HomeMy WebLinkAbout0082 WINDSHORE DRIVE - Health 82 WINDSHORE DRIVE, HYANNIS
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TOWN OF BARNSTABLE
LOCATION �� L!/ly S� � �/�J��_ SEWAGE # _
VILLAGE )/—:J /tl/t� ASSESSOR'S r AP& LOT a
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY I O OC)
LEACHING FACILITY: (type) � �G/l� l�'�� (size)
NO. OF BEDROOMS o'Z.
BUILDER OR OWNER
PERMITDATE: COMPLIANCE DATE:
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 Wedand and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
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COMMONWEALTH OF MASS C USETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION t
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TITLE 5 .t
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A r
CERTIFICATION
Property Address: 82 WINDSHORE DRIVE HYANNIS,MA 02601
Owner's Name: EILEEN SCHERE ! / `-
Owner's Address: 82 WINDSHORE DRIVE HYANNIS,MA 02601
Date of Inspection:vA&
Name of Inspector: (please print) ;, JOHN GRACI
Company Name: SEPTIC INSPECTIONS f
Mailing Address: P.O BOX 2119 TEATICKET,MA.02536
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Telephone Number: 508-564-6813 FAX 508-564-7270
CERTIFICATION STATEMENT ;4
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 r
E
_ Conditionally Passes
_ Needs Furthew Pvaluation by the Local Approving Authority '
Fails
Inspector's Signature: i,.
I Date: q 12- [Q)
The system inspector shall submi „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 to the buyer,if applicable,and the approving authority.
Notes and Comments
SYSTEM PASSES TITLE V-RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM USEFUL ,
LIFE. +"'}
****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. r
Title• 5 Inc—Minn rnrn, (11 5/?(1(1(1'•
Page 2 of 11
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OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
;r
Property Address: 82 WINDSHORE DRIVE HYANNIS,MA 02601
Owner: EILEEN SCHERE
Date of Inspection: n/a
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:
SYSTEM PASSES TITLE V RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM !
USEFUL LIFE. "
B. System Conditionally Passes:
_ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system, >r.
upon completion of the replacement or repair,as approved by the Board of Health,will pass. Ry;_
Answer yes,no or not determined(Y,N,ND)in the for the following statements.If"not determined"please explain.
J:.
n/a 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 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: n/a
n/a 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: n/a
n/a 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: n/a t
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. Page 3 of l 1 "F
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OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 82 WINDSHORE`DRIVE HYANNIS,MA 02601
Owner: EILEEN SCHERE
Date of Inspection: n/a
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 will protect public health,safety and the environment:
_ Cesspool or privy is withii;50 feet of a surface water
_ Cesspool or privy is within.5.0 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 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 feet of a private water supply well.
t
_ 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 n/a
"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 wthis form.
3. Other: "
n/a
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Page 4 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 82 WINDSHORE DRIVE HYANNIS,MA 02601
Owner: EILEEN SCHERE 4
Date of Inspection: n/a
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to.'each of the following for all-inspections:
Yes No
_ X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged r `
SAS or cesspool
X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool
X Liquid depth in cesspool is less than 6"below invert or available volume is less than '/2 day flow
X Required pumping more than 4 times in the last year NO3 due to clogged or obstructed pipe(s).Number of times
pumped nLa.
X Any portion of the SAS,cesspool or privy is below high ground water elevation.
X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface.water supply. 4
X Any portion of a cesspool or privy is within a Zone 1 of a public well.
_ X Any portion of a cesspool or privy is within 50 feet of a private water supply well.
X 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 r
less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be
attached to this form.]
_ (Yes/No)The system fails l have determined that one or more of the above failure criteria exist as described in 310
CMR 15.303,therefore the systeni�fails.'The system owner should contact the Board of Health to determine what will be -
necessary to correct the failure. {
E. Large Systems: i `
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
X the system is within 400 feet of a surface drinking water supply
X the system is within 200 feet of a tributary to a surface drinking water supply
't _ X 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"tozny question in Section E the system is considered a significant threat,or answered =r:
"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. The system owner
should contact the appropriate regional office of the Department.
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Page 5 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 82 WINDSHORE DRIVE HYANNIS,MA 02601
Owner: EILEEN SCHERE
Date of Inspection: n/a
Check if the following have been done.You must indicate"yes"or"no"as to each of the following:
Yes No
X _ Pumping information was provided by the owner,occupant,or Board of Health
X Were any of the system components pumped out in the previous two weeks?
X _ Has the system received normal flows in the previous two week period? `
X Have large volumes of water been introduced to the system recently or as part of this inspection?
