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HomeMy WebLinkAbout0017 DOLAR DAVIS ROAD - Health 17 DOLLAR DAVIS RD., CENTERVILLE � A= UPC 12534 No.21_ �. � HASTINGS. UN a C s « r I COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL"AFFAIE0 DEPARTMENT OF ENVIRONMENTAL PROTECTION . ONE WINTER STREET, BOSTON MA 02108 (617) 292-5500 MAY 19 P000 " ' TQ1INOF � ) H TRUDY COXE Secretary ARGEO PAUL CELLUCCI f f i ' tp e6AVID B. STRUHS Governor _ Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM �p� PART A 9 vu4ti DOAj{6. Q CERTIFICATION ry� Property Address: Name of Owner 1►l K ZJA0kN,0_ liloo Address of Owner: a >( �� Date of Inspection: f 1 Name of Inspector:(Please Print) M►CV%O►p�` d 1 L O"%1•w I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000) Company Name: Maing Address: "Z +-{ �mpl Telephone Number: 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: asses Conditionally Passes Needs Further Evaluation By the Local Approving Authority Fails d �V Inspector's Signature: Date: ."M The System Inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within thirty(30)days of completing this inspection. If the system is a shared system or has a design'flow of 10,1000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the Department ofvEnvironmental Protection. The original should'be sent tom system owner and copies sent to the buyer,if applicable, and the approving authority.'. �1 NOTES AND COMMENTS rt r l •: revised 9/2/98 Page Iof11 Printed on Recycled Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A ,�,,; CERTIFICATION (continued) `'Q Property Address: ` "O � D`'n A � , DirtOwner: pecLert. Ine INSPECTION SUMMARY: Check 4� B, C, of D: A. SYSTEM PASSES: I have not found any information which indicates that any of the failure conditions described in 310 CMR 16.303 exist. Any failure criteria not evaluated are indicated below. COMMENTS: B. SYSTEM CONDITIONALLY PASSES: e or more system components as described in the "Conditional Pass" section need to be replaced or repaired. a system,upon comp n of the replacement or repair, as approved by the Board of Health, will pass. Indicate yes, no, or not de ined(Y, N, or ND). Describe basis of determination in all instances. If "not d mined",explain why not. The septic tan ' metal,unless the owner or operator has provided the system ins p r with a copy of a Certificate of Compliance(attache ' dicating that the tank was installed within twenty(20 ars prior to the date of the inspection;or the septic tank, whether or t metal, is cracked,structurally unsound, s substantial infiltration or exfiltration, or tank failure is imminent. The system 'I pass inspection if the existin ptic tank is replaced with a complying septic tank as approved by the Board of Health. Sewage backup or breakout or high st water level obser in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or une distribution box. The syste ill pass inspection if(with approval of the Board of Health). broke ipe(s)are replaced o ruction is removed distribution box is levelled or replaced The s ern required pumphig-room than fourtimes a yeardue to broken or obstructed pipels . The system Wit1 piss-- i action if(with approval of the Board of Health)- broken pipe(s)are replaced obstruction is removed revised 9/2/98 Page 2ofII I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A �Q CERTIFICATION(continued) Property Address: """ � "0 &, Owner: Date of Inspection: Li l'etQ"1'©G C. FUR EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditio exist which require further evaluation by the Board of Health in order to determine if the sys o is failing to protect the public healt , safety and the environment. 1) SYSTEM WILL PA UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 R 15.303 0)(b)THAT THE SYSTEM IS NOT FUNCTIONIN N A MANNER WHICH-MLL.PRQT ECT THE PUBLIC HEALDLAND S AND THE ENMIBONMEN.T_ Cesspool or privy i ithin 50 feet of surface water Cesspool or privy is w in 50 feet of a bordering vegetated wetland or a It marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF H (AND PUBLI ATER SUPPLIER,IF ANY)DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTEC THE PUBLIC HEALTH D SAFETY AND THE ENVIRONMENT: - The system has a septic tank d soil absorption system(SAS)and a SAS is within 100 feet of a surface water supply or tributary to a surface Ovate upply. The system has a septi ank and soil absorption system and the SAS is w in a Zone I of a public water supply well. The system has a s is tank and soil absorption system and the SAS is withi 50 feet of a private water supply well. The system has septic tank and soil absorption system and the SAS is less the 100 feet but 50 feet or more from a private water pply well,unless a well water analysis for coliform bacteria and vol 'le organic compounds indicates that the well is fre om pollution from that facility and the presence of ammonia nitrogen an itrate nitrogen is equal to or less than 5 m. Method used to determine distance (approximation not valid). 