HomeMy WebLinkAbout0015 SHORT BEACH ROAD - Health 1
15 SHORT BEACH RD., CENTERVILLE
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UPC 12543
NO� 53L
HASTINGS,MN
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DATE.: .11/25./98 ,
PROPERTY ADDRESS: 15r—Shortb•eacfi Road
2F-
IVCenterville ,Mass. : r�02632 c,_n' 19J8On the above date,, I Inspected the saptic system a' '"thdLdress!:*This system consists of the following: �� r�4,1 . 1-1000 gallon septic tank. ��.2 . 1—Distribution box , Vk
3 . 2—flow diffussors .Packed in stone .
Based bn my Inec-action, I certify the following conditions:
4 . This is a title five .s'eptic system. ( 7.8-,Cede * )
5 . The septic system is' in proper working order
at the -present t-ime .
Flow Diffussors are dry. "
SIGNATURE:
Name J P _H*acomber Jr,
Company:_J. P_Macorgber. & y on•_Yrtc ,
� f
Address:_-8a�c-66------ -- --
entQvlLe �Ma,,sgs_Q2532
Phone:
___548...:Z7��338_______ • I
THIS CERTIFICATION DOES NOT CONSTfrUTE A GUARANTY OR WARRANTY
JOSEPH P. MACOM�BER '& SON, INC,
T+nks-C#upools-Lsach(laids
Pump+d Instilled '
' Town Sewer Connections
P.O. Box W Centerville, MA 02632.0066
775-333$ 775-6412
T �• r � ` l
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
ONE WINTER STREET, BOSTON, MA 02108 617-292-5500
WILLIAM F.WELD TRUDY COaIE
Govemor Secretary
ARGEO PAUL CELLUCCI DAVID B.STRUHS
Lt.Govemor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Commissioner
PART A
CERTIFICATION
Property Address:15 Shortbeach Road Centerville Address of Owner:37 Waterside Drive
Date'of Inspection: 11/2 5/9 8 Mass. (If different) Centerville ,Mass .
Name of Inspector:Joseph P.Macomber Jr . 02632
1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000)
Company Name: J. P.Macomber & Son Tnr _
Mailing Address: Box 66 rpnt-erui11e-,Magr, Q-2E332
Telephone Number: 5 0 8—7 7 5=3'I'I R
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:
Passes
Conditionally Passes
Needs Further Evaluation By the Local Approving Authority
_ Fails
Inspector's Signature: Date:
The System Inspector 0all 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) SYSTEM PASSES:
I 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.
COMMENTS:
e) SYSTEM CONDITIONALLY PASSES:
—Ift 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.
Indicate 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, unless the owner or operator has provided the system inspector with a copy of a Certificate of
Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection; or
�- the septic tank, whether or not metal, is 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.
(revimed 04/25/97) Page 1 of 10
DEP on the World Wide Web: http:/Avww.magnet.state.ma,us/dep
> Printed on Recycled Paper
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 15 Shortbeach Road Centerville ,Mass .
Owner: Donald F. Richter
Date of Inspection: 1 1/2 5/9 8
B) SYSTEM CONDITIONALLY PASSES (continued)
Aej� 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). Describe observations:
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) FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
46 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 HEALTH DETERMINES THAT THE SYSTEM 15 NOT FUNCTIONING IN A MANNER
WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
.I Cesspool or privy is within 50 feet of a surface water
y�Q 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 FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
The system has a septic tank and soil absorption system (SAS) and the SAS 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 the SAS is within a Zone I of a public water supply well.
414 The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well.
The system has a septic tank and soil absorption system and the SAS 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 free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm. Method used to determine distance g�14 —(approximation not valid).
3) OTHER
I
(sevimod 04/25/97) Pay 2 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM �J
PART A
CERTIFICATION (continued)
Property Address:
Owner:
Date of Inspection:
D] SYSTEM FAILS--
You must indicate ei;+'.er "Yes" or"No" as to each of the following:
_ 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.
Yes No
y/ 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.