X Were as built plans of the system obtained and examined?(If they were not available note as N/A)
X _ Was the facility or dwelling inspected for signs of sewage back up?
X _ Was the site inspected for signs of break out?
X _ Were all system components,excluding the SAS, located on site?
X _ Were the septic tank manholes'uncovered,opened,and the interior of the tank inspected for the condition of the 1
baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? t:
X _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance
of subsurface sewage disposal systems?
c.,F
The size and location of the Soil Absorption System(SAS)on the site has been determined based on:
Yes no
X Existing information. For example,a plan at the Board of Health.
X _ 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)]
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Page 6 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM =#:
PART C
SYSTEM INFORMATION
Property Address: 82 WINDSHORE DRIVE HYANNIS,MA 02601
Owner: EILEEN SCHERE
Date of Inspection: n/a
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): 2. Number of bedrooms(actual): 2
DESIGN flow based on 310 CMR'15.203 (for example: 110 gpd x#of bedrooms): 220
Number of current residents: 2
Does residence have a garbage grinder(yes or no): NO
Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required]
Laundry system inspected(yes or no) NO
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: n/a
COMMERCIALANDUSTRIAL
Type of establishment: n/a
Design flow(based on 310 CMR 15.203): n/agpd
Basis of design flow(seats/persons/sqft,etc.): n/a
Grease trap present(yes or no):NO
Industrial waste holding tank present(yes or no):NO
Non-sanitary waste discharged to the Title 5 system(yes or no): NO
Water meter readings,if available: n/a
Last date of occupancy/use: n/a
OTHER(describe): n/a
,,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: n/agallons--How was quantity pumped determined?n/a
Reason for pumping: n/a
TYPE OF SYSTEM
X 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 a copy of the DEP approval
Other(describe): n/a ,
Approximate age of all components,date installed(if known)and source of information: : •
1978 ';s
Were sewage odors detected when arriving at the site(yes or no): NO
}
Page 7 of l l
OFFICIAL INSPECTION FORM—NOT FOR.VOLUNTARY ASSESSMENTS
SUBSURFACE'SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 82 WINDSHORE DRIVE HYANNIS,MA 02601
Owner: EILEEN SCHERE
Date of Inspection: n/a
BUILDING SEWER(locate on site plan)
Depth below grade: 12"
Materials of construction:_cast iron X40 PVC_other(explain): n/a
Distance from private water supply well or suction line: n/a
Comments(on condition of joints,venting,evidence of leakage,etc.):
TOWN . .
SEPTIC TANK:X(locate on site plan)
t;.
Depth below grade: n/a
Material of construction: Xconcrete ' metal_fiberglass_polyethylene other(explain)n/a
If tank is metal list age: n/a Is age confirmed by a Certificate of Compliance(yes or no): NO(attach a copy of certificate)
Dimensions: 1000G L 8' 6"HtV 7"W14' 10""
Sludge depth: 2"
Distance from top of sludge to bottom of outlet tee or baffle:32"
Scum thickness: 1"
Distance from top of scum to top of outlet tee or baffle:6"
Distance from bottom of scum to bottom'of outlet tee or baffle: 0"
How were dimensions determined: MEASURED
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related
to outlet invert,evidence of leakage,etc.):
THE SEPTIC TANK AND ALL COMPONENTS APPEAR TO BE STRUCTURALLY SOUND AND
FUNCTIONING PROPERLY. RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEMS ,
USEFUL LIFE.
GREASE TRAP:_(locate on site plan) '
Depth below grade: n/a
Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a
Dimensions: n/a
Scum thickness: n/a r
Distance from top of scum to top of outlet tee or baffle: n/a
Distance from bottom of scum to bottom of outlet tee or baffle: n/a �.
Date of last pumping: n/a
Comments(on pumping recommendations,,inlet and outlet tee or baffle condition,structural integrity, liquid levels as related
to outlet invert,evidence of leakage,etc.):
n/a ;t
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Page 8 of 1 l
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OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued) - ..
