HomeMy WebLinkAbout0040 SEA MEADOW CIRCLE - Health 40 Sea Meadow Circle
Centerville
A = 246 237
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1
/17/I/iPlllG® ��
10259
No.C_H1630R
HASTINGS.UN
Commonwealth of Massachusetts
Executive Office of Environmental Affairs
Department of REMOVED
yD E P Environmental Protection
OCT 3 1 1995
3
William F.Weld Goamor HEALTH DEPT.
Trudy Coxe TOWN OF"BARNSTABLE
Seentary, EA
David B.Struhs
Commit"ner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM '
PART A
►)')�/7�n Ire y►✓►e k, CERTIFICATION
y O Se.a r>? dew G i ivy�. )A ytln n/aS ��T
Property Address: Ad ress of Owner:
Date of Inspection: -U23 - s (If different)
Name of Inspector: W.E. Robinson Sr.
Company Name, Address and Telephone Number: W.E. Robinson Septic Service
P.O. Box 1089
Centerville MA
CERTIFICATION STATEMENT ��7 7�7�7
I certify that I have personally inspected the sewage disposl s�s(erh6at 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 se age disposal systems. The system:
Passes '
_ Conditionally Passes
_ Needs Further Evaluation By the Local Approving Authority
_ Fails
Inspector's Signature: All 1, Date: /b
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: f
Check A, B, C, or D:
A] SYSTE PASSES:
7I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303.
Any failure criteria not evaluated are indicated below.
B] SYSTEM CON TIONALLY PASSES:
One or more stem components need to be replaced or repaired. The system, upon completion of the replacement or repair,
passes inspecti
Indicate yes, no, or not d ermined (Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain wiry rwty
_ The se is tank is metal, cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure a
immin nt. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as
not
ed by the Board of Health.
(revised 8/15/95) �/t/t� 1
One Winter Street • Boston,Massachusetts 02108 a FAX(611)SW1049 a Telephone(617)2924=
f
0 Printed on Recycled Paper
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
o
Property Address: JNo Sea,/Y1e« Odd G r rc,/
Owner: I YI A�^ h 7✓'i9/7/cJ�ci/G
Date of Inspection: ,a 3 9 S
B]SYSTEM CONDITIONALLY PASSES (continued)
_ Sewage backu or breakout or high static water level observed in the distribution box is due to broken or obstructed
pipe(s) or due t 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 requ red pumping more than four times a year due to broken or obstructed pipe(s). The system will pass
inspection if(wi n approval of the Board of Health):
broken pipe(s) are replaced
p obstruction is removed
W"
C] FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
Conditions exist which r),qeher evaluation by the Board of Health in order to determine if the system is failing to protect the
public health, safety andonment.
1) SYSTEM WILL PASS UNRD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER
WHICH WILL PROTECTBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
Cesspool or priin 50 feet of a surface water
Cesspool or priin 50 feet of a bordering vegetated wetland or a salt marsh.
2) _SYSTEM WILL FAIL UNBOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT
THE SYSTEM IS FUNCTIONING N A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
_ The system has a septic ank and soil absorption system and is within 100 feet to a surface water supply or tributary to a
surface water supply.
_ The sv tem ha, a septic tank and soil absorption system and is within a Zone I of a public water supply well.
_ The system has a septi tank and soil absorption system and is within 50 feet of a private water supply well.
_ The system has a septi tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water
supply well, unless a ell water analysis for coliform bacteria and volatile organic compounds indicates that the well is
free from pollution fr m that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5
ppm•
D] SYSTEM FAILS:
I have determined that the system iolates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis
for this determination is identifi low. The Board of Health should be contacted to determine what will be necessary to correct
the failure.
Backup of sewage into cility or system component due to an overloaded or dogged SAS or cesspool.
Discharge or pondin of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or
cesspool.
(revised 8/15/95) (�" 2
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: L/(�
Owner: ni'
Date of Inspection:
DJ SYSTEM FAILS (continued):
Static liquid level n the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
Liquid depth in ces pool is less than 6" below invert or available volume is less than 1/2 day Flow.
Required pumping ore than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pu ped
Any portion of the S it Absorption System, cesspool or privy is below the high groundwater elevation.
Any portion of a ces pool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
Any portion of a ces pool or privy is within a Zone I of a public well.