ZStatic liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
a, Pea) VW44wr& ,A`X4a I
Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow.
4 times in h last year NOT due to clogged or obstructed ipe(s).
v Required pumping more than t es the y gg P
q P P g —
Number of times pumped JCL.
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] LARGE SYSTEM FAILS:
You must indicate either "Yes" or "No" as to each of the following:'
The following criteria apply to large systems in addition to the criteria above:
AJV. 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:
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
/JIff- 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 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.
(revised 04/25/97) Page 3 01 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 15 Shortbeach Road Centerville ,Mass .
Owner: Donald Richter
Date of Inspection: 1 1/2 5/9 8
Check if the following have been done: You must indicate either "Yes" or"No" as to each of the following:
Yes No
Pumping information was provided by the owner, occupant, or 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.
_ 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.
The system does not receive non-sanitary or industrial waste flow.
The site was inspected for signs of breakout.
_ All system components,4Kluding the Soil Absorption System, have been located on the site.
_ The septic tank manholes were uncovered, opened,and the interior of the septic tank was inspected for condition of
baffles or tees, material of construction, dimensions,depth of liquid, depth of sludge, depth of scum.
—The size and location of the Soil Absorption System on the site has been determined based on:
The facility owner(and occupants, if different from owner) were provided with information on the proper maintenance of
Sub-Surface Disposal System.
_ Existing information. Ex. Plan at B.O.H.
t✓ _ Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is
unacceptable) [15.302(3)(b)J
(revised 04/25/97) Page 4 of 10
FRQOM,,: WRLSH REALTY 775-7330 :'HONE NO. 508 771 1282 Nov. 09 1999 01:06PM
TOWN OF BARNSTA,BLE
GoT z 9 8 9- Z54
LOCATION If 5/402T 13 �c SEWAGE #
VILLAGE. C2A/G v11-LC ASSESSOR'S MAP Q LO 45'
INSTALLER'S NAME & PHONE NO.
SEPTIC TANK CAPACITY /000 G
LEACHING FACILI TY:(.type) �W DlrFv5o�25 (slze)�' S'�"�
NO. OF BEDROOMS 3 PRIVATE WELL OR PUBLIC WATERPO e) G
BUILDER OR OWNER
DATE PERMIT ISSUED: g
-DATE CO.LIPLIANCE ISSUED,
VARIANCE GRANTED:
i-2n&.-ir
`!y
_ f .
+ Z
rt vwP1FFU6oRS
� � r
SE"Tr
TANK
p6r
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address:15 Shortbeach Road Centerville ,Mass .
Owner: Donald Richter
Date of Inspection: 1 1/2 5/9 8
FLOW CONDITIONS
RESIDENTIAL:
Design flow: IX g.p.d./bedroom for S.A.S.
Number of bedrooms:
Number of current residents:
Garbage grinder (yes or no): d
Laundry connected to system (yes or no):_,dZ()
Seasonal use (yes or no):
Water meter readings, if available (last two (2) year usage (gpd): — /ii' •g
Sump Pump (yes or no):_ALQ / ,q 49t7 ygt u! l ,
Last date of occupancy:_uA)4
COMMERCIAUINDUSTRIAL:
Type of establishment: .41,4
Design flow: 42# gallons/day
Grease trap present: (yes or no).-4
Industrial Waste Holding Tank present: (yes or no)AA
Non-sanitary waste discharged to the Title 5 system: (yes or no)&
Water meter readings, if available:_&K
Last date of occupancy:_ N
OTHER: (Describe)
Last date of occupancy:_�[i
GENERAL INFORMATION
PUMPING RECORDS and s rc f information:
a ������
System pumped as part of inspection: (yes or no) A/D
If yes, volume pumped: /y11 allons
Reason for pumping:
TYPE OASYSTEM
Septic tank/distribution box/soil absorption system
" Single cesspool
Alt Overflow cesspool
Privy
Shared system (yes or no) (if yes, attach previous inspection records, if any)
IM I/A Technology etc. Copy of p to date contract?
