HomeMy WebLinkAbout0042 WOLLEY ROAD - Health 42 WOLLEY ROAD.
A= 270— 167
Hyannis
I
I
TOWN OF BARNSTABLE
LOCATION SEWAGE #
"VILLAGE ASSESSOR'S MAP & LC?r,O IG-110)r
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACIL=: (type) (size)
NO. OF BEDROOMS
BUILDER OR OWNER
PERMITDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted.Groundwater Table to the 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 Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
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COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
David B. Mason, R.S,Certified Title V Inspector,508-833-2177
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 42 Wolley Road,Hyannis, MA
Owner's Name: Cohen S
Owner's Address: 250 Willow Street,West Roxbury,MA 02132
Date of Inspection: October 22,2009
Name of Inspector: (please print)David B.Mason
Company Name:-4 Glacier Path
East Sandwich,MA 02537
Telephone Number: 508-833-2177
F.t�ER�'IFICATION STATEMENT
Ficerti y that I have personally inspected the sewage disposal system at this address and that the information reported
%.elow0itrue,accurate and complete as of the time of the inspection.The inspection was performed based on my
ainin&and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP
c'approvied system 1mspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system:
U-
X_ Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails ,
Inspector's SignatL Date: �09
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 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 as inspected appears to have pass. An increase in occupancy may result in hydraulic
failure. The information as identified represents only the condition of the system on October 22,2009 at 1:00 PM.
****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: 42 Wolley Road,Hyannis, MA
Owner's Name: Cohen
Date of Inspection: October 22,2009
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
_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: Parking area should be defined to prevent parking on septic tank and pump chamber.
B. System Conditionally Passes:
One or more system components as described in the"Conditional Pass"section need to be replaced or
repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass.
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* 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:
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:
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: There is evidence that the septic tank is leaking. Effluent level is well below the outlet invert. There is
evidence of historic staining in the leaching pit with past indication of possible hydraulic failure.
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
Title 5 Inspection Form 6/15/2000 2
Page 3 of 11
PART A
CERTIFICATION(continued)
Property Address: 42 Wolley Road,Hyannis, MA
Owner's Name: Cohen
Date of Inspection: October 22,2009
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 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
"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:
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
Title 5 lnsnection Form 6/15/2000 3
Page 4 of 11
CERTIFICATION(continued)
Property Address: 42 Wolley Road, Hyannis Mills, MA
Owner's Name: Cohen
Date of Inspection: October 22,2009
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 SAS or cesspool
—NA_ 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''/z 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
_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 I 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.]
NO_(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.The system owner should contact the appropriate regional office of the Department.
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
Title 5 Inspection Form 6/15/2000 4
Page 5 of 11
PART B
CHECKLIST
Property Address: 42 Wolley Road,Hyannis, MA
Owner's Name: Cohen
Date of Inspection: October 22,2009
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?(INCLUDING THE SAS)
_X _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the
condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of
scum?
_X_ _ 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
_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)]
OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
Title 5 Insnection Form 6/15/2000 5
Page 6 of 11
PART C
SYSTEM INFORMATION
Property Address: 42 Wolley Road,Hyannis, MA
Owner's Name: Cohen
Date of Inspection: October 22,2009
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): 3_ Number of bedrooms(actual):3
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms):330
Number of current residents:
Does residence have a garbage grinder(yes or no):NO(Not Allowed)
Is laundry on a separate sewage system(yes or no):NO [if yes separate inspection required]
Laundry system inspected(yes or no):NA
Seasonal use:(yes or no):NO
Water meter readings,if available(last 2 years usage(gpd)): 2007; 1500gpd 2008;,4500 gpd
Sump pump(yes or no):NO
Last date of occupancy: Unknown
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): gpd
Basis of design flow(seats/persons/sqft,etc.):
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:Barnstable Board of Health
Was system pumped as part of the inspection(yes or no):
If yes,volume pumped: gallons--How was quantity pumped determined?
