HomeMy WebLinkAbout0520 OLD CRAIGVILLE ROAD - Health 520 Old Craigville Road
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COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
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d DEPARTMENT OF ENVIRONMENTAL PROTECTION
SV RECEIVED
DEC 0 3 2002
TITLE 5 TOWN OF BARNSTABLE
HEALTH DEPT.
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A � � � �ft
CERTIFICATION
Property Address: 520 Old Craigsville Road Centerville
Owner's Name: Rick Leseburce
Owner's Address:
Date of Inspection: 9/3/02
''
Name of Inspector: Timothy Lovell MAP —2
Company Name:Accurate Inspections PARCEL
Mailing Address:550 Willow Street
W.Yarmouth,MA. LOT
Telephone Number:508-771-3700
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my
training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system:
X_Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signatu . Date:9/3/02
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
****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.
L
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Page 2 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:520 Old Craigsville's Road
Owner:Rick Leseburce
Date of Inspection: 9/3/02
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:
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 by the Board of Health,will pass.
Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined"please
explain.
_N/A The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally
unsound,exhibits substantial infiltration or infiltration or tank failure is imminent.System will pass inspection if the
existing tank is replaced with a complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
N/A Observation of sewage backup or break out or high static water level in the distribution box due to
broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if
(with approval of Board of Health):
Broken pipe(s)are replaced
Obstruction is removed
Distribution box is leveled or replaced
ND explain:
N/A_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:
Page 3 of 11
OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address:520 Old Craigsville's Road
Owner:Rick Useburce
Date of Inspection: 9/3/02
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.
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:
_N/A_Cesspool or privy is within 50 feet of surface water
—N/A—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:
_n/a 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.
_n/a_ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply.
_n/a The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
n/a_ 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:
1
Page 4 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A,
CERTIFICATION(continued)
Property Address:520 Old Craigsville's Road
Owner: Rick Leseburce
Date of Inspection: 9/3/02
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
—x_Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
_n/a _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 m 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 1 of a public well.
_ _x_Any portion of a cesspool or privy is within 50 feet of a private water supply well.
_ _x_Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis. [This system passes if the well water analysis,
performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria
are triggered.A copy of the analysis must be attached to this form.]
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: NIA
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 H 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.
i
Page 5 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address:520 Old Craigsville's Road
Owner:Rick Leseburce
Date of Inspection: 9/3/02
Check if the following have been done.You must indicate`des"or"no"as to each of the following:
Yes No
_x _Pumping information was provided by the owner,occupant,or Board of Health
_x Were any of the system components pumped out in the previous two weeks?
_x _Has the system received normal flows in the previous two-week period?
_x Have large volumes of water been introduced to the system recently or as part of this inspection?
_x Were as built plans of the system obtained and examined?(If they were not available note as N/A)
_x _Was the facility or dwelling inspected for signs of sewage back up?
_x _Was the site inspected for signs of break out?
_x _Were all system components,excluding the SAS,located on site?
