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HomeMy WebLinkAbout0039 SHEAFFER ROAD - Health 39 SIiEAFFER RD, CENTERVILLE IIII J�QECYCiEp�p UPC 12543 No. �sr.coNS°s HASTINGS, MN • f BORTOLOTTI CONSTRUCTION, INC. OC r 1 45 INDUSTRY ROAD MARSTONS MILLS MA 02648 8 7 f 2000 508-771-9399 508-428-8926 FAX: 508-428-9399 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM"�) �` . t PART A CERTIFICATION Property Address: Date Of Inspection Inspector's Name: O -er's Name and Address- C'E,RTIFICATION STATEMENT: I Certify that I have personally Inspected the Sewage Disposal System at this address and that the informa- tion reported below is true,accurate and complete as of the time of Inspection. The Lispection was perform- ed based on my Training and Experience in.the Proper Function and Maintenance of On-Site Sewage Dis- posal Systems.T>e system: Passes Conditionally . es Needs Furth f val ti y the Local Approving Authority Failure Inspector's Signature Date: The System Inspector shall submit a copy of this Inspection Report to the Approving Authority with 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• A) SYSTE PASSES: I have not found any Information which indicates.Chat the System violates any of the fail- ure criteria as defined in 310 CMR 15.303. Any Failure Criteria not evaluated are indi- cated 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,nor,or not determined(Y,N,OR ND). Describe bases of determination in all instances. If"not determined",explain why not. The Septic Tank is Metal,Cracked,Structurally Unsound,shows Substantial Infiltration or exfil- tration,or Tank Failure is imminent. The System will Pass Inspection if 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 clue 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): -1- F SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM :. PART A CERTIFICATION (continued) Broken pipe(s)replaced Obstruction is removed Distribution Box is leveled 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)FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board Of.Health in order to determine if the System is failing to protect the Public Health,Safety and the Environment. 1)SYSTEM WILL PASS UNLESS BOARD OF HELATH 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 Water . 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 APPROPRIATE)DETERMINES THAT THE SYSTEM IS FUNCTION- ING IN A MANNER THAT PROTECTS 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 with a Zone 1 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 coliform bacteria and volatile organic compounds indicates that the Well is from pollution from the 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 violates one or more of the following Failure Criteria as defined in 310 CMR 15.303. 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 overload 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 clog- ged 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 - 2 - I . SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) 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 1 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 coliforin bacteria,volatile organic compounds,ammonia►itrogen and nitrate nitrogen. E) LARGE SYSTEM FAILS: The following criteria apply to a large system in addition to the criteria above: The design flow of a system is 10,000 ggd 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 II of a public water supply well. The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 315 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST 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 atleast 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. _j�/As-built plans have been obtained and examined. Note if they are not available with N/A. Tlie facility or dwelling was inspected for signs of sewage back-up. r,6The system does not receive non-sanitary or industrial waste flow. _/The site was inspected for signs of breakout. =J11 system components,excluding the Soil Absorption System,have been located on site. The septic tank manholes were uncovered,opened,and the interior of the septic tank was in- �pected for condition of baffles or tees,material of construction,dimensions,depth of liquid, deptli of sludge,depth of scum. 