Reason for pumping: Pumping on October 15,2001
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):With pump chamber
Approximate age of all components,date installed(if known)and source of information: approx. 1996
Were sewage odors detected when arriving at the site(yes or no):NO
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
Title 5 Inspection Form 6/15/2000 6
Page 7 of 1 I
PART C
SYSTEM INFORMATION(continued)
Property Address: 42 Wolley Road, Hyannis, MA
Owner's Name: Cohen
Date of Inspection: October 22,2009
BUILDING SEWER(locate on site plan)
Depth below grade: Approx. 30 Inches
Materials of construction:_cast iron _X_40 PVC_other(explain):
Distance from private water supply well or suction line:_NA
Comments(on condition of joints,venting,evidence of leakage,etc.): Appears in good condition.
SEPTIC TANK: (locate on site plan)
Depth below grade: 10"
Material of construction:_X_concrete_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: Typical 1500 gallon tank
Sludge depth: 6 inches
Distance from top of sludge to bottom of outlet tee or baffle: 3 inches
Scum thickness: 5 inches
Distance from top of scum to top of outlet tee or baffle:3 inches
Distance from bottom of scum to bottom of outlet tee or baffle: 14 inches
How were dimensions determined: Actual
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels
as related to outlet invert,evidence of leakage,etc.) Tank appeared in good condition,tees in place at time of
inspection.
GREASE TRAP: N.A.
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.):
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
Title 5 Inspection Form 6/15/2000 7
Page 8ofII
PART C
SYSTEM INFORMATION(continued)
Property Address: 42 Wolley Road,Hyannis, MA
Owner's Name: Cohen
Date of Inspection: October 22,2009
TIGHT or HOLDING TANK:—N.A.—(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 last pumping:
Comments(condition of alarm and float switches,etc.):
DISTRIBUTION BOX:_X_(if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: Equal with 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.): Approx. 17 inches below grade. No leakage.Good condition.
PUMP CHAMBER:_NA_(locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no):
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
Title 5 Inspection Form 6/15/2000 8
Page 9 of 11
PART C
SYSTEM INFORMATION(continued)
Property Address: 42 Wolley Road, Hyannis, MA
Owner's Name: Cohen
Date of Inspection:October 22,2009
SOIL ABSORPTION SYSTEM (SAS):__(locate on site plan,excavation not required)
If SAS not located explain why:
Type
leaching pits,number:
X leaching chambers,number:—4 Infiltrators with 4'of stone_
_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,
etc.):No signs of hydraulic failure,Probed soil and no saturated soil,no ponding.
CESSPOOLS:_(cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration:
Depth—top of liquid to inlet invert: Above 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:_N.A._(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.):
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
Title 5 Inspection Form 6/15/2000 9
Page 10 of 11
PART C
SYSTEM INFORMATION(continued)
Property Address: 42 Wolley Road, Hyannis, MA
Owner's Name: Cohen
Date of Inspection: October 22,2009
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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Im Won'
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Title 5 Inspection Form 6/15/2000 10
Page 11 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 42 Wolley Road, Hyannis, MA
Owner's Name: Cohen
Date of Inspection: October 22,2009
SITE EXAM
Slope
Surface water
Check cellar (crawl space)
Shallow wells
Estimated depth to ground water_20 feet
Please indicate(check)all methods used to determine the high ground water elevation:
_X_Obtained from system design plans on record-If checked,date of design plan reviewed:
_X_Observed site(abutting property/observation hole within 150 feet of SAS)
_X_Checked with local Board of Health-explain:Recent Test Holes, Existing engineer records with BOH
_X_Checked with local excavators, installers-(attach documentation)
Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Utilized existing site design information on file with the Board of Health. Additionally,existing site and abutting
site topography does not indicate ground water to be within 4 feet of bottom of leaching facility.
Title 5 Inspection Form 6/15/2000 11
COMMONWEALTH OF MASSACHUSETTS :' �:
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS '
DEPARTMENT OF ENVIRONMENTAL PROTECTION
��Ay
' TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS 4F
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART'A h "
CERTIFICATION
j Property Address: 42 WOLLEY RD HYANNIS,MA 02601
Owner's Name: DECARVAHLO `-�.