I
Property Address: 82 WINDSHORE DRIVE HYANNIS,MA 02601
Owner: EILEEN SCHERE
Date of Inspection: n/a
TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade: n/a
Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a
Dimensions: n/a
Capacity: n/a gallons ' }
Design Flow: n/a gallons/day -
Alarm present(yes or no): N/A
Alarm level: N/A Alarm in working order(yes or no): NO
Date of last pumping: n/a t°
Comments(condition of alarm and float.switches,etc.):
n/a
DISTRIBUTION BOX:X(if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: LEVEL WITH BOTTOM OF PIPE
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 APPEARS TO BE STRUCTURALLY SOUND
PUMP CHAMBER:_(locate on site plan) t:
Pumps in working order(yes or no)`NO' '
Alarms in working order(yes or no):NO
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
n/a
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Page 9 of l l
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 82 WINDSHORE DRIVE HYANNIS,MA 02601
Owner: EILEEN SCHERE
Date of Inspection: n/a
SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required)
If SAS not located explain why:
n/a
Type
1000 GAL 6'X 6' leaching pits, number: 1
n/a leaching chambers, number: n/a
n/a leaching galleries, number: n/a
n/a leaching trenches, number, length: n/a
n/a leaching fields, number: n/a ' S
n/a overflow cesspool, number: n/a
n/a innovative/alternative system
Type/name of technology: n/a
_ s
Comments(note condition of soil'(signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.):
THE PIT APPEARS TO BE FUNCTIONING PROPERLY.THERE ARE NO SIGNS OF HYDRAULIC FAILURE
CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration: n/a }
Depth—top of liquid to inlet invert: n/a
Depth of solids layer: n/a
Depth of scum layer: n/a
Dimensions of cesspool: n/a E j
Materials of construction:n/a
Indication of groundwater inflow(yes or no):NO
Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
n/a
PRIVY: (locate on site plan)
Materials of construction: n/a ,
Dimensions: n/a
Depth of solids: n/a
Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
n/a
o
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: 82 WINDSHORE DRIVE HYANNIS,MA 02601
Owner: EILEEN SCHERE
Date of Inspection: n/a
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.
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Pagc I 1 of 1 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 82 WINDSHORE DRIVE HYANNIS,MA 02601
Owner: EILEEN SCHERE
Date of Inspection: n/a
SITE EXAM
_Slope
_Surface water
_Check cellar
Shallow wells
Estimated depth to ground water 12+feet
Please indicate(check)all methods used to determine the high ground water elevation:
NO Obtained from system design plans on record-If checked,date of design plan reviewed: n/a
YES Observed site(abutting property/observation hole within 150 feet of SAS)
NO Checked with local Board of Health-explain: n/a
NO Checked with local excavators, installers-(attach documentation)
NO Accessed USGS database-explain: n/a
You must describe how you established the high ground water elevation:
GROUNDWATER DETERMINED BY HAND AUGER-NO WATER ENCOUNTERED A'1' 12' -BOTTOM AT 7'
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Q4
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
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DEPARTMENT OF ENVIRONMENTAL PROTECTION
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ti
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VO
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 82 WINDSHORE DRIVE HYANNIS,MA 02601
Owner's Name: EILEEN SCHERE
Owner's Address: 82 WINDSHORE DRIVE HYANNIS,MA 02601
Date of Inspection: 9/21/01
Name of Inspector: (please print) JOHN GRACI
Company Name: SEPTIC INSPECTIONS -
Mailing Address: P.O. BOX 2119 TEATICKET,MA.02536
Telephone Number: 508-564-6813 FAX 508-564-7270
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:
X Passes }
_ Conditi
on II
_ Needs by the Local Approving Authority
Fails
Inspector's Signature: Date: 9/21/01
The system inspector shall submiection 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 now of 10,000 gpd or greater,the
inspector and the system owner shall submit the report to the appropriate regional office ofthe 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
SYSTEM PASSES TITLE V RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM USEFUL
LIFE.
****This report only describes conditions at the time of ins�ectiomand under the conditions of use at that time.This
will perform the future under the same or different conditions of use.
inspection does not address how the system
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,Page 2 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 82 WINDSHORE DRIVE HYANNIS,MA 02601
Owner: EILEEN SCHERE
Date of Inspection: 9/21/01
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes: a
i
X 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:
SYSTEM PASSES TITLE V RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM
t{
USEFUL LIFE.
B. System Conditionally Passes:
_ One or more system components as described in the"Conditional Pass"section Reed 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.
n/a 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 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 t .y
that the tank is less than 20 years"old is available.
ND explain: n/a g
n/a 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: n/a
ji
n/a 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: n/a
`Y.
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Page 3 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
' PART A
i14" CERTIFICATION(continued) k..
Property Address: 82 WINDSHORE DRIVE HYANNIS,MA 02601
Owner: EILEEN SCHERE
Date of Inspection: 9/21/01
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 will protect public health,safety and the environment:
Z
_ 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 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 1 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 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 n/a
**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: -
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n/a
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OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY-ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PAR
T A
CERTIFICATION(continued) `Property Address: 82 WINDSHORE DRIVE HYANNIS,MA 02601
Owner: EILEEN SCHERE
Date of Inspection: 9/21/01
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all-inspections:
Yes No
X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool M1
X Discharge or ponding;of effluent to the surface of the ground or surface waters due to an overloaded or clogged .
