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HomeMy WebLinkAbout0044 LAKEWOOD DRIVE - Health 44 LAKEWOOD DR., CENTERVILLE A= 212 003 ` i Commonwealth of Massachusetts 0 0 1996 Executive of Environmental Affairs `jDDEP Department of Environmental Protection a� a SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A by 3 CERTIFICATION Property Address: 44 Lakewood Drive. Centerville Ma. Address of O wner: Robin Weiner (if different) 70 Birchwood Heights. Storrs, CT 06268 Date of Inspection: 06/03/96 Name of Inspector: Michael DeDecko Company Name, Address and Telephone number: Atlantic Environmental P.o B ox 2384 - M ashpee M a 02649. Tel : (508) 4771420 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 4= Passes ---- Conditionally Passes ---- Needs further evaluation by the local Approving Authority ---- Fails Inspector 's Signatu 4. 414 ` � Date: 06/04/96 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 or the Department of Environmental Protection. The original should be sent to the system owner and copy sent to the buyer, if applicable and the approving authority. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 44 Lakewood Drive. Centerville Ma. Owners : Robin Weiner Date of Inspection: 06/03/96 INSPECTION SUMMARY: Check A,B, C,or D A)SYSTEM PASSES: I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CM 15.303. Any failure criteria not evaluated are indicated below B)SYSTEM CONDITIONALLY PASSES: ---- One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair, passes inspection. Indicate yes,no, or not determinate (Y,N, or ND). Describe basis of determination in all instances. If"not determinated", explain why not. ---- The septic tank is metal, cracked, structurally unsound, shows substantial infiltration or exfiltration , or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. ---- 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). ----- broken pipe(s) are replaced ----- obstruction is removed ---- distribution box is levelled 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 pipes)are replaced ----- obstruction is removed SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address : 44 Lakewood Drive,Centerville Ma. Owner : Robin Weiner Date of Inspection: 06/03/96 C) FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: -- Conditions exist which require further evaluation by the Board of Health in order to de- termine if the system is failing to protect the public health , safety and the environ- ment. 11 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 of water ---- Cesspool or privy is within 50 feet of a bordering vegetated wetland or a small marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNC- TIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT. ---- The system has a septic tank and soil absorption system and is within 100 feet to a surface water supply or tributary to a surface water supply. ---- The system has a septic tank and soil absorption system and is within a Zone I of a public water supply well ---- The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. ---- The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analy- sis 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 notrogen is equal to or less than 5 ppm. D) SYSTEM FAILS: -- I have determined that the system violates one or more of the following failure criteria as defined in 310 CM 15.303. The basis for this determination is identified below.. The Board of Health should be contacted to determine what will be necessary to cor- rect the failure. --- Backup of sewage into facility or system component due to an overloaded or or clogged SAS or cesspool 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) L Property Address: 44 Lakewood Drive. Centerville,M a Owner: RobinWeiner Date of Inspection : 06/03/96 D)SYSTEM FAILS (continued) -- Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. --- Static liquid level in the distribution box above outlet invert due to an over- loaded or clogged SAS or cesspool. --- Liquid depth in cesspool is less than 6" below invert or available volume is less than 1!2 day flow. --- Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). number of times pumped --- Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. --- Any portion of cesspool or privy is within 100 feet of a surface water supply ortributary 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 ana- lysis. 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. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 44 Lakewood Drive. Centerville, Ma Owner: Robin Weiner Date of Inspection : 06/03/96 E) LARGE SYSTEM FAILS: The following criteria apply to large systems in addition to the criteria above : The design flow of system is 10,000 gpd or greater Large System and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist : -- the system is within 400 feet of a surface drinking water supply --- the system is within 200 feet of a tributary to a surface drinking water supply --- the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area - IWPA) or a mapped Zone I I of a public water supply well. The owner or operator of any such system shall bring the system and facility into full compli- ance 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. 