Owner's Address: 42 WOLLEY RD HYANNIS,MA 02601 Y :
Date of Inspection: 11/5/01 �����® ¢ n
Name of Inspector: (please print) JOHN GRACI ®1 ;
Company Name: SEPTIC INSPECTIONS NQ� �+ '
Mailing Address: a' P.O.,BOX 2119 TEATICKET,MA.02536 ��g�RNST g�E
TOWH����H DEP
! Telephone Number: 508-564-6813 FAX 508-564-7270 ,; n Sx
CERTIFICATION STATEMENT '
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is'y'�,
true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and e $:
' 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: g '~
X Passes`
_ Conditionally P ses
_ Needs Furt valuation by the Local.Approving Authority
"r5 nox�
_ Fails
Inspector's Signature: Date: 11/5/01 r
The system inspector shall submit copy of this inspection report to the Approving Authority(Board of Health or DEP)wtthitt
..
30 days of completing this inspec on. If the system is a shared system or has a design now of 10,000 gpd or greater,the
E 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. A >
Notes and Comments
I THE SYSTEM PASSES TITLE V INSPECTION.RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE'
SYSTEMS USEFULL LIFE.RECOMMEND RAISING COVER TO INFULTRATORS 'ice;5�`
+ ****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 ��
t•, , r ri aj ,�,<,.
x YP
T;��,. c In ,•ti„., 17nr,n /,/I S/711 M1 1
Page 2 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS # `
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM "
PART A
CERTIFICATION (continued)
Property Address: 42 WOLLEY RD HYANNIS,MA 02601 '.
�.,
' Owner: DECARVAHLO i.°
Date of Inspection: 11/5/01 ;
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D �
S�.
A. System Passes:
�y
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.
y
Comments:
THE SYSTEM PASSES TITLE V INSPECTION.RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG,;" ;
THE SYSTEM'S USEFULL LIFE.RECOMMEND RAISING COVER TO INFULTRATORS
i B. System Conditionally Passes:
One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system;
upon completion of the replacement or repair,as approved by the Board of Health,will pass.
Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined"please explain Yr yy�
n/a The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,exhibitslo,
substantial infiltration or exfiltration or tank failure is imminent.System will pass inspection if the existing tank is replacedM1 '
with a complying septic tank as approved by the Board of Health.
s *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating,." ; 3
that the tank is less than 20 years old is available. 1 y
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 `.
iVi
pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board offi.
"* 4;
Health):
broken pipe(s)are replacedi `
'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
-Sbt
1 inspection if(with approval of tile' Board of Health): 'x
f t 5
+ _broken pipe(s)are replaced h
_obsti ruction is removed ' '
yF.
_ r t L � ..
ND explain: n/apt
et,
Page 3 of 11 .. .4
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ,
PART
'Y
CERTIFICATION(continued)
Property Address: 42 WOLLEY RD HYANNIS,MA 02601
Owner: DECARVAHLO X' f
,
w�.
Date of Inspection: 11/5/01
,Rif- .
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. s. '
1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is':a jri:
not functioning in a manner which will protect public health,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
ru,
2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the ' Y
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. u'
_ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply.
{ p .
_ 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 y
supply well".Method used to determine distance n/a t
"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 copyi
of the analysis must be attached to this form.
3. Other:
j n/a :-
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Page 4 of I 1 :Y ;
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS : <
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A j
CERTIFICATION(continued) ,`- �}
Property Address: 42 WOLLEY RD HYANNIS,MA 02601
Owner: DECARVAHLO
! Date of Inspection: 11/5/01
,s
D. System Failure Criteria applicable to all systems: r "
You must indicate"yes"or"no"to each of the following for all-inspections: k� '
�, R.r °`s•.
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 NOT due to clogged or obstructed pipe(s).Number of times ;.F ,
pumped nla. w 's
_ X Any portion of the SAS,cesspool or privy is below high ground water elevation. r
_ X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. rat
X Any portion of a.cesspool or privy is within a Zone I of a public well.
X An portion of a cesspool or privy is within 50 feet of a private water supply well. 1
- YP p P "Y P PPY
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 f
no acceptable water quality analysis. This system asses if the well water analysis,performed at a DEP ,F
p q Y Y ] Y P Y +P ,.... , a.
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 0r4jj
less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be t -
attached to this form.] �yK �.
(Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in310
CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be
i necessary to correct the failure.
E. Large Systems: 4
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) a,
F � w ;
yes no
X the system is within 400 feet of a surface drinking water supply N =
X the system is within 200 feet of a tributary to a surface drinking water supply
in 20
_ X the system is located in,' nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped '-
{ Zone lI 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 threaars :
under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner ,Innj ;
should contact the appropriate regional office of the Department.
°r rat
{
Page 5 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS ;`
' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM 'w; ac
PART B . s:,
CHECKLIST #
Property Address: 42 WOLLEY RD HYANNIS,MA 02601 s
Owner: DECARVAHLO
Date of Inspection: 11/5/01
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? ;
X _ Has the system received normal flows in the previous two week period? X:
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) + S
X _ Was the facility or dwelling inspected for signs of sewage back u ?
X _ Was the site inspected for signs of break out
wt:
e T G7
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
of liquid,depth of sludge and depth of scum?bales or tees,material of construction,dimensions,depth
X _ Was the facility owner,(and occupants if different from owner)provided with information on the proper maintenances L
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 =
X _ Existing information. For example,a plan at the Board of Health. l ,
X _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is w.
unacceptable)[310 CMR 15.302(3)(b)]
e
e ��a
Page 6 of 11 �
y ti
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS x
f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
tlst
SYSTEM INFORMATION 17
Property Address: 42 WOLLEY RD HYANNIS,MA 02601 3 4
Owner: DECARVAHLO
Date of Inspection: 11/5/01
FLOW CONDITIONS
RESIDENTIAL ,
Number of bedrooms(design):3 Number of bedrooms actual 3
j DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms):330 a• f ?.
Number of current residents: 5 .
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] J�^
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 pumpes or no): NO
a Last date of occupancy: n/a
COMMERCIAL/INDUSTRIAL E
Type of establishment: n/a
! Design flow(based on 310 CMR,15.203):,n/agpd
Basis of design flow seats/ ersons/s ft etc.): n/a
Grease trap present(yes or no): NO Y
n 18�,
Industrial waste holding tank present(yes or no):NO
Non-sanitary waste discharg4to"the Title 5 system(yes or no):NO
1 Water meter readings, if available: n/a
4 Last date of occupancy/use: n/a v
OTHER(describe): n/a
GENERAL INFORMATION ;'
Pumping Records 3
Source of information: n/a y
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 .frs.
A v.�
i TYPE OF SYSTEM ,
X Septic tank,distribution box,soil absorption system ��v
Single cesspool
{ _Overflow cesspool
_Privy
_Shared system(yes or no)(if yes,attach previous inspection records,if any) R .
_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 `
— �.
i Other(describe): n/a
i
Approximate age of all components,date installed(if known)and source of information:
1971
Were sewage odors detected when arriving at the site(yes or no):NO * "
i
Page 7 of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C s
SYSTEM INFORMATION(continued)
Property Address: 42 WOLLEY RD HYANNIS MA 02601
Owner: DECARVAHLO 14,
Date of Inspection: 11/5/01
i_ yr:
BUILDING SEWER(locate on site plan) '
Depth below grade: 14"
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 WATER
SEPTIC TANK: X(locate on site plan) ;
Depth below grade: 8" `
Material of construction: Xconcrete_metal_fiberglass_polyethylene other(explain)n/a x
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)
i Dimensions: 1000G L 8' 6" H 5' 7"W 4',10"" ?;
Sludge depth: 1" .
Distance from top of sludge to bottom of outlet tee or baffle:33" ;;
Scum thickness: 1"
Distance from top of scum to top of outlet tee or baffle: 6" r
Distance from bottom of scum to bottom of outlet tee or baffle: n/a ;
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: 4 ;
USEFUL LIFE SYSTEM.
GREASE TRAP:_(locate on site!plan) -'
4.
Depth below grade: n/a
1 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
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.):''
t" r
n/a
a
r^.
