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HomeMy WebLinkAbout0009 SOUTHWINDS CIRCLE - Health 9-Southwinds Circle Centerville P 226 158 UPC 12543 No. 53t_Od4 ..�c*a4c yN i COMMONWEALTH OF MASSACHUSETTS ExECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION Z2 _ RECEIVED „AAP PARCEL ®, SEP282004 TOWN OF BARNSTABLE HEALTH DEPT. TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address ' Owner's Name: e�r Owner's Address: 6 J O C,t/ifi� Date of Inspection: Name of Inspector:(please print) C'hgrles S. (4,owc Company Name:TP.wks6u.ru CPe.)~ ice �1 Mailing Address: AQ P**cZ Rd. �1r ► '' T Telephone Number.(97¢ 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: Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signatu e: Date: ' 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. Title 5 Inspection Form 6/15/1000 page 1 hr Page 2 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION_ FORM PART A CERTIFICATION (continued) Property Address: Owner: Date of Inspection: Inspection Summary: Check A,B,C,D or E I ALWAYS complete all of Section D A�ze Passes: 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. Comm .B. .System.Conditionally Passes: . One or more system components as described in the"Conditional Pass"section need to be re ced or repaired.The system,upon completion of the replacement or repair,as approved by the Board of ealth,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements. "not determined"please explain. The septic tank is metal and over 20 years old*or the septic tank(w er metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is minent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by a Board of Health. ;A metal septic tank will pass inspection if it is structurally sound of leaking and if a Certificate of Compliance indicatinc,that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or ven distribution box.System will pass inspection if(with approval of Board of Health)` broken ipe(s)are replaced ob ction is removed d' 'bution box is leveled or replaced ND explain: The system required mping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with ap oval of the Board of Health): broken pipe(s)are replaced obstruction.is removed ND explain: 2 Page 3 of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A �^ CERTIFICATION(continued) Property Address: J�ta�� �S /l•- Owner: Date of Inspection: C. Further Evaluation is Required by the BoXaH alth: Conditions exist which require further evy the Board of Health rder to determine if the systcm is failing to protect public health.safety or the ent. 1. System will pass unless Board of Healtnes in accor nee with 310 CMR 15303(1)(b)that the system is not functioning in a manner wl protect blic health,safety and the environment: Cesspool or privy is within 50 feet o rCesspool or privy is within 50 feet og vegetated wetland or a salt.marsh 2. Svstem will fail unless the Board of Health(and Public Water Supplier,if any) ermines that the system is functioning in a manner that protects the public health,safety and envi nment: _ The system has a septic tank and soil absorption system(SAS)and th AS is within 100 feet of a surface water supply or tributary to a surface water supply. _ The system has a septic tank and SAS and the SAS is with' Zone 1 of a public water supply. The system has a septic tank and SAS and the SAS i ithin 50 feet of a private water supply well. _ The system has a septic tank and SAS and the S is less than 100 feet but 50 feet or more from a private water supply well".Method used to det ine distance "This system passes if the well water ana sis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic com oun ndicates that the we g p 11 is free from pollution from that facility and , the presence of ammonia nitrogen nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A co of the analysis mast be attached to this form. 3. Other: 3 Page 4 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: Owner: Date of Inspection: D. Svstem Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ischarge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or y / clogged SAS or cesspool Lv 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 '/: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 SAS,cesspool or privy is below high ground water elevation. Any portion of 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. [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.] (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: To be considered a large system the system must serve a facility with JILAKign 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 a criteria above) yes no the system is within 400 feet of a s e drinking water supply the system is within 200 feet a tributary to a surface drinking water supply the system is located ' nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public ater supply well If you have answered" s"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. 4 Page 5 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: Owner: Date of Inspection: Check if the followine have been done. You must indicate`ves"or"no"as to each of the followins: Y No es . Pumping information was provided by the owner,occupant,or Board of Health — /Were any of the system components pumped out in the previous two weeks? -Has the system received normal flows in the previous two week period? Have large volumes of water been introduced to the system recently or as part of this inspection? Were as built plans of the system obtained and examined?