Number.of bedrooms,(actual):: DESIGN flow based on 310 CMR 13.203(f r example: 11:0 gpd x#of bedrooms): � Number of current residents: Does residence.have a garbage grinder(yes or no)v�& Is laundry on a separate sewage"system(yes or no if yes separate inspection required] Laundry system inspected Oilable or no)- Z(i' Seasonal use: (yes or no): Water meter readings, if a (last 2 years usage(gpd)): Sump pump(yes orin9l?!�LD' Last date of occupancy: Q00-Z&A COMMERCIALANDUSTRIAL.1 Type of establishment: Design flow(based on 310 CMR.15.203): gpd Basis of design flow(seats/persons/sgft,etc.)i 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: Was system pumped as part of the ' specti n{yes or no): If yes,volume pumped: gallons--How was quantity pumped determined? Reason'forpumping- TYPE OF SYSTEM _Septic tank,distribution box,soil absorption system Single cesspool _Overflow cesspool _.Priry _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): a!G i a2 z sxw ( &az" 7�,-,,,/ Approximate age of all components,date installed(if known)and source of information': Were:sewage odors detected when arriving at the site(yes or no):I jTQ 6 Page 7 of I 1 t OFFICIAL INSPECTION FORM—NOT,FOR NOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: �L�CP i oq OwneKa& Date of Inspection: t,1!9/O/ BUILDING SEWER(locate,on site plan)./903— Depth.below grade: Materials of construction:_cast iron 40 PVC_other(explain):- Distance from private water supply well or suction liner Comments(on condition of joints,venting, evidence of leakage,etc.): SEPTIC TANK: (locate on site plan) Depth below grade: /01 Material of construction: ,iEoncrete 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: Sludge depth: /0 Distance from top of sludge to bottom of outlet.tee or baffle: f? Scum thickness:l/ � Distance from top of scum to top of outlet tee or baffle: Z Distance from bottom of scum to bottom of outlet tee or baffle: 7. How were dimensions determined` 3V Comments(on pumping recommendation , inlet and outlet tee or baffle condition, structural integrity, liquid levels related to outlet invert, evidence of leakage, C. GREASE TR ocate 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 l 1 t " `OFFICIAL INSPECTION FORM. NOT FOR VOLUNTARY,ASSESSIVMENTS S.UBSURFACE-SEWAGE.DISPOSAL SYSTEM INSPECTION'FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner. .Date of Inspection: / TIGHT or HOLDING TANK✓/1-�(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 fast pumping: Comments(condition of alarm and float switches, etc.): DISTRIBUTION BOX/)1277�(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 into or out of box,etc..):. PUMP CHAMBER 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 I 1 OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE.SEWAGE DISPOSAL.SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: M� Owne Date of Inspection. v/ SOIL ABSORPTION SYSTEM(SAS): I/i (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: 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, c.): i ,S CESSPO.OLJS,;-'� (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:-,4&jPcate-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 l l OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE`SEWAGE DISPOSAL SYSTEM'INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property.Address: nV A f � /'� Owner. Date of Inspectio D 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. t/ /A�/ ' r � 10 Page 11 of l 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C . SYSTEM INFORMATION(continued) Property Address: JIV 1-14 Owner. Date of Inspection. SITE EXAM. Slope Surface water Check cellar. Shallow wells Estimated depth to ground water 2 feet Please indicate(check).all methods used to d.etermine.the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: hecked with local excavators, installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: 9 , Y 11 LOCL�TIOt�1 /�L� SEW NC�E PERMIT QG �y IMSTQLLER 5 IJWE ADDRESS BUILDERS Q &VAE ADDRESS - 0DTE PERMIT ISSUED DATE COMPLH.Jt CE ISSUED : �o .i / r P No.......�/®.......... FEE.... ........ ....... THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HE LTH E If ...�. .OF........ .......................... Applira#ion -for Ui,iipuiitt1 Workii Totuitrurtion Vrrutit Application is hereby mad for a Permit to Construct ( ) or Repair ( �n Individual Sewage Disposal System at: iE atioyny��ff/A1d e or Lot No. -------•------------------ rA.flL-�---l.........._1 i...................._........ ----------------------------••-----•--•---•••-------•------------------------•-------------------- TM, Ow er, & �^ ress W. �� n �— .................P_..__._....___.._.._..__....._._...___.__._ ._.._._.__ ... __..__................................................. Installer Address UType of Building Size Lot----------------------------Sq. feet Dwelling—No. of Bedrooms-----------------------_--------------------Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ---------------------------- No. of persons---------------------------- Showers ( ) — Cafeteria ( ) a' Other fixtures ------------------------------- -- W Design Flow--------------------------------------------gallons per person per day. Total daily flow--------------------------------------------gallons. Septic Tank—Liquid capacity-:_--_--_-_gallons Length---------------- Width----------- ---- Diameter--__.___.._----. Depth.__...-__.----- xDisposal Trench—No- ____________________ Width-------------------- Total Length-------------------- Total leaching area.----.-._----..-_--_sq. ft. Seepage Pit No--_----------------- Diameter.................... Depth below inlet.................... Total leaching area.......