,1 7
Page 8 of 11
f }}
4
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS : ,
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 42 WOLLEY RD HYANNIS,MA 02601
Owner: DECARVAHLO
Date of Inspection: 11/5/01
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 ='M'
DISTRIBUTION BOX:X(if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: LEVEL WITH BOTTOM OF PIPE h
Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into'' ''�3'
or out of box,etc.): . , `
BOX IS STRUCTURALLY SOUND. k'F
PUMP CHAMBER: _(locate on site plan)
Pumps in working order(yes or no): NO
Alarms in working order(yes or no):NO
r• �-
jComments(note condition of pump chamber,condition of pumps and appurtenances,etc.): `.
1 n/a
' L
s 1:
j FK
L
i
Page 9 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS '` E`
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM : {�
PART C
SYSTEM INFORMATION(continued)
Property Address: 42 WOLLEY RD HYANNIS,MA 02601
Owner: DECARVAHLO
Date of Inspection: 11/5/01
F
SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required)
If SAS not located explain why:
i n/a
Type ?%
n/a leaching pits, number: 0
i INFULTRATORS leaching chambers, number: 1
' n/a leaching galleries, number: n/a `a
n/a leaching trenches, number, length: n/a t, .
n/a leaching fields, number: nla s -
n/a overflow cesspool, number: n/a w;
n/a k 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.): f
THE LEACH FIELD IS FUNCTIONING PROPERLY.THE SYSTEM SHOWS NO SIGNS OF FAILURE. Ars*
RECOMMEND RAISING COVER TO FIELD-BOTTOM AT 7'
shTA„
CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) p
Number and configuration: n/a
Depth—top of liquid to inlet invert: n/a .
Depth of solids layer: n/aJL
'
Depth of scum layer: n/a
Dimensions of cesspool: n/a '
Materials of construction: n/a
Indication of groundwater inflow(yes or no): NO 7 �'
Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
n/a
PRIVY: (locate on site plan) "
YK y
Materials of construction: n/a .E�
Dimensions: n/a f S "
Depth of solids: n/a
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): 7iyl
n/a a4 ,.
e
Page 10 of I I r;"
's Y,
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
! SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
3T
PART C '�
s �a
SYSTEM INFORMATION(continued)
Property Address: 42 WOLLEY RD HYANNIS,MA 02601
Owner: DECARVAHLO
Date of Inspection: 11/5/01 =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. zK
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Page 11 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 42 WOLLEY RD HYANNIS,MA 02601
Owner: DECARVAHLO
Date of Inspection: 11/5/01
SITE EXAM
_Slope
_Surface water
_Check cellar
Shallow wells
Estimated depth to ground water 10+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/af
NO Checked with local excavators,installers-(attach documentation)
NO Accessed USGS database-explain: n/a
4
You must describe how you established the high ground water elevation: _
GROUNDWATER DETERMINED BY AUGER- 10' NO WATER ENCOUTERED
• L'
4.
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vr:
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFF
Liy �
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UFPARTNIENT OF ENVIRONMENTAL PR TPN
• ON X(INTFR STRFF.1. 130STON. NIA 02109 hl#-292-5 C�'
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W11.1 IAM F 11 FLh 9& T C(1XF.
CiOvernor 350 MAIN STREET s' Sccrcly\
& WEST YARMOUTH,MA �' �� STR1111C
ARGFO PAl 11-CI.l_I.l1CC1 508-775-2800
1.I Govcmor t Commissir,ncr
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
I- CERTIFICATION
MAP 270 PAR 167
PROPERTY ADDRESS: 42 WAY ROAD, HYANNIS ADDRESS OF OWNER:
DATE OF INSPECTION: OCTOBER 15,1998 DUDA,DAVID
NAME OF INSPECTOR: JAMES D.SEARS
I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 9310 CMR 15.000)
COMPANY NAME: A&B Canco
MAILING ADDRESS: 350 Main Street,West Yarmouth,MA 02673
TELEPHONE NUMBER: (508)775-2800
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,
accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper
function and maintenance of on-site sewage disposal systems. The system:
�l PASSES
CONDITIONALLY PASSES
NEEDS FURTHER EVALUATION BY THE LOCAL APPROVING AUTHORITY
FAILS
INSPECTORS SIGNATURE: 04zmDATE: OCTOBER 21, 1998
The system Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this
inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall
submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the
system owner and copies sent to the buyer,if applicable and the approving authority.