Other
AAPROXIMATE AGE of all components, date installed (if known) and source of information:
Sewage odors detected when arriving at the site: (yes or no)_
(revised 04/25/97) Page 5 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 15 Shortbeach Road Centerville ,Mass .
Owner: Donald Richter
Date of Inspection: 1 1/2 5/9 8
BUILDING SEWER:
(Locate on site plan)
1�
Depth below grade:
Material of construction: _cast iron /40 PVC—other (explain)
Distance from pJivate water supply well or suction line Id (--
Diameter_
Comments: (condition of joints, venting, evidence of leakage, etc.)
Joints appear tight No evidence of lPakagP
System is vpntPd through the hnnca vent,
SEPTIC TANK:-&W 9" p,Al
(locate on site plan)
l
Depth below grade:
Material of construction: Zncrete _metal _Fiberglass _Polyethylene _other(explain)
If tank is metal, list age VIs age confirmed by Certificate of Compliance dZJ(Yes/No)
�tb�t� #�
Dimensions: ` !lJrG�l &-�'L� G/)
Sludge depth: IF
Distance from to oQ f sludge to bottom of outlet tee or baffle:
Scum thickness: tr
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottomof outlet tee or baffler
How dimensions were determined:
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.) Pump tank annually , Inlet & o u t l e t t P P, a r e i n =1 a r P
Liquid level at theof I invert s: fifty nna inrhac The teak is
a1rrtr1-ttrn113r --mind The tank shouro no oirl tQaae Af leakageAeeae lies
had veFy-4iitle use fer the past 1
GREASE TRAP:IV
(locate-on site plan)
Depth below grader
Material of construction NAconcrete /.�i metaWAFiberglassoVAPolyethylene/,/&other(explain)
itJA
Dimensions: AIA
Scum thickness:W.
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scwn to bottom of outlet tee or baffle:
Date of last pumping:
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.)
Grease trap is not present
(revised 04/25/97) Page 6 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:15 Shortbeach Road Centerville ,Mass .
Owner: Donald Richter
Date of Inspection: 11/2 5/9 8
TIGHT OR HOLDING TANK: (Tank must be pumped prior to, or at time, of inspection)
(locate on site plan)
Depth below grade: A:44
Material of construction:,tt/ concreteN�metal W Fiberglass4&Polyethylene4f4other(explain)
n114
AJA
Dimensions: AA
Capacity: AA gallons
Design flow:_ A A gallons/day
Alarm level: AJj%Alarm in working order,VA Yes;4a No
Date of previous pumping: IA
Comments:
(condition of inlet tee, condition of alarm and float switches, etc.)
Tight or holding tanks are not present .
DISTRIBUTION BOX:
(locate on site plan)
Depth of liquid level above outlet invert: Ala
Comments:
(note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.)
Distribution box has one lateral;No evidence of solids carry evpr ;
nn avi denre r.f leakage into nr out of the hox
PUMP CHAMBER:..
(locate on site plan)
Pumps in working order: (Yes or No) 40
Alarms in working order (Yes or No)
Comments:
(note condition of pump chamber, condition of pumps and appurtenances, etc.)
Pump chamber is not present
(revised 04/25/97) Page 7 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 15 Shortbeach Road Centervi1le ,Mass .
Owner: Donald Richter
Date of Inspection: 11/2 5/9 8
SOIL ABSORPTION SYSTEM (SAS): g� �'
(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: t� 9tr��tt y(�
leaching chambers, number:k/XOW 01, a ���✓
leaching galleries, number:
leaching trenches, number,length: r�
leaching fields, number, dimension
overflow cesspool, number:
Alternative system:
Name of Technology: !f
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
Loamy Gann Yn f; nA hpnrb cnpd No signs of hydraulic failure
n in • Ve t tion i n rm 1 Flow
or o d e a s p Q � o a F o diffusors are dry _
CESSPOOLS: -Aboe
(locate on site plan)
Number and configuration: C9
Depth-top of liquid to inlet invert: AA
Depth of solids layer: AM
Depth of scum layer:
Dimensions of cesspool: A9
Materials of construction: AM
Indication of groundwater: N
inflow (cesspool must be pumped as part of inspection)
Cesspools are not present .