SAS or cesspool z:.
X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool
X Liquid depth in cesspool is less than 6"below invert or available volume is less than'/2 day flow
X Required pumping more than-4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times
pumped nLa.
X Any portion of the SAS,cesspool or privy is below high ground water elevation.
X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
X Any portion of a cesspool or privy.is within a Zone 1 of a public well.
X Any portion of a cesspool or privy is within 50 feet of a private water supply well.
X 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 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'fa Is.The system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E. Large Systems: 3-;
To be considered a large system the system must serve a facility with-a design now of 10,000 gpd to 15,000 gpd. a;.
You must indicate either"yes"or"no"-to each of the following:
(The following criteria apply to large' tems in addition to the criteria above) .,.
yes no
X the system is within 400 feet of a surface drinking water supply
X the system is within 200 feet of a tributary to a surface drinking water supply
X 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.The system owner
should contact the appropriate regional office of the Department.
a�
... a t
Page 5 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
r ;;
Property Address: 82 WINDSHORE DRIVE HYANNIS,MA 02601 "
Owner: EILEEN SCHERE
Date of Inspection: 9/21/01
Check if the following have been done. You must indicate"yes"or"no"as to each of the following:
Yes No
X _ Pumping information was provided by the owner,occupant,or Board of Health
_ X Were any of the system components pumped out in the previous two weeks? is
X _ Has the system received normal flows in the previous two week period? {
X Have large volumes of water been introduced to the system recently or as part of this inspection? r" '
_ X Were as built plans of the system obtained and examined?(If they were not available note as N/A)
X _ Was the facility or dwelling inspected for signs of sewage back up? r' ` `
X _ Was the site inspected for signs of break out?
X _ Were all system components,excluding the SAS, located on site?
Y;
X _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the h
baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? x <'
X _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance A {
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 .k
X Existing information.Forexample,a plan at the Board of Health.
WA
X _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is s
unacceptable)[310 CMR 15.302(3)(b)] .£'
.?<
r
Page 6 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 82 WINDSHORE DRIVE HYANNIS,MA 02601
Owner: EILEEN SCHERE
Date of Inspection: 9/21/01
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): 2 Number of bedrooms(actual): 2
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms):220
Number of current residents:2
Does residence have a garbage grinder(yes or no): NO
Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required]
Laundry system inspected(yes or no):NO
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: n/a
COMMERCIAL/INDUSTRIAL
Type of establishment: n/a
Design flow(based on 310 CMR 15.203):n/agpd t
Basis of design flow(seats/persons/sgft,etc.): n/a
Grease trap present(yes or no): NO t_
Industrial waste holding tank present(yes or no):NO
Non-sanitary waste discharged to the Title 5 system(yes or no):NO
Water meter readings, if available: n/a As;'
Last date of occupancy/use: n/a
OTHER(describe): n/a
GENERAL INFORMATION .
r
Pumping Records
Source of information: n/a
Was system pumped as part of the inspection(yes or no): NO
If yes,volume pumped: n/agalloris=;How was quantity pumped determined?n/a
Reason for pumping: n/a
TYPE OF SYSTEM ?._
X Septic tank,distribution box,soil absorption system
_Single cesspool
_Overflow cesspool
_Privy 4�
_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): n/a
Approximate age of all components,date installed(if known)and source of information: s
1978
d
Were sewage odors detected when arriving at the site(yes or no):NO
t
Rage 7 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 82 WINDSHORE DRIVE HYANNIS,MA 02601
Owner: EILEEN SCHERE
Date of Inspection: 9/21/01
BUILDING SEWER(locate on site plan)
Depth below grade: 12"
Materials of construction:_cast iron X40 PVC_other(explain): n/a
Distance from private water supply well or suction line: n/a
Comments(on condition of joints,venting,evidence of leakage,etc.):
TOWN
SEPTIC TANK: X(locate on site plan)
Depth below grade: n/a
Material of construction: Xconcrete_metal_fiberglass_polyethylene other(explain)n/a
If tank is metal list age: n/a Is age confirmed by a Certificate of Compliance(yes or no): NO(attach a copy of certificate)
Dimensions: IOOOG L 8' 6" H 5' 7" W 4' 10""
Sludge depth:2"
Distance from top of sludge to bottom of outlet tee or baffle:32"
r
Scum thickness: 1"
Distance from top of scum to top of outlet tee or baffle: 6"
Distance from bottom of scum to bottom of outlet tee or baffle:0"
How were dimensions determined: MEASURED
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels as related
to outlet invert,evidence of leakage,etc.):
THE SEPTIC TANK AND ALL COMPONENTS APPEAR TO BE STRUCTURALLY SOUND AND
FUNCTIONING PROPERLY. RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S
USEFUL LIFE.