INSPECTION SUMMARY: Check A, B, C, or D:
A] SYSTEM PASSES:
vl I have not found any information which indicates that the system violates any of the failure criteria as defined in
310 CMR.15.303. Any failure criteria not evaluated are indicated below.
COMMENTS: SITE OVER ALL PASSES, INSPECTION OF SYSTEM IS BASED ON CONDITION OF SYSTEM
AT THE TIME OF THE INSPECTION.THERE IS NO GUARANTEE ON THE LIFE OF THE SYSTEM.
B SYSTEM CONDITIONALLY PASSES:
N/A One or more system components as described in the"Conditional Pass"section need to be replaced or
repaired. The system,upon completion of the replacement or repair,as approved b the Board of Health,will
pass.
Indicate yes,no,or not determined(Y,N,or NO). Describe basis of determination in all instances. If"not determined",
explain why not)
The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of
_ a Certificate of Compliance(attached)indicating that the tank was installed within twenty(20)
Years prior to the date of the inspection;or the septic tank,whether or not metal,is cracked,structurally
unsound,shows substantial infiltration or exfiltration,or tank is 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.
Page 1 of 10
(Revised 04/25/97)
DEP on the World Wide Web:http://www.magnet.state.ma.un/d
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (CONTINUED)
Property Address:
Owner:
Date of Inspection:
B]SYSTEM CONDITIONALLY PASSES(continued)
Sewage backup or breakout or high static water level observed in the distribution box is due to
broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. The system will
pass inspection if(with approval of the Board of Health). Describe observations:
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
C]FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
Conditions exist which require further evaluation by the Board of Health in order to determine if the system
is failing to protect the public health,safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES 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 PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
The system has a septic tank and soil absorption system(SAS)and the SAS is within
100 feet to a surface water supply or tributary to a surface water supply.
The system has a septic tank and soil absorption system and the SAS is within a Zone
1 of a public water supply well.
The system has a septic tank and soil absorption system and the SAS is within 50 feet
of a private water supply well.
The system has a septic tank and soil absorption system and the SAS is less than 100
feet but 50 feet or more from a private water supply well,unless a well water analysis for
coliform bacteria and volatile organic compounds indicates that the well is free from
pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen and
nitrate nitrogen is equal to or less than 5 ppm. Method used to determine distance
(approximation not valid).
3) OTHER
(Revised 04/25/97)
Page 2 of 10
r
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 42 WOLLEY ROAD,HYANNIS
Owner: DUDA,DAVID
Date of Inspection: OCTOBER 15,1998
D]SYSTEM FAILS:
You must indicate either"Yes"or"No"as to each of the following:
N/A 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.
Yes No
Backup of sewage into 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 over-
loaded 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''V2 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 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:
You must indicate either"Yes"or"No"as to each of the following:
The following criteria apply to large systems in addition to the criteria above:
N/A 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:
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
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 04/25/97)
Page 3 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 42 WOLLEY ROAD,HYANNIS
Owner: DUDA,DAVID
Date of Inspection: OCTOBER 15, 1998
Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following:
Yes No
�l Pumping information was provided by the owner,occupant,or Board of Health.
None of the system components have been pumped for at least two weeks and the system
has not 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.
As built plans have been obtained and examined. Note if they are not available with N/A.
�- The facility or dwelling was inspected for signs of sewage back-up.
—� The system does not receive non-sanitary or industrial waste flow.
The site was inspected for signs of breakout.
�— All system components,including 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:
�l The facility owner(and occupants,if different from owner)were provided with information on
the proper maintenance of Sub-Surface Disposal System.
Existing information.Ex. Plan at B.O.H.
Determined in the field(if any of the failure criteria related to Part C is at issue,approximation
of distance is unacceptable)[15.302(3)(b))
(Revised 04/25/97)
Page 4 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 42 WOLLEY ROAD,HYANNIS
Owner: DUDA,DAVID
Date of Inspection: OCTOBER 15, 1998
FLOW CONDITIONS
RESIDENTIAL:
Design flow: 330 g.p.d./bedroom for S.A.S.