5 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 44 Lakewood Drive. Centerville, M a. Owner: Robin Weiner Date of Inspection: 06/03/96 Check if the following have been done : -x Pumping information was requested of the owner , occupant and Board of Health. --x None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during the period. Large volumes of water have not been introduced into the system recently or as part of this inspection. --x As built plans have been obtained and examined. Note if they are not available with N IA. --x The facility or dwelling was inspected for signs of sewage back-up. --x The system does not receive non-sanitary or industrial waste flow. --x The site was inspected for signs of breakout. --x All system components, excluding the Soil Absorption System, have been located on the site. ---x The septic tank manholes were uncovered, opened and the interior of the sep- tic tank was inspected for conditions of baffles or tees, material of construc- tion, dimensions, depth of liquid, depth of sludge, depth of scum. ---x The size and location of the Soil Absorption System on the site has been deter- mined based on existing information or approximated by non-intrusive methods ---x The facility owners and occupants if different from owner were provided with information on the proper maintenance of Subsurface Disposal System. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 44 Lakewood Drive. Centerville Ma Owner: Robin Weiner Date of Inspection: 06/03/96 RESIDENTIAL: Design flow : `aa v gallons Number of bedrooms : o'Z Number of current residents: Cb Garbage grinder (yes or no) : t-b Laundry connected to system (yes or no): N I i� Seasonal use (yes or no) : fNC) Water meter readings, if available: to (A Last date of occupancy : Qczg>a�. . COMMERCIAL/INDUSTRIAL Type of establishment: Design flow : gallons/day 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 : ........�J. ...............................................I System pumped as part of inspection (yes or no) :....1q?.......... if yes, volume pomped : .................... gallons Reasonfor pumping :............................................................................................................ SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 44 Lakewood Drive. Centerville M a. Owner: Robin Weiner Date of inspection: 06/03/96 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) -y t� C 1 N -Other (explain)... ........�R...�....�?..�n APPROXIMATE AGE of all components, date installed (if known) and source of information !la x.....R. ......�.�.?................................................................................................... ................................................................................................................................................ ................................ Sewage odors detected when arriving at the site : (yes or no)..... SEPTIC TANK : (locate on site plan) r� Depth below grade: . ..... Material of construction: ... . concrete ......... metal ........ FRP ........ other (explain) ................................................................................................................................................ Dimensions: 5�►?..!�.` ...s S Sludge depth :..b.......... Distance from top of sludge to bottom of outlet tee or baffle:...... ..y.................. Scum thickness :...C ''............ Distance from top of scum to top of outlet tee or baffle: .........tv.......................... Distance from bottom of scum to bottom of outlet tee or baffle :.....Le................ Comments : (recomm6ndation for pumping , condition of inlet and outlet tees or baffles, depth of liquid level in fel tiorlto outlet invert, structural integrity, evidence of leakage, etc.)...................... c— Cc/ ......... SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 44 Lakewood Drive. Centerville M a. Owner: Robin Weiner Date of inspection: 06/03/96 GREASE TRAP : ..... (locate on site plan) Depth below grade: ............... Material of construction: ........concrete.........metal........FR P........other(explain).... ........................................................................................................................................... Dimensions:............................... Scum thickness:........................ Distance from top of scum to top of outlet tee or baffle:....................................... Distance from bottom scum to bottom of outlet tee or baffle:............................... 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.)........................ ................................................................................................................................................ TIGHT OR HOLDING TANKS:...Nd....... (locate on site plan) Depth below grade-..:............. Material of construction:........concrete........metal.........FR P..........other (explain).......... ................................................................................................................................................ Dimensions:............................ Capacity:....................gallons Design flow:...............gallons/day Alarm level:............................. Comments: (condition of inlet tee, condition of alarm and float switches, etc.) ................................................................................................................................................ ................................................................................................................................................ b f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PAR T C SYSTEM INFORMATION (continued) Property Address: 44 Lakewood Drive. Centerville Ma. Owner: Rabin Weiner Date of inspection: 06/03/96 DISTRIBUTION BOXW: .—s (locate on site plan) y �Nve�T— Depth of liquid level above outlet inverk:....