_x_ _Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition
of the 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)]
I
Page 6 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address:520 Old Craigsville's Road
Owner: Rick Leseburce
Date of Inspection: 9/3/02
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design):_2_Number of bedrooms(actual):_2_
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms):_330
Number of current residents:_2
Does residence have a garbage grinder(yes or no):_no_
Is laundry on a separate sewage system(yes or no):_no_ [if yes separate inspection required]
Laundry system inspected(yes or no):_n/.a_
Seasonal use: (yes or no):yes_
Water meter readings,if available past 2 years usage(gpd):
Sump pump(yes or no):_no_
Last date of occupancy:_current
COMMERCIAL/INDUSTRIAL n/a
Type of establishment:
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(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: 1997
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:
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):
Approximate age of all components,date installed(if known)and source of information:
2/19/02
Were sewage odors detected when arriving at the site(yes or no):_no_
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Page 7 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:520 Old Craigsville's Road
Owner:Rick Leseburce
Date of Inspection: 9/3/02
BUILDING SEWER(locate on site plan)
Depth below grade:_2'3"
Materials of construction:_cast iron _x_40 PVC_other(explain):
Distance from private water supply well or suction line: 50'
Comments(on condition of joints,venting,evidence of leakage,etc.):
Joints are tight no evidence of leakage venting looks to be fine
SEPTIC TANK: x (locate on site plan)
Depth below grade:_1'
Material of construction:_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: 1000 Gallon Tank
Sludge depth: 2"
Distance from top of sludge to bottom of outlet tee or baffle:_30"
Scum thickness:_2"
Distance from top of scum to top of outlet tee or baffle:_6"
Distance from bottom of scum to bottom of outlet tee or bale:_14"
How were dimensions determined: in the field tape measurements_
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.):
No evidence of leakage,tank is structurally sound liquid levels are at invert out,Recommend pumping every 2
stars,tees are in place
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(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.):
I
Page 8 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:520 Old Craigsville's Road
Owner:Rick Leseburce
Date of Inspection: 9/3/02
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:_0"_
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.):
Liquid level is at invert out no evidence of solid carry over,no evidence of leakage cover is 10"deers
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.):
Page 9 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:520 Old Craigsville's Road
Owner:Rick Leseburce
Date of Inspection: 9/3/02
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:—3_cultex_
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 evidence of hydraulic failure,no damp soil,vegetation normal
CESSPOOLS: n/a (cesspool must be pumped as part of inspection)(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(yes or no):
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
PRIVY:_a/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.):
c
Page 10 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:520 Old Craigsville's Road
Owner: Rick Useburce
Date of Inspection: 9/3/02
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.
Rear of Home
M
1000 Gallon
Tank
"sf
Distribution
Box
3 Cultex units
10'x25'x2'
Page 11 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:520 Old Craigsville's Road
Owner:Rick Leseburce
Date of Inspection: 9/3/02
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water_19' 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: Plate 2
You must describe how you established the high ground water elevation:
Information provided by Cape Cod Commission Well Data shows water table at 22' adjusted to 19'with a
separation of 4.5'from bottom of system
I
a'
Page 10 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:520 Old Craigsville's Road
Owner: Rick Leseburce
Date of Inspection: 9/3/02
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.
Rear of Home
ti
1000 Gallon
Tank
.SAS
Distribution
Box
3 Cultex units
10'x25'x2'
Commonwealth of Massachusetts RE
Executive Office of Environmental Affairs MAR 2 8 )Seawary
TABLE
Department of TO ALIHDEPEnvironmental Protectio
VAIIllGoverom F.weld Coxo
Argeo Paul Celluccl David B.Struhs
u.governor GommWwo—
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A -
CATION
C aigville F�Old J.}�e Satt
Property Address: 520 520 Ol Address of Owner.
7
Date of Inspection: (If different)
Name of Inspector. W.E. Robinson SR
Company Name,Address and Telephone Number. ( 5 0 8 ) 7 7 5-8 7 7 6
W.E. Robinson Septic Service
P.O. Box 1089 Centerville MA
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,acxurate
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:
�assea
Conditionally Passes
_ Needs Further Evaluation By the Local Approving Authority
Fails
Inspector's Signature: ,1"V , Date- 7
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] SYS PASSES:
I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 16.303.
Any failure criteria not evaluated are indicated below.
Bl 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. .
to yes, no,or not determined(Y,N,or ND). Describe basis of determination in all instances. If"not determined",explain why not)
The septic tank is metal, cracked,structurally unsound, shows substantial infiltration or enfiltmtion,.or tank failure is
imminent. The system will pass inspection if the existing septic tank is replaced with a Fonforming septic tank as approved
by the Board of Health.