Number of bedrooms: 3
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(last two(2)year usage(gpd): 47936 GAP PER YEAR
Sump Pump(yes or no): NO
COMMERCIAL/INDUSTRIAL:
Type of establishment:
Design flow: gallonstday
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 occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
NONE
System pumped as part of inspection:(yes or no) NO
If yes, volume pumped: Gallons
Reason for pumping
TYPE OF SYSTEM
Septic tank/distribution box/soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system (yes or no)(if yes, attach previous.inspection records, if any)
I/A Technology etc. Copy of up to date contract?
Other
APPROXIMATE AGE of all components,date installed(if known)and source of information:
1996 PERMIT#96-429
Sewage odors detected when arriving at the site:(yes or no) NO
(revised 04/25/97)
Page 5 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 42 WOLLEY ROAD,HYANNIS
Owner: DUDA,DAVIDQ
Date of Inspection: OCTOBER 15,1998
BUILDING SEWER: N/A
(Locate on site plan)
Depth below grade:
Material of construction cast iron 40 PVC other(explain)
Distance from private water supply well or suction line
Diameter
Comments:(condition of joints,venting,evidence of leakage,etc.)
SEPTIC TANK: 4
(Locate on site plan)
Depth below grade: 8"
Material of construction X concrete metal Fiberglass Polyethylene other(explain)
If tank is metal,list age Is age confirmed by Certificate of Compliance (Yes/No)
Dimensions: 1,500 GALLON PRE CAST
Sludge depth: 1"
Distance from top of sludge to bottom of outlet tee or baffle: 32"
Scum thickness: 0"
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: 15"
How dimensions were determined ASBUILT&TAPE
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.)
TANK AT WORKING LEVEL,OUTLET TEE TANK AND COVERS 8"BELOW GRADE.
GREASE TRAP: N/A
(locate 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:
(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 04/25/97)
Page 6 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 42 WOLLEY ROAD,HYANNIS
Owner: DUDA,DAVID
Date of Inspection: OCTOBER 15, 1998
TIGHT OR HOLDING TANK: N/A (Tank must be pumped prior to,or at time,of inspection)
(Locate on site plan)
Depth below grade:
Material of construction _ concrete _ metal _ Fiberglass _ Polyethylene _ other(explain)
Dimensions:
Capacity:
Design flow: gallons/day
Alarm level: Alarm in working order _ Yes; _ No
Date of previous pumping:
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: 0
Comments:
(note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc,)
D-BOX IS 16"X 16", 16"BELOW GRADE,ONE LINE IN,ONE LINE OUT.BOX IS CLEAN,SOLID AND LEVEL
PUMP CHAMBER: N/A
(locate on site plan)
Pumps in working order:(Yes or No)
Alarms in working order(Yes or No)
Comments:
(note condition of pump chamber,condition of pumps and appurtenances,etc.)
(revised 04/25/97)
Page 7 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
. Property Address: 42 WOLLEY ROAD,HYANNIS
Owner: DUDA,DAVID
Date of Inspection: OCTOBER 15, 1998
SOIL ABSORPTION SYSTEM(SAS):4
(locate on site plan,if possible;excavation not required,but may be approximated by non-intrusive methods)
If not determined to be present,explain:
Type:
leaching pits, number:
leaching chambers,number: 4 INFILTRATORS
leaching galleries,number:
leaching trenches,number,length:
leaching fields,number,dimensions:
overflow cesspool, number,
Alternative system:
Name of Technology:
Comments:
(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.)
LEACHING IS 4'BELOW GRADE, PROBED ABOVE AND AROUND LEACHING,CAME UP DRY. UNABLE TOOPEN
AS LEACHING IS 4'BELOW GRADE AND INFILTRATORS NO SIGN OF WET GROUD ON PROBLEMS INBOX.
CESSPOOLS: N/A
(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(cesspool must be pumped as part of inspection)
Comments::
(note condition of soil,signs of hydraulic failure, ,level of ponding,condition of vegetation,etc.)
PRIVY: N/A
(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 04/25/97)
Page 8 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C.
