HomeMy WebLinkAbout0048 CYPRESS POINT - Health 48 Cypress Point —lilt
Barnstable P
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YOU WISH TO OPEN A BUSINESS?
For Your Information: Business certificates (cost$30.00 for years). A business certificate ONLY REGISTERS
you must do by M.G.L.-it does not give you.permission to operate.) Business Certificates are available at the Town YOUR
's Offi NAME m town ,which
Main Street, Hyannis, MA 02601 (Town Hall) ice, 1"FL., 367
DATE:
APPLICANT'S Fill in please:
,� YOUR NAME/S: -
�Y '+ w�� BUSINESS %JM/�- /�
�3rk,61 '. YOUR HOME ADDRESS
xx
TELEPHONE #. Home Tele hone Nu
P tuber' Sc r Z��• 3 .� ,
p�.
NAME OF CORPORATION: •
NAME OF NEW:BUSINESS
1S THIS A HOME OCCUP TYPE ATION ES Y NO
ADDRESS.OF BUSINESS
PE OF BUSINESS ih ��f�_
.r v�MA R P/PARCEL NUMBE
U (AsseSsin
When starting a new business there.are several things you must do in order to be in with the rules and regulations gJ
Barnstable..This form is intended.to assist you in obtaining the information you may need. You MUST GO TO 200 Main St.ns of Town.of
Rd. & Main Street) to make sure you have the appropriate permits and licenses required to legally;operate your business in this town.
1. BUILDING COMM K R'S OF CE`
This individual a b infor e f a p
it requirements that pertain to this type of busines RtJL T COMPLY WITH HOME OCCUP
COMMENT Author ed Signat r ES AND REGULATIONS. FAILURE TI N
1, COMPLY MAY RESULT IN FINES.
2. -BOARD OF HEALTH
This individual has ee inform d per �uireme at, ertain to this e of business.
p typ
Authorized Sig ture**
COMMENTS:
3. CONSUMER AFFAIRS, (LICENSING AUTHORITY)
This individual has been informed of the licensing requirements that pertain to this type of business.
Authorized Signature**
COMMENTS:
i " '.•+ _ 9
L(.)MMONW'f:nl.'fH 01� MASSACI-RJS;f,T`C�- �}
ExixuTIV[ nh[�[(,l�,Of� ENVIRONMENTAL Ai, hALRS
d DEPARTMENT or,,ENVIRONMENTAL PROTECTION.
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Map: Lot:
Par: `
TITLE 5
OFFICIAL INSPECTION FORM— NOT FOR VOLUNTARY A'SSESSMENTSTx
SUBSURFACE SEWAGE DISPOSA a, .
- PART A
_ CERTIFICATION
Property Address:_48 Cypress Point- Cummaquid 1
MAY 1 , 2004
_Barnstable_ 1
Owner's Name: William & Mary'ingram_` v # °` '•TOWN OF BARNSTABLE .
Owner's Address: _640 Pelham Rd.#31) HEALTH DEPT.
_New Rochelle,N.Y. 10805
Date of Inspection:_4/29/04_ .
Name of Inspector: Dion C. Dugan
Company Name:_ 1543 Main St.
Mailing Address: Brewster,MA 02631r '
Telephone Number:_508-896-9390:
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:
r X= Passes
Conditionally Passes 4 y w
-Needs Further Evaluation by,the,,!.Deal Approving°Authority .;
t Fails t -
Inspector's Signature.` Date. 4/29/04
* �.
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 *Recommend,, Maintenance pumping' 5 yrs �,
****This report only describes conditions at the time of inspection and tinder 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.
Page 2 of I I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE.,SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A Y
rCERTIFICATION 'continued)"'
Property Address:_48 Cypress Point Cummaquid "
_Barnstable_
Owner's Name:_William & Mary Ingram
Date of Inspection:_4/29/04_
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of.Section.D
A. System Passes:
_X_ 1 have not found any information which indicates that any,of the failure criteria described in 3,10 CMR
15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below.