(revised 11/03/95) 1
One Winter Street a Boston,Massachusetts 02108 a FAX(617)556-1049 a Telephone(617)292-MM
i,Printed on Recycled Paper
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 520 Old Craigville Rd W. Hyannisport MA
Owner J.Rene Scutt
Date of Inspection: 2/19/9 7
B]SYSTEM CONDITIONALLY PASSES(continued)
Sewage backup or breakout or high static water level observed in the distribution bout 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 pipe(s)are replaced
obstruction is removed
C) FUR ER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
nditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the
lic health,safety and the environment.
1) SY TEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A
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) S STEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER,IF APPROPRIATE)
INES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND
AFETY 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 analysis for ooliform 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.
S) O ER
(revised 11/03/95) 2
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 520 Old Craigville Rd W. Hyannis-port MA
Owner. J. Rene Scutt
Date of Inspection: 2-19-97
D) YSTEM FAILS:
I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 16.303. The basis for
this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the
failure.
Backup of sewage 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 overloaded 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 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 a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
Any portion of a cesspool or privy is within a Zone 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)LARG SYSTEM FAILS:
e following criteria apply to large systems in addition to the criteria above:.
The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public
health and safety and the environment because one or more of the following conditions exist:
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area(IWPA)or a mapped Zone U of a public
water supply well)
The owns or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program
requireme is of 314 CMR.5.00 and 6.00. Please consult the local regional office of the Department for further information..
(revised 11/03/95) 3
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 520 Old Craig;7ille Rd W. Hy:Annisport MA
Owner. J. Rene Scutt
Date of Inspection 2-19-97
Check if the following have been done:
✓Pumping information was requested of the owner,occupant,and Board of Health.
_"None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates
during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection.
V As t plans have been obtained and examined. Note if they are not available with N/A.
facility or dwelling was inspected for signs of sewage back-up.
system does not receive non-sanitary or industrial waste flow
site was inspected for signs of breakout.
�Ze
m components,excluding the Soil Absorption System,have been located on the site.
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.
'he size and location of the Soil Absorption System on the site has been determined based on existing information or
approximated by non-intrusive methods.
he facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of Sub-
Surface Disposal System.
(revised 11/03/95) 4
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address:. 520 Old Cra gville Rd W. Hyannisport MA
Owner. J.Rene Scutt
Date of Inspection: 2-19-97
FLOW CONDITIONS
RESIDENTIAL:
Design flow:,// gaIIons
Number of bedrooms:
Number of current residents:
Garbage grinder(yes or no): AL-O _
Laundry connected to system(,yes or no):. s
Seasonal use(yes or no):— 1995 24,000 gals
Water meter readings,if available:
r
Last date of occupancy: ^q /
COMMERCIAL/INDUSTRIAL-
Type of establishment:
Design flow:_ illons/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 RECORD�d so}}rce of information:
System pumped as part of inspection: (yes or no)_
If yes,volume pumped: gallons
Reason for pumping:
M
SYSTEM
Septic tank/distnbution box/soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system(yes or no) (if yes,attach previous inspection records,if any)
Other(explain)
APPROXIMATE AGE of all components,date installed(if known)and source of information: A-ti-e t
Sewage odors detected when arriving at the site: (yes or no) U
(revised 11/03/95) 5
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 520 Old Craigville Rd W. Hyannisport MA
Owner. J. Rene Scutt
Date of Inspection: 2-19- 97
SEPTIC TANK I/
(locate on site plan) 1
Depth below grader `
Material of construction:_concrete_metal_FRP_other(e:plain)
Dimensions: 1
Sludge depth: r?
Distance from top of sludge to bottom of outlet tee or baffle: 11 3
Scum thickness: 6
Distance from top of scum to top of outlet tee or baffle: g
Distance from bottom of scum to bottom of outlet tee or baffle: I _f`f
Comments:
(recommendation for pumping,condition of inlet and tlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,
evidence of leakage,etc.) _�'��% o +�— !� l"e ✓L t � --! �' -7
G E TRAP:
(locate o site plan)_
Depth belo grade:
Material o construction:_concrete_metal_FRP—other(explain)
Dimensio
Scum ass:
Distance m top of scum to top of outlet tee or baffle:
Distance m bottom of scum to bottom of outlet tee or baffle:
Comments:
(recomme daticn for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,
evidence f leakage,etc.)