Any portion of a ce pool or privy is within 50 feet of a private water supply well.
_ Any portion of a c sspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no
acceptable water uality 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.
El LARGE SYSTEM FAILS:
The following criteria apply to large ystems in addition to the criteria above:
The design flow of system is 10,000 d or greater (Large System) and the system is a significant threat to public health and safety
and the environment because one or ore of the following conditions exist:
the system is within 400 f of a surface drinking water supply
the system is within 200 f t of a tributary to a surface drinking water supply
the system is located in nitrogen sensitive area (Interim Wellhead Protection Area(IWPA) or a mapped Zone 11 of a
public water supply we )
The owner or operator of any such syste shall bring the system and facility into full compliance with the groundwater treatment program
requirements of 314 CMR 5.00 and 6. Please consult the local regional office of the Department for further information.
��
(revised 8/15/95) 3
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
/S er
Property Address: .4�
Owner: r)l Ar•tn )'j^.A/ a
Date of Inspection:
Check if the following have been done:
umping information was requested of the owner, occupant, and Board of Health.
4//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 ag part of this inspection.
V 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.
/TThe system does not receive non-sanitary or industrial waste flow
t/The site was inspected for signs of breakout.
VAII.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.
_L/The size and location of the Soil Absorption System on the site has been determined based on existing information or
/approximated by non-intrusive methods.
'V The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of Sub-
Surface Disposal System.
(revised 8/15/95) 4
1
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: �—/d Se a., M 6a.fl ek) G �✓'C'J
Owner: m Iq r*,;l Tj^141, k/ I 1C
Date of Inspection: / 0 3_ 9 6/
FLOW CONDITIONS
RESIDENTIAL:
Design flow:�gallons
Number of bedrooms:3
Number of current residents:
Garbage grinder(yes or no):A
Laundry connected to system (yes or no):y
Seasonal use (yes or no): A-*"
Water meter readings, if available: fgsl
Last date of occupan
COMMERCIAL/IND STRIAL:
Type of establishm nt:
Design flow: allons/day "
Grease trap pres t: (yes or no)_
Industrial Wast Holding Tank present: (yes or no)_
Non-sanitary aste discharged to the Title 5 system: (yes or no)_
Water meter readings, if available:
Last date of occupancy: Q 3-4
OTHER: (Describe)
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
System pumped as part of inspection: (yes or no)_&I/'0
If yes, volume pumped. eallons
Reason for pumping:
TYPE O 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)
Other (explain)
APPROXIMATE AGE of all components, date installed (if known) and source of information: ;L y zy z64-
f;i r`I G �6
Sewage odors detected when arriving at the site: (yes or no)A
(revised 8/15/95) 5
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: N e 5e d_m e`Lt1 d-,L) C i r G I�e-- 01'I/yi9114/S �d r
Owner: rA,4 r I✓J T/ c/ I/I X
Date of Inspection: ,a 3_ cj S
SEPTIC TANK:_v
(locate on site plan)
Depth below grade:
Material of construction: 1oncrete _metal _FRP—other(explain)
t /
Dimensions:
Sludge depth: d a 1
Distance from top of sludge to bottom of outlet tee or baffle:'
Scum thickness:
9 '
Distance from top of scum to top of outlet tee or baffle: t �
Distance from bottom of scum to bottom of outlet tee or baffle: 73
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.) JV A y5
GREASE TRAP:_
(locate on site plan)
Depth below grade:
Material of construction: _c crete _metal _FRP—other(explain)
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom rn sou in t,onom of outiet tee or baiiie
Comments:
(recommendation for pump ng, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
integrity, evidence of leaka c•, etc.,
I/1
(revised 8/15/95) 6
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: °L�d Sea /Nea'04 /rc�7�'
Owner: /Y1 ff/`7`/h T;'gl9 y W/G/C
Date of Inspection:
TIGHT OR HOLDING T K:_
(locate on site plan)
Depth below grade:
Material of construction: _c ncrete _metal _FRP—other(explain)
Dimensions:
Capacity: gallons
Design flow: gallon day
Alarm level:
Comments:
(condition of inlet tee, conditio of alarm and float switches, etc.)
DISTRIBUTION BOX:V
(locate on site plan)
Depth of liquid level above outlet invert: O
Comments:
(note if level and distribution is equal, evidence of solids carr)-ovc , evidence of leakage into or out of box, etc.)