�. .�.�..W Comment: (note if level and di b lion equal evidenge of solids carryover, ev ence f leakage into or ,ut ofto�, etc.) ..: L... 6..5p..; t1 ... lf.t:.:� `� ,S:r..}.1�.5�.....G.U.I �: . !.'?l,ja.t..,................ �. ................................................................................................................................................... PUMP CHAMBER:...,J:� (locate on the site) Pumps in working order: (yes or no).....�? . Comments: ote co dikian of pump chambe condition of pint rps and appur�pnances, etc.). ... .. ......... ,......t.,x>.Yi.-.�:.,.......`...a.��2� SOIL ABSORPTION SYSTEM (SAS):.....(.Ar.c....... (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: ... umber: ... leaching chambers, number:..�S.�. R leaching galleries, number:........... leaching trenches, number , length:...................... leaching fields, number, dimensions:................... overflow cesspool, number:.......... Comments: (note Gondition of soil , sig49frdr ulic failure, level of pondin condition of vegetation, etc ).. . , .. 5...�1�I��t.0�!� :-:. .v .......d�1.A...�.\er :^` .1...1 ,:1.. �. .S. ... << ' < �?(.^+: /•. .�U • SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property address: 44 Lakewood Drive. Centerville Ma. Owner: Robin Weiner Date of inspection: 06/03/96 CESSPOOLS:....... (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: ..................... Indicator of ground water: .................... 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 : ...tV.v.... (locate on the site) Material of construction: ................................... Dimensions: ...................... Depth of solids: ................ Comments: (note condition of soil, signs of hydraulic failure, level of ponding;condition of vegetation, etc.) . ................................................................................................................................................ w, SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address : 44 Lakewood Drive. Centerville Ma Owner: Robin Weiner Date of inspection: 06/03/96 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate at wells within 100'. 1 2 dv DEPTH TO GROUNDWATER: Depth to groundwater: A.S.feet Method of determination r approximativ ��.........5�.....................��T.. ... �. ,................................................................................. ................................................................................................................................................ C TOWN OF BARNSTABLE `` LOCATION44 LaKeu--6C il9C: SEWAGE # VILLAGEoe-jCdgt-oj Ike ASSESSOR'S MAP & LOTO��C�O3 INSTALLER'S NAME & PHONE NO- 1d41' ar) qQR-- n SEPTIC TANK CAPACITY :T)(,Lvy) (1 I LEACHING FACILITY:(type) r- 3 QQ, 7 NO. OF BEDROOMS PRIVATE WELL O PUBLIC WATER BUILDER R OWNERS` r DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: 1 I 1 VARIANCE GRANTED: Yes No o 30 / �r K r_7UIZEIEC-5eA�y �� JI�2 Oil 6ESSfcOL 0 o3 F�s.....'�6.. ...... APPRMTHE COMMONWEALTH OF MASSACHUSETTS � M BOARD OF HEALTH !' 9 TOWN OF BARNSTABLE Wcd Xppltrali inntar Diripw3al Workii C owitrnrtinn tirrntit Application is hereby made for a Permit to Construct ( ) or Repair an Individual Sewage Disposal System at: -----------------••-•....---------------------------------------------------------- .................................... ....................................................... ocation-Address - or Lot No. ----•-•---_-•CtJ�1 N L -------------•--•----------------••-••••-.....1�_ Goo ilY/.U,ca �' ��_�C`3� J` �_r�f. - ........ Address Installer Address Type of Building Size Lot............................Sq. feet ►.� Dwelling— No. of Bedrooms.............c..........3...----_---Expansion Attic ( ) Garbage Grinder ( ) Pk Other—Type of Building ---------------------------- No. of persons---------------------------- Showers ( ) — Cafeteria ( ) Otherfixtures ------------------------------------------------ -••-----------------••----------------- ---------•____........ W Design Flow.................. .... � _.____.--gallons per person per day. Total daily flow_----------- �a.__..--._--_._..._gallons. WSeptic Tank—Liquid capacity-MP-gallons Length---------------- Width---------------- Diameter----..--........ Depth................ x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No..................... Diameter...........--------- Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date........................................ a Test Pit No. I----------------minutes per inch Depth of Test Pit.................... Depth to ground water........................ fi Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ W •••••-••------------------------------------------------------------------------------ ---••..... •--- ----------------------------------------- -...... •••...... 0 Description of Soil............................................................................................................................................-........................... W W ---------------------- ---------------------------- ------------------------------------------------------------------------------------------•• ••••-•._.... ••••••••--• --•--_.._. U Nature of Re airs or Altera 'ons—Ans) r when applicable.-N.S. JOa� -:�6¢�� ....•f�-o'. ,(�........ . Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance b en is a by t and of health. Signed ..........0..�' ........ .. .:..... .......... ............. ....... -5�:...