GREASE TRAP:_(locate on site plan)
Depth below grade: n/a
Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a
Dimensions: n/a
Scum thickness: n/a
Distance from top of scum to top of outlet tee or baffle: n/a
Distance from bottom of scum to bottom of outlet tee or baffle: n/a r
Date of last pumping: n/a
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels as related
s
to outlet invert,evidence of leakage,etc.):
n/a
7
-Page 8 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 82 WINDSHORE DRIVE HYANNIS,MA 02601
Owner: EILEEN SCHERE
Date of Inspection: 9/21/01
TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade: n/a
Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a
Dimensions: n/a
Capacity: n/a gallons
Design Flow: n/a gallons/day
Alarm present(yes or no): N/A
Alarm level:N/A Alarm in working order.(yes or no): NO
Date of last pumping: n/a
Comments(condition of alarm and float switches,etc.):
n/a
}
DISTRIBUTION BOX:X(if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: LEVEL WITH BOTTOM OF PIPE
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 APPEARS TO BE STRUCTURALLY SOUND
PUMP CHAMBER:_(locate on site plan)
Pumps in working order(yes or no): NO
Alarms in working order(yes or no):NO
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
n/a
e
Page 9 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 82 WINDSHORE DRIVE HYANNIS,MA 02601
Owner: EILEEN SCHERE
Date of Inspection: 9/21/01
SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required)
t
If SAS not located explain why:
n/a
Type
1000 GAL 6' X 6' leaching pits, number: 1
n/a leaching chambers, number: n/a
n/a leaching galleries, number: n/a
n/a leaching trenches, number, length: n/a
n/a leaching fields, number: n/a
n/a overflow cesspool, number: n/a
n/a innovative/alternative system
Type/name of technology: n/a
Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.):
THE PIT APPEARS TO BE FUNCTIONING PROPERLY.THERE ARE NO SIGNS OF HYDRAULIC FAILURE : .
CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) -'
Number and configuration: n/a
Depth—top of liquid to inlet invert: n/a
Depth of solids layer: n/a f.
Depth of scum layer: n/a
Dimensions of cesspool: n/a
Materials of construction: n/a
Indication of groundwater inflow(yes or no):NO
Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
n/a
PRIVY: (locate on site plan) :
Materials of construction: n/a
Dimensions: n/a
Depth of solids: n/a
Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
n/a
I
i
ti.
Q
Page 10 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 82 WINDSHORE DRIVE HYANNIS,MA 02601
Owner: EILEEN SCHERE
Date of Inspection: 9/21/01
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.
�QR
o A
AA as`
AC 37
Page 11 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 82 WINDSHORE DRIVE HYANNIS,MA 02601
Owner: EILEEN SCHERE
Date of Inspection: 9/21/01
SITE EXAM
_Slope
_Surface water
_Check cellar
Shallow wells
Estimated depth to ground water 12+feet
Please indicate(check)all methods used to determine the high ground water elevation:
NO Obtained from system design plans on record-If checked,date of design plan reviewed: n/a
YES Observed site(abutting property/observation hole within 150 feet of SAS)
NO Checked with local Board of Health-explain: n/a
NO Checked with local excavators, installers-(attach documentation)
NO Accessed USGS database-explain: n/a
You must describe how you established the high ground water elevation:
GROUNDWATER DETERMINED BY HAND AUGER-NO WATER ENCOUNTERED AT 12' -BOTTOM AT 7'
G��ze
01, �-
COmmorweatth of MOSSOChLiSetts John Grad
a r9lb Executive Office of Er Mromwiitai Affairs D.E.P. Title V Septic Ittspector
Department of P.O. Box D Environmental Protection Teaticket,MAA 02536
(508) 564-6813
% 9
d�
SUBSURFACE.SEWAGE DISPOSAL SYSTEM INSPECTION FORM A
l PART A Rr� ��"�
�✓
CERTIFICATION
m JUN
Property Address: 82 Windshore Dr. Hyannis Address of Owner: 1 LE N
P TOwNOFBARNSTABLE
Date of Inspection:619197 (If different)
Name of Inspector:John Graci Louppi S HEALTHDEpT
Company Name,Address and Telephone Number: A
E
CERTIFICATION STATEMENT
1 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 sewage disposal systems. The system:
X Passes This Inspection Is based on criteria defined in Title V
Conditionally Passes code 310 CMR 15.303.My findings are of how the system is
performing at the time of the Inspection.My Inspection does
_ Needs Fu er aluation By the Local Approving Authority not Imply any warranty or quarantee of the longevity of the
Fails septic system and any of its components useful life.