PUMP CHAMBER:_
(locate on site plan)
Pumps in working order(yes or no)
Comments:
(note condition of pum chamber, condition of pumps and appurtenances, etc.)
(revised 8/15/95) 7
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
s2��I2� E'101� /�
Property Address:'y4 4 �
Owner: 0119 t-1-i'J 7l7,4)1 V c K'
Date of Inspection:
l �3� 9
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:
Comments: (note condition of soil, signs of hydraulic failure, level of ponding, conditiof of vegetation,etc.)
15T
CESSPOOLS: _
(locate on site plan)
Number and configuration:
Depth-top of liquid to inlet in ert:
Depth of solids layer:
_ f
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater:
inflow (cesspool ust be pumped as part of inspection)
Comments: (note conditi n of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
PRIVY:_
(locate on site plan)
Materials of construction: Dimensions:
Depth of solids:
Comments: (note condition of soil, si ns of hydraulic failure, level of ponding, condition of vegetation, etc.)
(revised 8/15/95) 8
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
Owner: )FYI A/
Date of Inspection:
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100'
zj
�a Or-
DEPTH TO GROUNDWATER
Depth to groundwater: I�— feet � 1 ,
method of determination or approximation: 1 S � /''�
(revised 8/15/95) 9
TOWN OF BARNSTABLE of
LOCATION Ale SEWAGE # "
VILLAGE 7 ASSESSOR'S MAP & LOTI`IeX 7
INSTALLER'S NAME & PHONE NO.I 1%, (rid�jri►/�v nJ
SEPTIC TANK CAPACITY /000 G�g�
LEACHING FACILITY:(type) (size) o;Lr.< /
NO. OF BEDROOMS PRIVATE WELL.OR PUBLIC WATERprZ/,L-
BUILDER OR OWNER AXJGZ r,
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes Now
� 1, ry
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C �� � �---=_.� .
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,---� 3 fiou, y/Fjusct2 f i
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No.._ ".... ............. Fps .......
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH APPROVED
Oor1t2 -tJ.-.....................of !4� 9 �CaC'..._....-------------' ....... l°Cwtssrvation p�
Apphr�t#tut� for Uiipuua1 urku Tonstrur to � d
Application is hereby made for a Permit to Construct (� ) or Repair ( ) an Individual Sewage Disposal
4�6ystem at: 601
Location•Ad ess�-� o �...o.. .. ..
pl� =_�_'_�'-<<_.�.i---........-•-•-- �� �G
Q. --------...1._.._..-ess
a `` f y Owner �/ /Inl(A.t �/
/�4- L.._Q.. _____________________________ i/S.IQ{/-----
� Installer Address `�
UType of Building Size Lot__ ;.27._...___6�....Sq. #eet
Dwelling—No. of Bedrooms_________5_______________________________Expansion Attic ( Garbage Grinder 41 o
aOther—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria
Otherfixtures -------------------------------------------- ----------------------------------------------------------------------------•-•••-------------------
W Design Flow...... ----5 .........gallons per person per day. Total daily flow... =...........................gallons.
WSeptic Tank—Liquid capacii �1M_gallons Lengtfe-�__. Width.--A.'-id'. Diameter__---c.
x Disposal Trench—Now'_L_�! !A&1MSidth_...12........... Total Length._9t`k__.__.___. Total leaching area__J(&(C.').....sq. ft.
Seepage Pit No._____ ____._ Diameter____________________ Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box -- Dosing tank A
~' Percolation Test Results Performed by
Percolation Date........................................
r
a Y----
Test Pit No. 1...4Z::---minutes per inch Depth of Test Pit____----- Depth to ground water_._$.. ..........
44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
Description of 5oil..... ...5�aa5o?5-L.-- �_. ,ts►.�
-----------------•-•.--....--•.--.-----.........._.-------.--.....----------.
---------------------------------------------_............................................................................DESIGNING ENGINEER MUST SUPERVISE
U Nature of Repairs or Alterations—Answer when applicable.............INSTALLATION AND__ CERTIFY IN WRl'T1NG
------------.....
-.......------���---cs1--- 1! ! . _-------THE,SYSTEM WAS INS'rALI.ED Tf�STRTC'Y
Agreement: Ada ORDANGETO-PLAN------------------------- ----•----
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has be • sue by the and of health.