-.. - Day Application Approved By -- ----- ----------- Dace Application Disapproved for the following reasons: .................................. ................................... ................................................ . --------------------------- --------- �y ---------------- -------- -- Permit No. ! -�:.., ... . Issued -- ---y* -....-� ..-., ---? -..-. Daze [} CYI�f�C��N� No.. �. � Fr�s.....-Y6 -• .............. THE COMMONWEALTH OF MASSACHUSETTS ( BOARD OF HEALTH' s3TOWN OF BARNSTABLE IT7--4— / Appliratiou for Diriiaooal Works Toutitrurtion Permit Application is hereby made for a Permit to Construct ( ) or Repair an Individual Sewage Disposal System at: ..........`�y L-Q JL SAJ6d D Q2 V e�nr LV i c , --...---•------------------------------------••-------...._-----------•------....... ------•----•---------------•---•-•----..----------------...--•------------•-•.._.........•-_••..•. Location•Address �� � �1 �.�/or Lot No. ......-•--•--�- -..-�•���......•...........................•--•-....�--�•..... ....................G v'..� .�1fiCJ-✓, .[..�c.•qV<-r i,, kL)/ I CC ......................................... ..._...... O++ner �� k Address w �� t.0/ Gc,�s7L�7.7o, i tAj L3 / � ✓L'�7 ----------------------- •----•-------------- ................................................. -------•--•----......._.......................... Installer Address go UType of Building Size Lot............................Sq. feet ..� Dwelling— No. of Bedrooms.............. --�3------------Expansion Attic ( ) Garbage Grinder ( ) 114 Other—Type of Building --_------------------ ----- No. of persons------..--.-..-.------------ Showers ( ) — Cafeteria ( ) Aa Other fixtures ............................... . . w Design Flow................... _....._--..gallons per person per day. Total daily flow...-..-...--�3Q--_.._.._.._._._..gallons. WSeptic Tank—Liquid capacity.la�U.galIons Length............... Width.......--------. Diameter..-----------.-. Depth................ x Disposal Trench—No. .................... Width.............-----.. Total Length.................... Total leaching area....................sq. ft. 3 Seepage Pit No--------------------- Diameter.................... Depth below inlet.--................. Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) 0.4 Percolation Test Results Performed by-------- ---------------------------•----------------••-----------------.. Date...----•----•--•--------•----........... O.-� Test Pit No. I.............t.minutes per inch Depth of Test Pit.................... Depth to ground water---..................... �Z4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ P4 ............................................................................................................................................................ 0 Description of Soil........................................................................................................................................................................ x U VW ..........................--.........................................................................................................................._................................................. Nature of Repairs or Alterations—Answer when applicable..) �►�-�... .-!�U©( -` �I nri -t.._•-E�u,!►) ..__.__.. �AJ,A-n'1Q�lL {......... ....Lr.. ��.i... i ..�%. :s`��U� Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code-The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been is ue, by the board of health. __. . Signed . ........... --'.------/�-... -- ............... .........1�'s ..... ��...... Application Approved By .�'+�r -( ��. -•-----/_ � �....... .... .v .......................... .. ............. Date 1 Application Disapproved for the following reasons: .......................................................................... . .........---...................---.................. .................... ...... . ............................. ........................ .................................................................................I...... .............. ........................................ /' TJare Permit No. ......9-r��/...........,P�.... ............ Issued ...... ......�......... / .... Dale THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARl.�NSTABLE C erti irate of Graylianre THIS IS TO CERTIFY,That the Individual Sewage Disposal System constructed ( ) or Repaired ( Xj by CG 5 vGi 7...._.) .. .................... .......................................... Ins"1" at ..................................................................... ............... has been installed in accordance with the provisions of TITLE of The State Environmental Code as described in the application for Disposal Works Construction Permit No. ...' ✓_.��. � ��... dated THE ISSUANCE OF THIS CERTIFICATE SHALL N T BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. 1 , DATE........._......... ..,.j�._ �`� ........._........ ._.............. Inspector ---------- E. ......... ...:........................ .................... THE COMMONWEALTH OF MASSACHUSETTS —)/� - G� BOARD OF HEALTH C/ TOWN OF BARNSTABLE FEE........................ Raposnl Workii Tnnotrudinn "prrntit Permission is hereby granted...................... � �...!.l_...._.____�G S�2:uG�/C ................•-•.......--••-- to Construct ( ) or Repair (D4) an Individual Seymge Disposal Syst at No.. :lD .............. --------------`�-U......0......... ��1nn Dated..-..�1.-.._....... .. as shown on the application for Disposal Works Construction Pet ot.-.�,� _ r" Board of Health DATE....... --•- ----•- ---------•--- FORM 36508 HOBBS&WARREN,INC.,PUBLISHERS