Comments:
B. System Conditionally,Passes
y
N/A One or more system components as described in the"Conditional Pass"section need to be replaced or
repaired. The s stem a on completion of the replacement or repair,as roved b the.Board of Health will ass. r `=
P Y , P P P . P , approved�Y p -
. Tl.,• - .. a ,. 34 v
Answer yes,no or not determined(Y,N,ND)in the for the following statements. If `not determined"please
explain. zRF c
The septic
is tank is metal and
over
e 20 "ears old or theseptic`tank wh P ether meta� r `
YI o not is structural) .
Y
unsound exhibits substantial infilt
ration or exfiltration or tank failure is immin ent: System will pass inspection if the•T
existing tank is replaced with a complying septic tank"as approved by the Board of•Health. .
• T P
*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 a "
obstructed pipe(s)or due to a broken;settled or uneven distribution box. System will pass inspection if(with
approval of Board of Health) . `.
.. _
b oken'pipe(s)are replaced'
` obstruction is removed
distribution box is leveled or replaced
ND explain N ,
The s stem re uired um in more than 4 times a car-due,to broken oi•obstructed Y Q P P„ b Y pipe(s). The system' will
pass inspection if(with approval of the Board of Health): "
broken pipes)are replaced' �- u' , •_ x•a•' A.
obstruction is removed _
ND explain: i
t•
Page 3 of' I I
OFFICIAL INSPECTION FORM - NOTTOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A },,t
CERTIFICATION(continued).
Property Address:_48 Cypress Point Cummaquid '
_Barnstable
Owner's Name:_William & Mary Ingram_
Date of Inspection:_4/29/04_
C. Further Evaluation is Required by the Board of Health:
N/A 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. 4
1. System will pass unless Board of Health determines in accordance with 310 CMR 15303(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
j
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. .
- } ,. -. .- a J. ' �• e. •!`mob k 1' .
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
y tic tank and SAS and the SAS is less than 100, feet
Pf 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.''
IN
3. Other:-
t " r
w
i
n 4
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Page 4 of I IA.
4� ;� a
OFFICIAL INSPECTION FORM-NOT FOR VOL'UNTARV ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL,SVSTEM INSPECTION FORM
4 CERTIFICATION (co itinued)
Property Address:_48 Cypress Point ,Cummaquid'.w r , ' f,' r ,,_ ,
k
_Barnstable .. -.• sa ,, , ::
Owner's Name: William & Mary Ingram`
Date of Inspection: '4/29/04_
D.' System Failure Criteria applicable to all systems g '
You must indicate"yes"or 'no"to each of the following for all inspections A�' ..
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 ;
_ _X_ Static liquid level in the distribution'box above,outlet'invert due io an overloaded or clogged SAS or F
cesspool 1
_X_ Liquid depth in cesspool is-less than 6"below invert or available volume is less than ''%Iday flow r y
_X_ Required pumpi
ng more than 4 tim
es in the last year NOT
due to clogged or obstructed pipe(s).
Number of times pumped z
_X Any portion of the SAS;,cesspool or pnvy 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 wiihin'50 feet of a private water supply,well.' ` ~
X An portion of a cesspool.or privy is less than 100 f— Y P P P vy feet but realer than SO feet from a private water
g— — _
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)PThe system fails.l have determined that one or more of the above failure«criteria exist as
a described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of
Health to;determine whatwill be necessary to correct'the failure.
E. Large Systems'N/A`
To be considered a large system the system must serve a facility with a design flow"of 10,000 gpd--to 15,000
gpd. M
You must indicate either.;"yes"or"noi%to each of the following: .' f
(The following criteria apply to large systems in addition to the criteria above)
es no a `r
r _N/A'._ the system is within 400 feet of a surface drinking water supply
r.
_N/A_ the system is within 200 feet of a tributary to a surface drinkingwater supply" .} •' ,a ",.
_N/A_ the system is-located in a n►tr6gen sensitive area(interim Wellhead Protection Area IWPA)`or a mapped
Zone Il 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 of Ice of the Department.