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
Cesspools are not present .
PRIVY:Qbvel
(locate on site plan)
Materials of construction: Dimensions:
Depth of solids: Vd
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
Privy is not present .
(roviaod 04/25/97) Dag• a of 10
SUBSURFACE SEWAGE DISPO AL SYSTEM INSPECTION FORM.
PA T C
SYSTEM INFOR TION (continued)
ss: 15 Shortbeach Road C,.enterville ,Mass .
Donald Richter
tion: 11/25/98
WAGE DISP DSAL SYSTEM:
e ties to at least o permanent references landmarks or benchmarks
all wells-wi hinA 0' (Locate where public water-supp y comes-into house)-
M
l •
Ik 3 �
_ 4A•-o a
a
I
SUBSURFACE SEWAGE DISP(:-> ,L SYSTEM INSPECTION FORM
P i(1 C
SYSTEM INFOR;.': .rION (continued)
Property Address:15 Shortbeach Road Centerville ,Mass .
Owner: Donald Richter
Date of Inspection: 11/2 5/9 8
Depth to Groundwater Feet
Please indicate all the methods used to determine High Groundwater Elevation:
�btained from Design Plans on record
Observation of Site (Abutting property, observation hole, basenxni sump etc.)
4/ Determine it from local conditions
heck with local Board of health
Check FEMA Maps
heck pumping records
Check local excavators, installers
Use USGS Data
Describe in your own words how you established the High GrouncWter Elevation. Must be completed)
Used water contours Map .
Gahrety & Miller
12/16/94
Hand augered 5 ' below the flow diffussors .
no water encountered . ( 7 ' )
(rrviz•d 04/25/97) Page '100f 10
s•wwnr�.�n ir.-•+r.n►rwnv.nwT,.��nnr•►�..n►�wwr..nyrsti
TOWN OF Barnstable BOARD OF HEALTH
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART D •- CERTIFICATION
.-TYPE OR PRINT CLEARLY-!
.•.
PROPERTY INSPEC7'ED
STREET ADDRESS 15 Shortbeach Road Centerville ,Mass .
ASSESSORS MAP, BLOCK AND PARCEL
OWNER' s NAME Donald Richter
i
PART D - CERTIFICATION
NAME OF INSPECTOR Joeseph P,MAcomber Jr .
COMPANY NAME J. P.Macomber & Sorrf `Inc .
COMPANY ADDRESS Box 66 Centerville ,Mass . 02632.
Street Town or City S tat 0-1 IF
COMPANY TELEPHONE ( 508 ) 775 - 3338 FAX I 508 ) 790- 1578
CERTIFICATION STATEMENT
I . certify that I have personally inspected the sewage disposal system at
this address and that the information reported
was performed and any
tfiUe , accurate , and
complete as of the time of .inspeetion . The in'sPect
recommendations regarding upgrade , maintenance , .a.nd repair ,are consistent
with my training and experience -in- the proper funet.ioh an'd maintenance of on-
site sewage disposal systems .
Check one : '
—Zsysteui PASSED t
The inspection which I have conducted has not found any information
which indicates that the system fails to adequately protect public
health or the environment as defined in 310 CMR 16 . 303 . Any failure
criteria not evaluated are as stated in the FAILURE CRITERIA section of
this form.
System FAILED*
The inspection which I have con ted has found that the system fails to
protect the public health and the environment in accordance with Title
5 , 310 CMR 15 , 303 , and as specifically noted on PART C - FAILURE
CRITERIA of this inspection form .
Inspector Signature Date
One copy of this rtifieation must be provided to the OWNER, the BUYER
( where applicable ) and the BOARD OP' ItEALTII,
IF If the inspection FAILED, the owner or""operator shall u d
within o'ne year of the date of the inspection, unless allowed ortrequiredm
otherwise as provided in 3.10 Cmil 16 . 306 ,
partd .doc