3) OTHER revised 9/2/98 Page 3ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) t� ��..o�n I`7 cwvy ►�aQ, Property Address: Owner: Date of Inspection: l0� D. SYSTEM FAILS: -t You ust indicate either "Yes" or "No" to each of the following: f I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. basis for this etermina Ttion is identified below. The Board of Health should be contacted to determine what will be necess to correct the failure. Yes No Backup of sewage intoiscilit"r-stem component-due%to an overloaded orvWggedSASor, sespool. Di harge or ponding of effluent to the surface of the ground or surface waters due to a verloaded or clogged SAS or cess ol. Static ligw level in the distribution box above outlet invert due to an overloaded o clogged SAS or cesspool. Liquid depth in sspool is less than 6" below invert or available volume is les than 1/2 day flow. Required pumping m e than 4 times in the last year NOT due to clogged r obstructed pipe(s). Number of times pump Any portion of the Soil Abso tion System, cesspool or privy is be w the high groundwater elevation. Any portion of a cesspool or privy' within 100 feet of a sur ce water supply or tributary to a surface water supply. Any portion of a cesspool or privy is-wi in a Zone I of a ublic well. Any portion of a cesspool or privy is within feet a private water supply well. Any portion of a cesspool or privy is less-than eat but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the we as be analyzed to be acceptable, attach copy of well water analysis for -coliform bacteria, volatile organiccompo ds, ammonia itrogen and nitrate nitrogen. -• E. LARGE SYSTEM FAILS: You must indicate either "Yes" or "No" to each o the following: The following criteria apply to large s ems in addition to the criteria above: The system serves a facility wit design flow of 10,000 gpd or greater(Large Sys m) and the system is a significant threat to public health and safety and the env' nment because one or more of the following condition xist: Yes No the syste is within 400 feet of a surface drinking water supply the stem-is-wi*Mn 200 feeta� ,V4ea eurfaoe.drirrkwtg.watsr•supplY.... the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area=IWPA)or a m pad Zone II of a public water supply well) The o ner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult local regional offic of the Department for further infortration. . revised 912198 Page 4orn SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST t� IDa&hb) G6 Property Address: Date of Inspection: rW'N�J Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Yet, No Pumping information was provided by the owner, occupant, or Board of Health. V _ None of the system compoalenu.hamabeen pua►ped+MrstJeast two xvo"a and•tba system hasA M ,=ceiaiagwrk:al 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. Y _ The system does not receive non-sanitary or industrial waste flow. _ The site was inspected for signs of breakout. All system components, excluding the Soil Absorption System, have been located on the site. _ The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. ./ The size and location of the Soil Absorption System orrthe site has been determined based on: v _ Existing information. For example, 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)] The facility owner land.wwpanu.if differeai irnm_owiner),were proxided.wiih informatioo.on.the prnpecmabUaaaooe of Subsurface Disposal Systems. .L•, revised 9/2/98 Page 5of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C 1—I (? 0AAA, (� STEM INFORMATION Property Address: M� �,(� Owner: � r i L Date of Inspection: L4 1, 06 FLOW CONDITIONS RESIDENTIAL: Design flow: 0 g.p.d./bedroom. Number of bedrooms Idesign):� Number of bedrooms(actual): 3 Total DESIGN flow a" Number of current residents: Cy Garbage grinder(yes or©o :_ Laundry(separate system) (yes o49:_; If yes, separate inspection.required Laundry system inspected (yes or no) Seasonal use E)or no):_ Water meter readings,if available(last two year's usage(gpd): »q� r 31 b0D C..Ou Sump Pump(yes o�:— tow tt Last date of occupancy: C MMERCIAL/iNDUSTRIAL: Type establishment: Design fl qpd 1 Based on 15.203) Basis of design Grease trap present: (yes o Industrial Waste Holding Tank presen . r no) �or Non-sanitary waste discharged to the Title 5 cycle �no) Water meter readings,if available: Last date of occupancy: OTHER:(Des ' Last of occupancy: GENERAL INFORMATION PUMPING I�RDS and source of informat'on: ((�� System pumped as part of inspection: (yes or(- If yes, volume pumped: gallons Reason for pumping: SYSTEM TYPE QF �/ Septic tank/distrlbUVVR M/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.Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other APPROXIMATE AGE of all components, date installed-{if known)•and source ef•iWormstion: -• �4fIFjG fVQ � Sewage odors detected when arriving at the site:(yes or�_ revised 9/2/95 Page 6orIf • SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Z �� Qm Owner: Date of Inspection: ►►C "�`t�c^iV 1 I t BUILDING SEWER: (Locate on site Depth below grade:_ Material of construction:_cast iron_ VC other(explain) Distance from private water supply well or suction line Diameter Comments:(condition of joints, v , vidence ofhakage.-etc.) SEPTIC—TANK: (locate on site plan) Depth below grade:Q Material of construction: Vconcrete_metal_Fiberglass _Polyethylene_other(explain) If tank is(petal,list age_ Js.age-confirmed by Certificate of Compliance_(Yes/No) Dimensions: q 46 44 '7 Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: 1� —• Scum thickness: a t� Distance from top of scum to top of outlet tee or baffle: 10 Distance from bottom of scum to bottom of outlet tee or baffle: 1 0l How dimensions were determined: d&, 12'.b Comments: (recommendation for pumping,, gnditi in of inlet and outlet tees or-baffles,depth of liquid Is el in relation to outlet invert, at ctur"tegrity, evidence of leakage,etc.) AA at GREASE TRAP: (lo a on site plan) Depth below grade:_ Materiel of construction:_co 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 r baffle: Date of last pumping: Comments: (recommendation fo umping,condition of inlet and outlet tees or baffles, depth of liquid level in relation to t invert,structural integrity, evidence of le e,etc.) revised 9/2/98 Page 7or11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Date of Inspection: ��t boo TIGHT OR HOLDING TANK: (Tank must be pumped prior to, or at time of, inspection) (loc on site plan) Depth below gr Material of constructs concrete_metal_Fiberglass_Polyethylene_other(explain) Dimensions: Capacity: gallons Design flow: gallons/day Alarm present Alarm level: Alarm in working order:Yes 0- Date of previous pumping: Comments: (condition of inlet tee, conditio a arm and float switches,etc.) DISTRIBUTION BOX:_ (locate on site plan) Depth of liquid level above outlet invert: Comments: (note if level a d distribution is equal, evidence of solids carryover, evidence of leakage into or out f box, gtc.) PU MBER:_ (locate on site p a Pumps in working order:(Yes or No) Alarms in working order(Yes or No) Comments: (note condition of pump chamber,condition of pumps and appurtenan revised 9/2/98 Page 8ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: l 1 . �Qv tb) Owner: Date of Inspection: y SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,if possible;excavation not required,location may be approximated by non-intrusive methods) If not located, explain: Type: leaching pits, number: 3 r5 6 leaching chambers,number:_ 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 po ding, damp soil, condition of v getation, etc.) CESSPOOLS: , (locate on site plan) Number and configuraflo Depth-top of liquid to inlet in 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 i action) 0 Comments: (note condition of soil, signs of hydraulic failure,level of pending,t itio<9egetation, etc.) PRIVY:_ (locate on site plan) Materjals of construction: Dimenso a:,_ _ Depth of solids: Comments: (note condition o i,signs of hydraulic failure,level of ponding, condition of vegetation;etc.) revised 9/2/98 page 9oril • SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner: Deft of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) PO I I 3'4 J� aa. yJ I O C revised 9/2/98 Page 10of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C �Q l� SYSTEM INFORMATION(continued) Property Address: Owner: Date of Inspection: (5o NRCS Report name Soil Type_ Typical depth to groundwater USGS Date website visited Observation Wells checked Groundwater depth: Shallow Moderate Deep SITE EXAM Slope Surface water Check Cellar Shallow wells Estimated Depth to Groundwater Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observed.Site(Abutting property, observation hole, basement sump etc.) Determined from local conditions Checked with local Board of health Checked FEMA Maps Checked pumping records Checked local excavators,installers Used USGS Data Describe how you established the High Groundwater Elevation. (Must be completed) o� , rarer an oX s revised 9/2/98 Page)IorII TOWN OF BARNSTABLE 1 '71 - -0 4 , LOCATION I Z ,� ®nr�, �C�/1/1.J`G8� bG SEWAGE # VILLAGE ( p ASSESSOR'S MAP & LOT INSTALLER'S NAME & PHONE NO. 7 SEPTIC T kNK CAPACITY 1000 t LEACHING FACILITY:(type) (size) r5 y 6 NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED— VARIANCE VARIANCE GRANTED: Yes. - No 0A A. 3 � � ��TV a