Inspector's Signature: Date: woty
The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this
inspections. 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.
INSPECTION SUMMARY:
Check A,B,C,or D:
A] SYSTEM PASSES:
x I have not found any information which indicates that the system violates any of the failure criteria
defined as 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 11115195)
One Winter Street • Boston,Massachusetts 02108 e FAX(617)556-1049 9 Telephone(617)292-5500
1
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 82VAndshore Dr.Hyannis
Owner: Louppl
Date of Inspection:e19197
_ Sewage backup or breakout or high static water level observed in the distribution box is 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 leveled 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.
2) SYSTEM WILL 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
ENVIRONMENT:
_ The system has a septic tank and soil absorption system and is within 100 feet to a
surface of water supply or tributary to a surface water supply.
The system has a septic tank and soil absorption system and is within a Zone 1 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 system 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 volatile organic compounds indicates that the well is
free from pollution for that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal or less than 5 ppm.
3) OTHER
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 in facility or system component due to an 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
cesspool.
SAS is in hydraulic failure.
(revised 11115195)
2
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 82 Wlndshore Dr.Hyannis
Owner: Louppl
Date of Inspection:619197
DJ 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).
Numbers 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 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. 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.
EJ LARGE SYSTEM FAILS:
The following criteria apply to large systems in addition to the criteria:
_ The 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 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 11115195)
i 3
I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECLIST
Property Address: 82 Mlndshore Dr.Hyannis
Owner: Louppi
Date of Inspection:619197
Check if the following have been done:
X Pumping information was requested of the owner,occupant, and Board of Health.
X None of the system components have been pumped for at least two weeks and the 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.
X As built plans have been obtained and examined. Note if they are not available with N/A.
X The facility or dwelling was inspected for signs of sewage back-up.
X The system does not receive non-sanitary or industrial waste flow.
X The site was inspected for signs of breakout.
X All system components,excluding the Soil Absorption System,have been located on the site.
X 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.
X The size and location of the Soil Absorption System on the site has been determined based on existing information or
approximated by non-intrusive methods.
X The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of Sub-
Surface Disposal System.
(revised 11115195)
4
I •
I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 82 Undshore Dr.Hyannis
Owner: Louppi
Date of Inspection:619197
FLOW CONDITIONS
RESIDENTIAL:
Design flow: 330 gallons
Number of bedrooms: 2
Number of current residents: 0
Garbage grinder(yes or no): No
Laundry connected to system(yes or no): Yes
Seasonal use(yes or no): No
Water meter readings,if available: n1a
Last date of occupancy: 2 weeks ago.
COMMERCIAL/INDUSTRIAL:
Type of establishment: n1a
Design flow:0 gallons/day
Grease trap present:(yes or no) No
Industrial Waste Holding Tank present: (yes or no) No
Non-sanitary waste discharged to the Title 5 system: (yes or no) No
Water meter readings,if available: n1a
Last date of occupancy: n1a
OTHER:(Describe) nla
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
System has not been pumped In the last two years.
System pumped as part of inspection:(yes or no)Yes
If yes,volume pumped: 100o gallons
Reason for pumping: Maintenance.
TYPE OF SYSTEM
X Septic tank/distribution box/soil absorptions 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 information:
5-5.79 by Our
Sewage odors detected when arriving at the site:(yes or no) No
(revised 11115195)
5
r
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 82 Wlndshore Dr.Hyannis
Owner: Louppl
Date of Inspection:619197
SEPTIC TANK: X
(locate on site plan)
Depth below grade: 1'
Material of construction:X concreate_metal_FRP_other(explain)
Dimensions: L 8'6'H 5'7"W 4'10-
Sludge depth:5'
Distance from top of sludge to bottom of outlet tee or baffle: 22'
Scum thickness:7'
Distance from top of scum to top of outlet tee or baffle:6'
Distance form bottom of scum to bottom of outlet tee or baffle: 11"
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.)
Septic tank and all components are structurally sound.Recommend pumping system every two years for maintenance.