" (revised 11/03/95) 6
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 520 Old Craigville Rd W. Hyannisport MA
Owner. J. Rene Scutt
Date of Inspection. 2-19-97
TIGHT.OR HOLDING TANK:_
(locate on ' plan)
Depth below
Material of n:_concrete_metal_FRP_other(e:plain)
Dimensions
Capacity: ons
Design flow: ons/day
Alarm level:
Comments:
(condition o inlet tee,condition of alarm and float switches,etc.)
DISTRIBUTION BOX:
(locate on site plan).
Depth of liquid level above outlet invert:
Comments:
(note if'level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.) L't�
/ g 17
PUMP C BEIL
(locate on plan)
Pumps in rking order:(yes or no)
Comments:
(note conditio of pump chamber,condition of pumps and appurtenances,etc.)
(revised 11/03/95) 7
i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
520 Old Craigville Rd W. Hyannisport MA
Property Address: J. Rene Scutt
Owner. 2-19-97
Date of Inspection:
SOIL ABSORPTION SYSTEM(SAS):-
(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:
leaching galleries,number:
leaching trenches, number,length:
leaching fields,number,dimensions:
overflow cesspool, number:
Co nts:(note_condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation etc.) 3 ti 4-:&f/ Q la A—
C POOLS:_
(loca on site plan)
Number and configuration: r
Depth- of liquid to inlet invert:
Depth solids layer:
Depth o scum layer:
Dime ' no of cesspool:
Mate ' of construction:
Indira n of groundwater:
inflow(cesspool must be pumped as part of inspection)
Comments: condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.)
PRIW-
(locate on plan)
Materials o astruction: Dimensions:
Depth of so
Comments:(n condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.)
(revised 11/03/95) g
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Address. 520 Old Craigville Rd W. Hyannisport MA
PropertyOwner. 2-19-97
Data of Inspection J. Rene Scutt
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100'
DEPTH TO GROUNDWATER
Depth to voundwater:—L�—feet / J
method of determination or approximation:T,<
(revised 11/03/95) 9
No. € • J I Fee $5 0 . 00
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
01pprication for Mf5pogaf *pgtem Congtruction Permit
Application for a Permit to Construct( )Repair( ")Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. 520 Old Cr a i gv i l l a EKvner's Name,Address and Tel.No. J Rene Scut t
Rd, W Hyannisport, MA 51 Thomas Drive, Chelmsford, MA
Assessor's Map/Parcel 5 0 8-2 5 6-0 5 6 7
Installer's Name,Address,and Tel.No. 7 7 5—8 7 7 6 Designer's Name,Address and Tel.No.
Wm I Robinson Sr Septic Sry
PO Bo)c 1089 , Centerville, MA
Type of Building:
Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( n�D
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
Size of Septic Tank Type of S.A.S.
Description of Soil sand
Nature of Repairs or Alterations(Answer when applicable) Title 5 Leach system consisting
°r 3 ;'330 infiltrators
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 Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued by this Boar of Healt1l.
Signed c DateO91 V
Application Approved by Date
Application Disapproved for the following reasons
Permit No. 7 y Date Issued
No. G G •, ';. Fee$5 0.0•0�
r �" Entered in computer: y
' 1•H'�COMMONWEALTH OF MASSACHUSETTS
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
Rmlicatiou for Mitponl 6potem Cougtruction Permit
Application for a Permit to Construct( )Repair(X)Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. 1 520 Old Craigvi Ile Owner's Name,Address and Tel.No. J Rene Scutt
Rd, W Hyannisport, MA 51 Thomas Drive, Chelmsfordo MA
Assessor's Map/Parcel,. 5 0 8—2 5.6 0 5 6 7
Installer's Name,Address,and Tel.No. 7 7 5—8 7 7 6 Designer's Name,Address and Tel.No.