.. ..-- ------ •-- ...............
_
Application Approved z ac
Date
Application Disapproved for the following reasons:...............................................----•--------•--------•--------•------------------------•••••••-
..........................••--------•----....._...----------....•--------•...•---•-----••••••----......•---..........-------------••-----....---•-----------------------•-----------------•----.._......
Permit No..� - -- --...._ Issued--••------•- �gl f ......................
Date
VNA �Z_,C)
No.- .- Fim ................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
r� _
^...._R��.`.r~;.f.?.......................OF...�.�A�Z.tA .........ke .......................................
Applirotion for Disposal Works Tontxnrtion 1hrmit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System_at:.... : ' ( .�•- .................. �jC � L ............. ....... .-• .1--......••-•--•.............- -•--•-••-- --...----......Location-Address or Lot No.
......................_.......................................................................... •••-••-•••--......................................................................................
Owner Address
W
Installer Address
Type of Building „� Size Lot.. .".,t- -..E�.� ----Sq. feet
Dwelling—No. of Bedrooms.-_........?...............................Expansion Attic (40 Garbage Grinder Ja
'4 Other—Type of Building ....... No. of persons.......................... Showers — Cafeteria
P4 Other. fixtures .---•------••----•------•-----------•--......--•-.............-
W Design Flow......::.: __..? .........gallons per person per day. Total daily flow__.... ...........................gallons.
WSeptic Tank—Liquid capaci�y�.(f�n..gallons Lengtl(2._ Diameter-__---=. Depth.,-°-6�...
x Disposal Trench— ........... Total Length..2_`A........... Total leaching area..41A'a......sq. ft.
Seepage Pit NO......:A-------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box �Ie� Dosing tank N '�. _
Percolation Test Results Performed by......f>k............................. ............... .......................... Date......... 2.° ��;�.
�
a Test Pit No. 1_.�..._-..__minutes per Inch Depth of Test Pit..... .......... Depth to ground water.... ..........
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
a ............................•----------------.......--•--••............................................................
O Description of Soil.... ... :`":"_ _ .._.7c� ?G---, .....1 ---- �(--'._....-`k'A=�=� �'
V .--------------------- S ----••---•------------•-•--.............----....................------------.....-------•---•----•---..............---•--------------------------....--------
W ................................................
UNature of Repairs or A terations—Answer when applicable...............................................................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TLITIZ4 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has be sueO by the board of health.
Si
gne = .......................................................... ......--D�t---••--�'
Application Approved��.•---- "_ ..`
Date
Application Disapproved for the following reasons:------•-------------------------...............................................................................
....-•---•----•----••--------------•----.............---••-•--••---......-----•-•-•--•-----•-----•--•---•--•--•---------------------•---...-----••----• -------....... ---•---
PermitNo......................................................... Issued................. 1-..............................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
...........O F.............................................................. .......................................................
Tintifirate of Tomplittnrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
by----------------------------------------------------------------------------------------------------------------------------------------------------------------------•-•-•-----------------•---•---
Installer
at-----------------•---•-------------..-----------•--•--------•-•-----•-•-----------•---------•-----•--------•-----•--•--------•-------.---.---------------------------------..-------------------•--•-
has been installed in accordance with the provisions of TITIE 5 of The_State Sanitary Code as des ibed in the
application for Disposal Works Construction Permit No...........�. ' _._ __._____. dated__...___._-'� C..._..__._.
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL.,FUNCTION ATISF T RY.
U. ' 7._....... �'_..... Inspect
DATE...
THE COMMONWEALTH OF MASSACHUSETTS
r-
BOARD F HEALTH
`^ d-�--
No22... --��.... FEE.........................
_.._._.
Disposal r �onotrudion rrn it
h
r //y S' Q N < ! - -- C-...................................................
Permisslon Is hereby granted.-•-.--•--------- 6...................-------------.--+�-�----- a,
to Construct ( ) or Repai (�) an Individual Sewage Disposal)System
atNo..,�- �, a ...,f �_. .f d. ._ �tl. .......................................
Street - `•7 Z �^�
as shown on the application for Disposal Works Construction Permit Now & '` . ..................•._... ...............
DATV/�` ..-I}- jl' ------------------ Board of Health
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS --
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No. 29733
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