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. - 3 - SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST(continued) V Tlie facility owner(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 / FLOW CONDITIONS RESIDENTIAL: v/ Design Flow:-30gallons Number of Bedrooms:_Number of Current Residents:. Garbage Grinder: Laundry Connected To System:(k� Seasonal Use: y- Water Meter Readings,if ilable: U .Last Date of Occupancy: r r COMMERCIAL/INDUSTRIAL.,/ Type of Establishment: Design Flow: gallons/day Grease Trap Present: (yes or no) Industrial Waste Holding Tank Present: Non-Sanitary Waste Discharged To The Title V System: Water Meter Readings,If Available: Last Date of Occupancy: OTHER: (Describe) Last Date of Occupancy: GENERV,11_'0j1'-"27&ee0✓1­.)' NFORMATION PUMPING RECORDS any source of information; ./�iI�YY'" '� System Pumped as part of inspection: I(yes,volume pum d: gallons Reason for Pumping: TYPE OF SYSTEM: optic Tank/Distribution Box/Soil Absorption System Single Cesspool Overflow Cesspool Privy Shared System(If yes,attach previous inspection records,if any) " Other(explain): APPROXIMATE AGE of all compon ts,date installed(if known)and source of information: Sewage od detected when arriving at the site:�lj� -4- SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C GENERAL INFORMATION (continued) SEPTIC TANK: Depth below grade: Material of Construction: concrete metal FRP Other (explain) Dimensions: V(o'yT4�Sludge Depth: ScumoThickness: 3 Distance from top of sludge to bottom of outlet tee or baffle: 7Z. Distance from bottom of scum to bottom of outlet tee or baffle: /© Comments: (recommendation for pumping,couditioin of inlet and outlet t es or baffles,depth of li �Ievel in relati/o )to outlet'avert,structural integrity,evidence of leakage,etc. ,�g 42 /DGb GREASE TRAP:�� Depth Below Gr de: Material of Construction: concrete metal FRP Other (explain): Dimensions: Scum Thickness: Distance from top of scum to top 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 TANK: Depth Below Grade: Material of Construction: concrete metal FRP Other (explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm Level: Comments: (condition of inlet tee,condition of alarm and float switches,etc.) DISTRIBUTION BOX — Depth of liquid level above outlet invert: Continents: (note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.) PUMP CHAMBER: r_ ` Pump is in working order: Comments: (note condition of pump chamber,condition of pumps and appurtenances,etc.) - 5 - SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM _ PART C SYSTEM INFORMATION(continued) SOIL ABSORPTION SYSTEM(SAS): (Locate on site plan,if possible; excavation not required,but may be approximately by non-intrusive methods) If not determined to be present,explain: Type: Leaching pits,number: Leaching chambers,number: Leaching galleries,number: Leacahing trenches,number,length: Leaching fields,number,dimensions: Overflow cesspool,number: C niments: (note conidt�f soil,signs of hydraulic failure level o ponding,co dition of vegetatio etc.) r ,, j/ amJ CESSPOOLS: 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(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: Materia s of construction: Dimensions: Depth of Solids: Comments: (note condition of soil,signs of hyddraulic failure,level of ponding,condition of vegetation, etc.) - 6 - SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) SKETCH OF SEWAGE DISPOSAL SYSTEM: Include ties to atleast two permanent references,landmarks or benchmarks. Locate all wells within 100 Feet. �v 1� 0 0 O DEPTH TO GROUNDWATER: / 5 Depth to groundwater: Feet ��/�sjQ4V O & Method of—Determination or Approxima iott: i- 7 - TOWN OF BARNSTABLE >D � LOCA:']0 SEWAGE # 96 - 30 4VILLAGE ASSESSOR' & LOT q� ��i?ECe .�TDRS:'NAME&PHONE N0. SEPTIC TANK CAPACITY /0 b0 7 LEACHING FACILITY: (type (size) 16co ° NO.OF BEDROOMS BUILDER OR C� Lz.Qi PERMIT DATE: `7-- /O T 9 0 COMPLIANCE DATE: "7—10 v 9ri 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 ~� °�`° �`� is 2q' � ��, J �" f ,_ �� O TOWN OF BARNSTABLE LCaCATION SEWAGE #90 � VILLAGE Ce�j���,'�1 ASSESSOR'S MAP & LOT INSTALLER'S NAME & PHONE NO.SEPTIC TANK CAPACITY LEACHING FACILITY:(type) T (size) NO. 017 BEDROOMS PRP'�LL OR PUBLIC WATER OR OWNER DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED:: VARIANCE GRANTED: Yes No s ' 07 1 ✓/7 0 hJ `