-----------so. ft. z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by............. ............................................................ Date------------------------------.-------.. a Test Pit No. 1----------------minutes per inch Depth of Test Pit-------------------- Depth to ground water-_-_--.__._--.-_...._.. Test Pit No. 2----------------minutes per inch Depth of Test Pit-_---_-----__------ Depth to ground water------------------------ .......... ------ 0 Description of Soil_____________ V -------------- -------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------ W VNature of Repairs or Alteratigns—Answer when applicable... ......P./d...t .................e ------------------------------ --•---- r�<ia.s ....... ../l�Q R� S7` 4 IO..Q�'- /p __-__�---�--- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article NI of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has b iss ed by the board of healt Si d- -�>�� s'� - --------------- /• Date Application Approved By------ ---- ---- --- . = —................. D to Application Disapproved for the following reasons---------------------------------------------------------------------------------------•---- ...--------------- -----•---•--•-------•----•------------••-••------------------------------------------•----------------------------------------------------------------------------------------------------------------- Date PermitNo......................................................... Issued....... ............. Date Wh r THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 6G4"h oF....... . ar ApplirFation -fur :41-ap al Works Toustrurtion Prrmit Application is hereby made for a'Permit to Construct'( ) or Repair ( n Individual Sewage Disposal System at: ot Eo tionJ,��- ddJt or Lot No. Owner ress aA.-A �----------------------------- Installer Address UType of Building Size Lot----------------------------Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons---------------------------- Showers ( ) — Cafeteria ( ) dOther fixtures -----------------------•-----------_--..------------------- .................. -------------------------------------••------------------------------- W Design Flow•............................................gallons per person per day. Total daily flow--------------------------------------------gallons. $ W Septic Tank—Liquid capacity------------gallons Length................ Width................ Diameter__.._-_---.____ Depth--_-...__.----- x Disposal"Trench—No- -------------------- Width-------------------- Total Length.................... Total leaching area--------------------sq. ft. Seepage Pit No......................'Dia""meter................... Depth below inlet.................... Total leaching area------- ----------sq. ft. z Other Distribution box ( ) Dosing tank Percolation Test Results Performed by........ .............•-•-------------•-•-----•--•-•-•----•-------•-••--•- Date--------------------------------------- fi a Test Pit No. 1_._.._..__n___-minutes per inch Depth of Test Pit_________________-- Depth to ground water-----------_---_.--...- LL, Test Pit No. 2_,_.xe_'___----minutes per inch. Depth of Test Pit.................... Depth to ground water-----------------_........ Pd Descriptionof Soil= -----•---•--------•..................•------•---•-•--._....---------•-------.........------------------. x . 4V_j-�--- V ...---.....•---------------•-----------•---..----•-----------_---.. ------•••-••--•••----•--------------•-------•-•----•••-•-.-----• •-•-•-•-•------•------•---•----------------------------------- -------- ---- ---------- ----------- ------= *------------------.--------------------•--•-----------------•-•-----------------------•----=•-----------•----------- ------------------••-.----- U Nature of Repairs or Altra tions—Answer when applicable._._ -------- ... 1 -C e— ---- x ------jl ' r* f}"t` 1tP*Dt�" + Agreement: The undersigned agrees-.to 'itisiall*the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article,XI of the State Sanitary Code—The undersigned further agrees not to place the system in operation until"a Certificate of,C&npliance::has been issued by the board of health. Sig; d.. ------------------ — a r _ to . Application Approved B A = - to =Application Disapproved forOlhe following reasons:----------••---•--------•-•------•------------•------•-----•-- ----•----------•-•----•---•••---••-•-•--------- ............................................9.............................. ....,, r Date Permit No.... ••. •• `, / d --•-•- -- ---•--. Issued------�4)_-�-`s---•... ..........••------ ¢ >- - Date y a S. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF :HEALTH P ........oF........ .. .............. G rtfiraa r of (I nipiJamrl IS IS TO CERTIFY„ hat the Individual Sewage spo System constructed �� ) or Repaired;.,( by-•- -- • . ' --- - -- '6 --------- - ----•-•- - - - t. Insta a has been installed-in acco'rdanceswKith the provisions of :Article XI of The State Sa tary Clode as des ibed in the application for Disposal Works Construction Permit Noy.._.., , ................... dated..._ r'd.. "�►_! *.____.._. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A UARAN EE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE ftf Inspector ---•---..... ----- , THE COMMONWEALTH OF MASSACHUSETTS } BOARD OF HEALTH No � ._.... FEE, ,,,.. - ...... 1 orkii fv rurtioaa Vamit Permission is hereby granted____ ..................................... to Construct'( ) or Re air ( " nI nd- R ual Se v a os sat No tem �I t ee i as shown on tfie applicatn for Disposal Works Construction Pe t No .__ _....... . ated.....Psi - --......... ••-• . . `Bo rd'of eal h. DATE ( _ /► •FORM 1255 'Hoses & WARREN. INC.. PUBLISHERS -