Page 5 of I I
.. 4'':� �+ha .. .; -�.4... i F ;Cp lei• -
OFFICIAL INSPECTIONFORM = NOT'FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
a . PART B ,
CHECKLIST
Property Address: 48 Cypress Point Cummaquid'
_Barnstable
Owner's Name:_William& Mary Ingram
Date of Inspection:_4/29/04_
- _.�, ems. � ,, ,� t'I' $#F•. y.:�3 •
Check if the following have been done. You must indicate"yes"or"no"as to each of the following:
Yes No
• . F
X Pumping information was provided b the owner,occu ant r,_ _ o .Board of Health
— P g a P Y ,
P _
_X. Were any of the system components pumped out in the previousawo weeksor
'
_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 backup'? '
_X_ _ Was the site inspected for signs of break out
41
_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 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 ?
r M s t }u
The size and location of fhe'Soil Akisorption System;(SAS)on the sife:has been determinedbased oil:
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))
r
s
OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 48 Cypress Point Cummaquid,
Barnstable_
Owner's Name: 'William & Mary Ingram
Date of Inspection:_4/29/04_
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:_2
Does residence,have a garbage grinder(yesMor no): no F
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):_yes
Water meter readings,if available(last 2 years usage(gpd)): 2002:. 168,E F '2003:`92,000
Sump Pump(yes or no):_no_ .
Last date of occupancy:_weekends/summer
COMMERCIALANDUSTRIAL: .N%A
Type of establishment: N/A
Design flow(based on 310 CMR 15.203): gpd
Basis of design flow(seats/persons/sgft,etc.): -
Grease trap present(yes or no):
Industrial waste holding tank present es or no
Non-sanitary waste discharged to the Title 5 system(yes or no):
Water meter readings, if available:
Last date of occupancy/use:
.ee .lw
OTHER(describe):
GENERAL INFORMATION r
Pumping Records a u „ • ,h -
Source of information:_pumped 500 gal. 3/20/98; owner '
Was system pumped as part of the inspection(yes or no): NO_
If yes, volume pumped: gallons--How was quantity pumped determined? `
Reason for pumping:--, A
TYPE OF SYSTEM
_Septic tank,distribution box,soil absorption system.
_X_Single cesspool t
_X_Overflow,cesspool
_Privy r
NO_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) F r,
_Tight tank.', _Attach a copy of the DEP approval t,
—Other(describe):
_—.. of e3
Approximate age of all components,date installed(if known)and source of information:
_Installed_1974 B.O.H. Records
Were sewage odors detected when arriving at the site(yes or no): NO
N -
Pagc 7 of I I y %r
OFFICIAL INSPECTION3FORM`— NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SVSTEM INSPECTION FORM
PART C
SVSTEM INFORMATION (continued)
Property Address:_48 Cypress Point Cummaquid
_Barnstable ;
Owners Name:_William & Mary Ingram
Date of Inspection: 4/29/04_ -F
BUILDING SEWER(locate on site plan)
f
Depth below grade:_3'_
Materials of construction _cast iron -X 40 PVC other(explain):
Distance from private water supply well or suction line: N/A
Comments(on condition of joints, venting,evidence of leakage,etc.):
, , .
_Joints are tight,venting is through the roof,no signs of leakage. '
I .
SEPTIC TANK: no locate on site plan)
�~ 1
_ _ P )
Depth below grade: 4,
Material of construction: concrete metal fiberglass" polyethylene'
_other(explain) — —
If tank is metal list age: Is age confirmedby'a Certificate of Compliance(yes or no):f'�_(attach a copy of
certificate) '
Dimensions:
Sludge depth
Distance from top of sludge to bottom of outlet tee or baffle:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle: Y
How were dimensions determined:
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity,* liquid levels
q
as related to outlet invert,evidence of leakage, etc.): t -
*Recommend: Maintenance pumping every 31-5 yrs.
P.