Wm E ";Robinson Sr Septic Sry
PO Box 1089, Centerville, MA
Type of Building:
i
Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( nip
Other Type of Building No. of Persons Showers
yp g ( Cafeteria( )
Other Fixtures
'i Design Flow gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank - Type of S.A.S.
Description of Soil sand
Nature of Repairs or Alterations(Answer when applicable) Tttle 5 Leach system consisting
Of 3 #330 infmltrators
h .- Date last inspected:
Agreement:
t 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 Environmental Code and not to place the system in operation until a Certifi-- i
cate of Compliance has been issued by this Boapd of Healt .
Signed rA ent A Dato/�'- 3_9 7
Application Approved by —Date -)
Application Disapproved for the following reasons
i
Permit No. 17 4, Date Issued
----- --" .'' . r
---------------'—
THE COMMONWEALTH OF MASSACHUSETTS�
Scutt BARNSTABLE, MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired ( X )Upgraded( )
Abandoned( )by Wm E Robinson Sr Septic Sry
at 520 Old Craigville Beach Rd, W Hyannis port, MA has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. /17"G G dated .2^12` P 2
Installer Wm E Robinson Sr Septic Srv. Designer
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
Date '1 Inspector
— �' G Fee$5
-------------------------- --
THE COMMONWEALTH OF MASSACHUSETTS
s
Scutt PUBLIC HEALTH DIVISION -BARNSTABLE,MASSACHUSETTS
wi!5pogar *pztem Cow5tructiou Permit
Permission is hereby granted to Construct( )Repair( X)Upgrade( )Abandon( )
Systemlocatedat 520 Old Craigville,Beach Rd, W Hyannisport, MA
` by WM E Robinson Sr Septic Srv.
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 conditions.
Provided: Construction must be completed within three years of the date of this�permit.
Date: 12 - 7 Approved by C�-•� l��'� �� �-�-�� -
i M �
NOTICE:""his form is to be used for the repair of failed
septic systems only
CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL
WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANS)
I,William E. Robinson, Sr.,hereby certify that the application for disposal works
construction permit signed by me dated 2-/3" 9 7 ,concerning the
property located at 520 Old Craigyille Beach Rd,W Hyannisport, MA meets all
of the following criteria:
* There are no wetlands within 300 feet of the proposed septic system.
* There are no private wells within 150 feet of the proposed septic system.
* The obseved groundwater table is 14 feet or greater below the bottom of the leaching facility.
* There is no increase in flow and/or change in use proposed.
* There are no variances requested or needed.
SIGNED: DATE �3 g
LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER 60
(Attach a sketch plan of the proposed system. Also if the licensed installer proposes a certification
plot plan,this plan should be submitted).
��
��
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� �-
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1
■"
� r �
T��OQppW�N OF BARNSTABLE
LOCATION LLD fej^" e-Ch f _ SEWAGE # — cc (V
VILLAGE I 0�� ASSESSOR'S MAP & LOT
INSTALLER'S NAME&PHONE NO. t4 2%
SEPTIC TANK CAPACITY /i^l7 D
LEACHING FACILITY: (type) (size)NO.OF BEDROOMS_
BUILDER OR OWNER
PERMIT DATE:��L. ' 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
01
0(k TOWN OF BARNSTABLE
LD C2i.C11 - SEWAGE # �? Co to
VILLA(. :. f ASSESSOR'S MAP &LOT ��,- Ind
INSTALLER'S NAME&PHONE NO. '►�
SEPTIC TANK CAPACITY I
LEACHING FACELrrY: (type) S C-0114Y (size)
NO. OF BEDROOMS
BUILDER OR OWNER
PERMITDATE: �d 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
r �
<17 ,�
TOWN OF BARNSTABLE
LOCATION 5,VO 0A4 SEWAGE #
VILL' JE 6" ASSESSOR'S MAP & LOT
INS r_��,-t: K'S N/aMF &PHONE NO. _, e&IA e /nS f�tc f�va 7, ?o d
SEPTIC TANK CAPACITY /0e)o a4l/oj 8�lrt %,fin /Z
LEACHING FACILITY: (type) 1-frk "et, fS (size) /ox 5•r z
NO. OF BEDROOMS a
BUILDER OR OWNER Rlhk to e kart •e.