(If they were not available note as N/A) Was the facility or dwelling inspected for signs of sewage back up? Was the site inspected for signs of break out? _ Were all system components,excluding the SAS,located on site? Z_ 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? _ 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 Existing information.For example,a plan at the Board of Health. 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)] 5 Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: Owner: Date of Inspection: FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):/��15.203 Number of bedrooms(actual): c.*4 DESIGN flow based on 310 C (for example: 110 gpd x#of bedrooms): Number of current residents: Does residence have a garbag grinder(yes or no): /✓ Is laundry on.a separate sewage system(ve or no):.V [if yes separate inspection required] Laundry system inspected(yes or no):1� Seasonal use:(yes or no):Y J-'v Water meter readings, if atlable(last 2 years usage Sump pump(yes or no):Z Last date of occupancy: COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): d Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no). Industrial waste holding tank present( or no):_ Non-sanitary waste discharged to itle 5 system(yes or-no):_ Water meter readings, if availab Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Was system pumped as part the inspection(yes or o): If yes,volume pumped:gallons—H w was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM _Septic tank,distribution box,soil absorption system _Single cesspool _Overflow cesspool Privy _Shared system(yes or no)(if yes,attach previous inspection records,if any) _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: zjz'zrr S Were sewage odors detected when arriving at the site(yes or no): o4,1 6 Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: :2,Sy ta�ZZra x.lS C� Owner: Date of Inspection: BUILDING SEWER(locate on site plan) Depth below grade: /, 1—. Materials of construction: i cast iron 40 PVC_other(plain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK:_(locate on site plan) ..Depth below grade: Material of construction:_concrete_metal_fiberglass Iv ylene —other(explain) If tank is metal list age:_ Is age confirmed by a Certificat f Compliance(yes or no):_(attach a copy of certificate) Dimensions: Sludge depth: p"�, _ �— /` ®d Distance from top of sludge to bottom.of outle ee or baffle: Scum thickness: Distance from top of scum to top of o tee or baffle: Distance from bottom of scum to bo m of outlet tee or baffle: How were dimensions determine . Comments(on pumping reco endations,inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert, dence of leakage,etc.): GREASE TRAP:_(locate on site plan) Depth below grade:_ Material of construction:_concrete_metal_fiberglass_pol ylene_other (explain): _. Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or b Distance from bottom of scum to bottom of outle a or baffle: Date of last pumping: Comments(on pumping recommendation Inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of ge,etc.): 7 Page 8 of I l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner: Date of Inspection: TIGHT or HOLDING TANK: (tank must be pumped at tim inspection)(locate on site plan) Depth below grade: Material of construction: concrete - metal erglass__polvethvlene other(explain): Dimensions: Capacity: V Design Flow: Alarm present(ves or Alarm level: es or no): Date of last pumping: Comments(condition s,etc.): DISTRIBUTION BOX: (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Comments(note if box is level and distribution to outlets equal;an evidence of solids carryover,any evidence of leakage into or out of box,etc.): vv � PUMP CHAMBER: (locate on site plan) Pumps in working order(yes or no): Alarms in 'working,order(yes or no): Comments(note condition of pump chamber ondition of pumps and appurtenances,etc.): 8 Page 9 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner Date of Inspection: SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number:_ leaching chambers,number: leaching galleries,number: eaching trenches,number, length: - ,/ /O leaching fields,number,dimensio . overflow cesspool,number: innovative/alternative system Typeiname of technology: Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation, etc.): CESSPOOLS: (cesspool must be pumped as.part of inspection)(locate on site plan) Number and configuration: /� �� � -e Depth-top of liquid to inlet . . en: _ Depth of solids laver: S� Depth of scum layer:" Dimensions of cesspodf: Materials of construction: t✓ , Indication of groundwater inflow(yes or no):. Comments.