GREASE TRAP: N/A locate on site plan)
Depth below grade:
Material of construction:_concrete metal fiberglass polyethylene r r other
(explain): —. <
Dimensions: �• e
Scum thickness:
Distance from top of scum to top of outlet teeor baffle'
Distance from bottom of scum to'bottom of outlet tee or'baffle .`'
Date of last pumping: ' 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.):
Page 8 of I IJt
,
afi
F O FICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM. INSPECTION FORM
PART C
SYSTEM INFORMATION('continued)
Property Address: _48 Cypress Point. Cummaquid � '' ,
_ Barnstable
Owner's Name:_William& Mary Ingram
Date of Inspection:_4/29/04V.
_
rr
TIGHT or HOLDING TANK:_N/A_(tank must be pumped at time of inspection)(locate on site plan)
Depth below grade: Y
Material of construction.-. concrete fiberglass_polyethylene other(ezplain)I'
Dimensions: F r
Capacity: _ gallons
Design Flow: _ Qallons/day, ,a
Alarm present(yes or no):
Alarm level: -Alarm in working order(yes or no):
Date of last pumping: f.
Comments(condition of alarm and float switches,etc.): {
. e
DISTRIBUTION BOX:_none_(if present must be opened)(locate on site plan) t 41, '
Depth of liquid level above outlet invert:
Comments(note if box is level and distribution to outlets'equal,any evidence sof solids carryover,,any evidence of
leakage into or out of box,etc.): "
PUMP CHAMBER:_N/A_(locate on site plan)
Pumps in working order(yes or no)
Alarms in working order(yes or,no)
I�
Comments(note condition of pump'chamber,condition of pumps and appurtenances,etc)". '
n , -
2.
z
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)'
Property Address: 48 Cypress Point Cummaquid
Barnstable
Owner's Name:_William& Mary Ingram_ �, "
Date of Inspection:_4/29/04
SOIL ABSORPTION SYSTEM (SAS):_YES_(locate on site plan,excavation not required)
If SAS not located explain,why:
y
Type c
_X_leaching pits,number:_one 6' x 6' pit w/stone
leaching chambers,number: `
leaching galleries,number:
leaching trenches, number, length: a
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.): Pit found dry,no staining,no sign failure.
CESSPOOLS: _YES_(cesspool mustibe pumped as part of inspection)(locate on site plan)
Number and configuration:_one converted cesspool w/outlet tee .
Depth—top of liquid to inlet invert: 14" ,
Depth of solids layer: 5" v z
Depth of scum layer: 1"
Dimensions of cesspool:_6'x 6'-P f
Materials of construction: it
Indication of groundwater inflow(yes or no): no
Comments(note condition of soil,signs of hydraulic.failure, level of ponding, condition of vegetation,etc.):
Pit found w/outlet tee in good condition. Leach pit found dry,no sign of infiltration.,
*Recommend: Maintenance pumping every 3—5 yrs.
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.):
M
Page 10 of I I
Y
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OFFICIAL INSPECTION FORM = NOTf �VOLUNTARY'ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION.FORM
PART
SYSTEM INFORMATION(cohtihued)i
'v.:� .,•,X� �t e, 5�'* .:, � a�'� s:�wqr••',a e+.� ��` �# r
Property Address:_48 Cypress Pomp ,Cummaquid ! ' fi "'
Barnstable_ '
Owner's Name:_William & Mary Ingram
Date of Inspection:^4/29/04 "` �� r �• y
SKETCH OF SEWAGE DISPOSAL�SYSTEM ', �
�^'
Provide a sketch of the sewage disposal system including ties to at least two permanent reference lanamarks or. -
benchmarks.Locate all wells within 100 feet. Locate where public water supply enters he,building.",'.'. y .
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Page I I of
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C >
SYSTEM INFORMATION(continued)
Property Address: _48 Cypress Point Cummaquid
_Barnstable_
Owner's Name:_William& Mary Ingram
Date of Inspection:_4/*04
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells _
Estimated depth to ground water ` 30_feet
Please indicate(check)all methods used to determine the high ground water elevation:
Obtained from system design plans on record-If checked,date of design plan reviewed:
Observed site(abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health-explain:
Checked with local excavators, installers-(attach documentation)
_X_Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
By U.S.G.S.atlas H A—692.
Tf, .
3:I
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