PERMIT DATE: C I GE DATE: C Z—
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
�PyoFtiM T°�o The Town of Barnstable
DAw,T,ffi Department of Health, Safety and Environmental Services
M6 9 ,� Public Health Division
�0 Mti'�k'
367 Main Street,Hyannis,MA 02601
Office 508-790-6265 Thomas A.McKean
FAX 508-775-3344 Director of Public Health
December 5,1996
Rene Scutt
51 Thomas Drive
Chelmsford, MA 01824
NOTICE TO ABATE VIOLATIONS OF 105 CMR 410.00, STATE SANITARY
CODE II MINIMUM STANDARDS OF FITNESS FOR HUMAN HABITATION
AND THE TOWN OF BARNSTABLE RENTAL ORDINANCE,ARTICLE 51
The property owned by you located at 520 Old Craigville Road, Centerville was inspected
on November 29, 1996 by Jerry G. Dunning, Health Inspector for the Town of Barnstable
because of a complaint. The following violations of the Town of Barnstable Rental
Ordinance Article 51 and the State Sanitary Code were observed:
410.500: Water leaks through the roof, resulting in large areas of dark mildew
observed on the ceiling in the back bedroom, bathroom, and kitchen. Blue
tarp observed on the roof.
410.351: Water leaks out of the drain pipe of the sink in bathroom.
You are directed to correct the above listed violations within seven (7) days of
receipt of this notice.
You may request a hearing if written petition requesting same is received by the Board of
Health within seven (7) days after the date order is received. However, this violation
must be corrected regardless of any request for a hearing.
Please be advised that failure to comply with an order could result in a fine of not more
than $500. Each separate day's failure to comply with an order shall constitute a separate
violation.
You are also subject to non criminal citations of$40.00 for the first violation and $15.00
for each additional violation. Tickets will be issued daily until the violations are corrected.
PER ORDER OF THE BOARD OF HEALTH
Thomas A. McKean
Director of Public Health
cc: Building Inspector
ID
NOTICE TO ABATE VIOLATIQNS OF 105 CMR 410,00 ANiTARX
(;OUL II, MINIMUM STANUARUS OF FITNESS FOR HUMAN HADITATION
AND 'MIL TOWN OIL BARNSTABLE RENTAL ORDINANCE,ARTICLE 51
The property owned by you located at O P�o iY l� was inspected on
1994 I)ya... G.' Ileallh Agent for the Town of Barnstable because of e
aoillphin wing violat
t. The folloions of the Town A Barnstable Rental Ordinance
Article 51 and the Sanilary Code II were observed:
r
You are directed to correct the violation of
within 24 hours of receipt of this
notice by
Yon are Also directed to correct the remaining above listed violations within seven
(7) days of receipt of this notice.
You may request a hearing if written petition requesting some is received by the Hoard of
I tealtl, within seven (7) days aRer the date order is received. I lowever, these violations
must be corrected regardless of any request for a hearing.
Please be advised that failure to comply with an order could result in a fine of not more
than $500. L;ach separate day's failure to comply with an order shall constitute a separate
violation. ,
You are also subject to non criminal citations of$40.00 for the first violation and $15.00
for each additional violation. 'Tickets will be issued daily until the violations are corrected.
to violations
[Inclosed are citation numbers due
observed on
PFR ORDER OF THE BOARD OF HEALTH
Thomas A. McKean
Director of Public Health
Town of Barnstable