GREASE TRAP:_
(locate on site plan)
Depth below grade: nla
Material of construction: _concrete_metal_FRP_other(explain)
Dimensions: nla
Scum thickness:nla
Distance from top of scum to top of outlet tee or baffle:nla
Distance from bottom of scum to bottom of outlet tee or baffle:n1a
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.)
nla
(revised 11115195)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 82 Windshore Dr.Hyannis
Owner: Louppi
Date of Inspection:619197
TIGHT OR HOLDING TANK:
(locate on site plan)
Depth below grade: n1a
Material of construction:_concrete_metal_FRP_other(explain)
Dimensions: n1a
Capacity: n1a gallons
Design flow: n1a gallons/day
Alarm level: n1a
Comments:
(condition of inlet tee,condition of alarm and float switches,etc.)
n1a
DISTRIBUTION BOX: X
(locate on site plan)
Depth of liquid level above outlet invert: Liquid level with bottom of pipe.
Comments:
(note if level and distribution is equal,evidence of solids carryover, evidence of leakage into or out of box etc.)
Distribution box is structurally sound
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.)
n1a
(revised 11115195)
7
r
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 82Wlndshore Dr.Hyannis
Owner: Louppl
Date of Inspection:919197
SOIL ABSORPTION SYSTEM(SAS):X
(locate on site plan,if possible;excavation not required,but may be approximated by non-intrusive methods)
If not determined to be present,explain:
nla
Type:
leaching pits,number: 1,990 gallon leach pit
leaching chambers,number:nfa
leaching galleries,number: nfa
leaching trenches,number, length: nla
leaching fields,number,dimensions:nla
overflow cesspool,number:nla
Comments:(note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.)
The overflow is structurally sound and functioning properly.It was empty at the time or the Inspection.
CESSPOOLS:
(locate on site plan)
Number and configuration: nla
Depth-top of liquid to inlet invert: nfa
Depth of solids layer: nfa
Depth of scum layer: nla
Dimensions of cesspool: nfa
Materials of construction: nfa
Indication of groundwater: nfa
inflow(cesspool must be pumped as part of inspection)
nla
Comments:(note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.)
nla
PRIVY:_
(locate on site plan)
Materials of construction: nfa Dimensions: nfa
Depth of solids: n1a
Comments:(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
nla
(revised 11115195)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 82 Windshore Dr.Hyannis
Owner: Louppl
Date of Inspection:619197
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100'
lc,
EO
ill �
DEPTH TO GROUNDWATER
Depth to groundwater:12 feet
method of determination or approximation:
USGS Maps and Charts
(revised 11115195)
9
LOCATION SEWAGE PERMIT NO.
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IN.STA LLEROS NAME & ADDRESS
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B UI'LDE R OR OWNER
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DA T E PERMIT ISSUED .77
DATE C.O*PLIANCE ISSUED
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
------.. 0..e/,'v...........OF..... ... /'" ` ..............................................
Appliration for Disposal Works Tonstrurtion Prrmit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at
�...................... ----•----•-- ................................................
r Locat -Address Lot o.
0 ..
Owner Address
a ..............44......--•-•.......n.U.0p%--------------------------------------•- ............................................
Installer Address
Type of Building Size Lot.,/� ....-.--..Sq. feet
U Dwelling—No. of Bedrooms..-..__.._. ............... Expansion Attic ( ) Garbage Grinder
U
4 Other—T e of Building No. of persons............................ Showers — Cafeteria
04
d Other fixtures `��` ----------------------•-------•--••-•-••--•••--•--••--------- -----------•--••-
W Design Flow....................� ,}-..........._..gallons per person per day. Total daily flow.......... ..................gallons.
W Septic Tank/—Liquid capacity_#1'--gallons Length---------------- Width................ Diameter..--..--........ Depth................
x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No.1dfa lAW.. Diamete e,__® pth below inlet.................... Tot,,�l area.---��7•_sq. ft.
Z Other Distribution box ( ) DosingADep
01 � It-- Z- 77 � ��✓L
aPercolation Test Resul Performed by.. ...... �� .__. Date........................................
a Test Pit No. 1- 5 .-__-minutes per inch h of Test Pit.................... Depth to ground water,._-_.---__-_---•-_-----
(i Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
P --------------------- �.•......._._..i
w/........................ -------------------------------
Descnption of Soil.•••------•-..---Q ai .._ 7 �•�. l
(V] ------------------•----•--• -------/Q.:..-....1 ------- . ...--Zl� c j' - -.------------------------------.....-------•-------•-------------------•----•-•-----.....--
^ ...........................•---------i-...................................................................................................................._..............................................
UNature of Repairs or Alterations—Answer when applicable.-_---_•--------------------------------------•-...•--.-•---__-_---_---._.-...._-_-----------.-.