(note condition of soil,signs of h�Y ulic failure, level of pondin ,condition of vegetation,etc.): ® o G 1 s tFrazel ., PRIVY: (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of by ulic failure,level of ponding,condition of vegetation,etc.): 17 Page 10 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address Owner: Date of Inspection: 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. � 3 � S r�v�s C�-• J 10 Page 11 of 11 . OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: T� Owner: Date of Inspection: SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water _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) Accessed USGS database-explain: You must describe how you established the high ground water elevation: Aj- 11 > Town of Barnstable Board of Health 200 Main Street, Hyannis MA 02601 Office:..508-862-4644 Susan G.Rask,R.S. FAX: 508-790-6304 SumnerKaufman,MSPH Wayne Miller,M.D.. September 15, 2004 Mr..Angelo. Petrosino 29 Westwood. Circle North. Reading, MA 01864 Dear Mr. Petrosino, You. are granted. a variance to continue to. utilize. the. existing. cesspools. while, obtaining. Health. Division approval. of the. building permit application to elevate.::.:.; your. dwelling and. to fill-in the foundation. with. cement at 9. Southwinds Circle;: Centerville. The.variance granted is as follows: :. .. PART VIII, SECTION 5.00:. To.continue to utilize.the. existing.cesspools while.,. ;.r obtaining Health Division approval of a building permit application to elevate the dwelling.and to.fill-in the.foundation.with cement. This variance is granted.with.the following.condition: • The existing cesspools. shall. be: inspected. by a. DEP certified.septic inspector. The variance is granted.only if both.cesspools "pass" inspection. However, if one or both cesspools fail. inspection,.the.applicant must replace the cesspools with a septic system.which. meets the.State Environmental. Code, Title 5, within two.years. . The basement becomes flooded from outdoor surface water run-off on a regular basis. causing mildew within. the. home and causing.the support beams within the basement to. become rotted... The homeowner testified. that the only resolution is. to elevate.the home and.to fill-in the.foundation with. cement. He also stated that the. cesspools are presently functioning. properly and. are. located several. feet above the. groundwater table. If the system passes. an. inspection, the Board. has. no.objection.to this. proposal to.fill-in the foundation with cement. Sincerely yours, Miller, M.D.Way Q:WP/Petrosino , t^ �F THE 1p� DATE: `2 �O FEE: + BARNSPABLE, R Hanes. REC. BY �1 9� i659. 1�g' ATF°"�rA Town of Barnstable SCHED. DATEc= ,' Board of Health 200 Main Street, Hyannis MA 02601 Office: 508-862-4644 Susan G.Rask,R.S. FAX: 508-790-6304 Sumner Kaufman,M.S.P.H. Wayne A.Miller,M.D. VARIANCE REQUEST FORM LOCATION n z4 ]�, Property Address: 1 - - of ,`moo I cA G1 f--C Assessor's Map and Parcel Number: 4Z—2- Size of Lot: 1 n / �7 Wetlands Within 300 Ft. Yes Business Name: No Subdivision Name: APPLICANT'S NAME: Phone Did the owner of the property authorize you to represent him or her? Yes ' No PROPERTY OWNER'S NAME CONTACT PERSON Name: C 1, PCI'4�0 51 Name: ` ?JV4,5 Address: `2-1 CAiQ-!!�-i fylir%- (2 dA�},ddress: �tPG,�P Phone: ([i ✓&,) Phone: VAMjLNCE FROM REGULATION(List Reg.) REASON FOR VARIANCE(May attach if more space needed) t2 <�- S P ~cps GP ,_.. w d j- Orq ra tzl "� 1C Sj5T^ C,0-,S,S16 ©e!' -7- PJ'Ji �5 NATURE OF WORK: House Addition 13❑❑❑❑❑ House Renovation ❑ Repair of Failed Septic System Checklist (to be completed by office staff-person receiving variance request application) Please submit copies in 4 separate completed sets. (:,/Four(4)copies of the completed variance,request-fQrt1L___. _ Four(4)copies of engineered plan submitted(e.e septic avite-*+fans) _ Four(4)copies of labeled dimensional floor plans submitted(e.g.house plans or restaurant kitchen plans) _ Signed letter stating that the property owner authorized you to represent him/her for this request _ Applicant understands that the abutters must be notified by certified mail at least ten days prior to meeting date at applicant's expense (for Title V and/or local sewage regulation variances only) _ Full menu submitted(for grease trap variance requests only) _ Variance request application fee collected (no fee for lifeguard modification renewals, grease trap variance renewals [same owner/leasee only], outside dining variance renewals [same owner/leasee only], and variances to repair failed sewage disposal systems [only if no expansion to the building proposed]) Variance request submitted at least 15 days prior to meeting date VARIANCE APPROVED Wayne A.Miller,M.D.Chairman NOT APPROVED Sumner Kaufman,M.S.P.H. REASON FOR DISAPPROVAL Susan G.Rask,R.S. Q:\HEALTH\Application Forms\VARIREQ.DOC Rbst, # 1 1 x t' ' t .,..N �t�) $�, a`C►i�. 13LD c �fi S -,,t ..r ���� ��L}> 1 r ' r .✓ i/ ar .: .c� Ole pt. s 3' t' ' r�► ".! tit Alf z D F4 hIZC Li gC�i -SAIA. JR. SA rt W 4 rA Z LLB M•IS► . es NO. 3$BS sn+� i NO. READINQ J.' ' SAIA J"# NO, avo'm. won $ .6 -_ : APPROXIMATE LOCATION OF 5' DIA. LEACHING CHAMBER 30" TALL 8p p LOT 2 6,670±SF w 4" PVC s co L-4 APPROXIMATE LOCATION OF 5' DIA, LEACHING CHAMBER 30" TALL #9 INVERT IS APPROX. Q,, 1-1/2 STY W/F 1.2 FT BELOW GRADE z s DWELLING IS APPROX. 1 FT BELOW GRADE INVERT IS APPROX. 79 1 ' 1 FT BELOW GRADE INVERT IS APPROX. SOUTHWIND CIRCLE 1.2 FT BELOW GRADE NOTES: SEPARATION BETWEEN BOTTOM OF CHAMBER AND GROUNDWATER ESTIMATED TO BE 4 FEET. DISTANCE TO ANY WETLANDS IS 100+ FEET. SKETCH OF EXISTING SEPTIC SYSTEM 0 10 20 40 FEET #9 SOUTHWIND CIRCLE AUGUST 31, 2004 SCALE: 1 "=20' f t r � a got f 7' 10 CAL"Z ! - ( mot p . a At v. � a JOSEPH NO. 3858 «+t MO. READINQ ,1`J J . 448 641W: 2.4 1211 .