-,; SYSTEM INFORMATION(continued)
Property Address: 42 WOLLEY ROAD,HYANNIS
Owner: DUDA, DAVID
Date of Inspection: OCTOBER 15, 1998
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100(locate where public water supply comes into house)
�P
33
3g �9•
(revised 04/25/97)
Page 9 of 10
TOWN OF BARNSTABLE /•vSPt cTa,L
I,QCATION ya2 I,yaLL£% ®P3 SEWAGE# 3/,;Z9
VILLAGE ASSESSOR'S MAP & LOT 90 1 `�
.INSTALLER'S NAME & PHONE NO. A & B CANCO 775-6264
SEPTIC TANK CAPACITY /S-,ov x4z-
LEACHING FACILITY:(type) y /ti/=/L17`- Tot (size)
NO. OF BEDROOMS)PRIVATE.PRIVATE WELL-O PUBLIC WATE
BUILDER OR OWNER 7�04
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No
..' °�. O �
� `® `^_
�,J
� � w
� � _
M
a
TOWN OF BARNSTABLE f
LOCATION "Mri RD SEWAGE # /fit '' 9
VILLAGE ASSESSOR'S MAP & LOTR 70—/d(7
INSTALLER'S NAME&PHONE NO. rO � ��� %�' �
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) (size)
NO. OF BEDROOMS - 2
BUILDER OR OWNER /J-&
PERMITDATE: xff Z�P-% 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 Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
► \ 1
� o -•A
v1
r
s (1
�r 9
i
b O
Afl
Fee
No:
THE COMMONWEALTH OF ASSACHUSETTS
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS
Z(ppliLotion for Mj.5pool *pgtem Com5trurtton Verna
Application is hereby made for a Permit to Construct( )or Repair( an On-site Sewage Disposal System at:
Location Address or Lot No. O er's Name,Add s and Tel.No.
kl
Lai
Installer's Name,Address,and Tel.X& B CANCO Designer's Name,Address and Tel.No.
' ✓ �'8�� 113��50 Main Street ��14
Type of Building:
Dwelling No.of Bedrooms Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Description of Soil
Na;7 of Rep/vairs or Alterations(Answer when applicable) ���Dp � �/C
( r b// ` l
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmen Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued by this Bo H h.
Signe Date
Application Approved by e
Application Disapproved for the following reasons
Permit No. Date Issued
———————————————————————————————————————
� .+ ..1 -y -.�.7�.Y�.- �"r. �.l .t-�t'., .�.. .+•vA•.•+....JY•.-✓ ...iW a .... '` _ +•4.i,�_.�V�i. .�W"•�. l�'"^.. •.r.�.,.'i. �..- .. ''•• r •q
No.
•. � Q Fee
THE COMMONWEALTH OF ASSACHUSETTS
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS
Appticattan fof Mt$ oat !Aem Cori.5truction ermtt
n n-site Sewage Disposal System at:
Application is hereby made for a Pe t to Construct( )or Repair( a O g p y
i
Location Address or Lot No. A Ow er's Name,Add and Tel.No.
r s
ye
Installer's Name,Address,and Tgl.�o. Designer's Name,Address and Tel.No.
0 �� H ,y 8 CANC� N/
351 Main Street
1 Type of Building:
Dwelling No.of Bedrooms Garbage Grinder( )
Other Type of Building No. of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Description of Soil .
1�
Na re of Repairs or Alterations(Answer when ap licable) l— /J"00 Q i
GZ t d v as<1P arm`fJ / ' u n d r r"
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environnmen Code and not to place the system in operation until a
Certifi-cate of Compliance has been issued by this Bo H h.
Signe Date o�
Application Approved by
Application Disapproved for the following reasons
J Permit No. Date Issued
r'
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS F
Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal System installed( )or epaired/replaced( on ;
by for
as t J / constru led in accordanc
with the provisions of Title 5 nd the for Disposal System Construction Permit No. dated-
Use of this system is conditioned on compliance with the provisions belo :
100,
No. Fee .r
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
lwiopaal *p5tem COn!tructton Vermtt
Permission is hereby granted to
to construct( )repair(wo*�an On-site Sewage System located at
and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to
comply with Title 5 and the following local provisions or special condition
All construction must be om le d wit in two years of the date below.
Date: Approved by i I � _ o i