------------------------------------------•---------------•------•-------------------------•---•-------•----••-------------------------------------------......-----------•----•-------•-•••-••..••---.
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TI'i U 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
p p Si ne _
g
operation until a Certificate of Compliance has been issuedY the board of health.
-----
Date
Application Approved BY st !j- --------------------------•--•-- Date"
Application Disapproved for the following reasons:.............................................
------•.............................•......-. -----...--••--
.........---•-•------•----•--•-------•----------------------•-------------------•--------------..--....-----------------------••----•--•••-••-----•-•--•-•-------•-------------•------••--••-----•----•-
Permit No.......................................................... Issued ---=�M-•-- .-Date.................. ............
Date
r a
No.... Fiz$ .............._
THE COMMONWEALTH OF MASSACHUSETTS
BOARD 9F HEALTH
......... Qom'fV............OF��. • �".•�. .. .......---
Applirdtinn for DisVn,ia11 ,3,Vvrks Cnnnitrnr#inn ' rrnti#
Application is hereby made for a Permit to Construct ( } or Repair ( ) an Individual Sewage Disposal
System,, f ;
.._r.X. -------------------- ............ : ,.... k r
Loca Addres s Lot No.
..
..............•--------•- ............-_�._" �-r--...'-!/y .....................................................
Owner Address
Installer Address
Type,of Building r *, ;: Size Lot.� Q '......Sq. feet
ell)lingNo of Bedrooms...._ ...____ ....Ex ansLon Attic Garbage Grinder
aOther
Type of Building ...............................................................
...._.. No. of persons_ ._.... Showers ( ) — Cafeteria
dOther fixtures .....---•-•--------------•---. -------- ------ .
Design Flow
-- gallons per person per day l daily,flow _. • ............gallons.
R; Septic Tan —Li uidcaPacit - allo Length - Diameter:.. __ ------- Depth................
Disposal Trench No. e�th Total Length. Total leaching area =sq. ft.
x ...--•.•--- �,,�,�
Seepage Pit No�4I�. '��_ Diamet (+ + 'epth b ow inlet........... ..... To�f 1 area. .a;7.._sq. ft.
Z Other Distribution box ( ) Dosing )� .It- .2" �r
Percolation Test Res s Performed by. ._..a.. ":�.••• Dafe:
aTest Pit NO. I . .....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.......................
Of� .t _ t _ + .•--......
Description of Soil r «r _ ...............-- -- ..................................
..------------------- ---------- :..
W
-.cR
U Nature of Repairs or Alterations—Answer when applicable._........:.....................................................................................
Agreement
The undersigned agrees to install the aforedescribed Individual Sewage.Disposal System in accordance with
the provisions of TIT1Z :5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate.of Compliance has been issued by th board of health.
'
•� Sign ---
7 D to
A lication A roved B ! ....
PP PP Y-••••• •-
...... .. .................................. •--- .•7.7.__-
Date
Application Disapproved for the following reasons .........................
•••--•------••-••--- j-..................................................................................
___--_•________-.-•-----•-•-------•----------------- ---------------- ...........----• = p. - .a
r k Date
Permit No___________________ _______ ..... Issued.
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
"t", "If
f✓'�-r' ....... OF. lr �'. .........................................
�rdifirtttr;,of.(Suutphatta
THIS IS TO RTIFF That the Individual Sewage Disposal System constructed or Repaired ( )
by............ T j- !. .-4 ......................:...................................................
------------ -----------
' installer 4r
>c r
has been installed in accordance with the provisions of T �5 Y of The State Sanitary Coder as described in the
application for Disposal Works Construction Permit No. ......... .................... dated--_ _ .rl__ ?.7.........-......
THE ISSUANCE OF THIS CERTIFICATE SMALL NOT: BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION�SATISFACTORY.
DATE DATE._.. ..
1_
----- ----....•-••-•...................•-.__._ Ins pet �
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..................OF..:...: � 2.... ........_....._.....----.._.......-••.........
No
......................... FEE _.�.................
Disposal Work.5 CDnnntrrudinn andt
Permission is hereby granted----------------- - -----------_-
:------------------•------------------•--------•--.-.------.---_--
to Con het or epa` ( ) aA
ndiv�dual5ewa'e Dosal System
`7 ;
atN 1 _.. �? _ �±.._ ...... ��''� .� . .--- -•------------------------•-------------------------------------.._._...--••--
Street.
as shown on the application for Disposal zWorks Construction Perm No `,y �"��'�
--- t !'!t. Dated r ...........
-
�, tt Board of th
DATE---- ;...... w
FORM 1255�'HOBBS4&.WARREN, INC.. PUBLISHERS
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