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Home My WebLink About0012 TANGLEWOOD DRIVE - Health (3) L nglew ood Driveille P 1 056 No. 4210 1/3 ORA do (s V 0- d�o U& 0 0 0 o I i COMMONWEALTH OF MASSACHliSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS t - DEPARTMENT OF ENVIRONMENTAL PROTECTION e SVOy TITLE.5. OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM RECEIVED PART A CERTIFICATION AUG 6 2002 Property Address: SET -' st/ /t° TOWN OF BARNSTABLE /a Iled o !�?j✓f HEALTH DEPT. Owner's Name: C .v 7 ea—,;Ile- 1"A Owner's Address: lq 4 Date of inspection: Name of Inspector: lease print)Ate% "'r Aeze- 411 ,d<�q'1/7- mAP Company Name: Iblaiiing Address: O C3 i PARCEL �J c_...�,..�,.�.�... Y.9wovis /yid na a/ LOT - Telephone Number: s o F 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 fimcdon and maintenance of on site sewage disposal systems.I am a DEP approved system inspector pursuant to Sectio 5.340 of Title 5(310 CMR-15.000). The system: Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspeetoes Signature: Date• <ile'l"'-lec;l- 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 o€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. 44 a Page 2 of 1 I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SFWAGE DISPOSAL SYMMA INSPECTION FOR - PART A CERTIFICATION(continued) Property Address: _ Z Owner: /vsi,.. 77 - Date of Inspection- . , Inspection Summary: Cheep A,B,C,ID or E[ALWAYS complete a&off Section D ` A. System es: -- I have riot found any information which indicates that any of the failure criteria described in 310 CRM 15303 or,in 31.0 CNM 15.304 exist.Any failure criteria not evaluated are indicated below. -- Comments: Spsiem,Co nditionalIy`Passes: -One-or-more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system;upon eoinpletion 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. 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 exfiltration or tan fidilim i5 imm rent-System will pass.inspection iftw- 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: Observation of sewage backup or break otrt or high static water.level in the.distribution box.due to bmk or obstructed pipe(s)or due to a broken,settled or u neven distribution box:System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed. distribution box is lets.orreplaced ND explain: The system required pumping more than 4 times a year due to.broken.or obstr�Tted pipe(s).The system will Pass inspection if(with approval of the Board of Health): broken . oken pipe(s)are replaced obstruction is removed ND explain: I Page 3 of 11 _ OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: l02 y ,ti wo e-°cl� ds't 7�9 Owner: o etls W� - - Date of Inspection: C. )Further Evaluation is Required by the BVzhed d f Health: Conditions exist which require furth b//Y�`the Board of ealth in order to determine if the system is failing to protect public health,safety or teht. 1. System will pass unless Board of Dines in ccordance with 310 CMR 15.3Q3(1)(b)that the system is not functioning in a manill pr ect public health,safety and the environment: Cesspool or pries is within 50 fa waterCesspool or privyis within SQ fering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier any)determines that tltw system is functioning in a manner that protects the public health,safety d environment: _ The system has a septic tanl: d soil absorption system(SAS) d the SAS is within 100 feet of a surface water supply or tributary t a surface water supply. _ The system has a septic tank d SAS and the SAS is w" in a Zone l of a public water supply. The system has a septic tank an SAS and the SAS s within 50 feet of a private water supply well. _ The system has a septic tank and AS and the AS is less than 100 feet but 50 feet or more frodt a private water supply well**.Method d to det ine distance **This system passes if the well water ly s,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds icates that the well is free from pollution from that facility and the presence of ammonia nitrogen and a nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy o the alysis must be attached to this form_ 3. Other: Page 4 of I) = _. OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM-INSPECTION EOM: - - PART A CERTIFICATION( ) Property Address:r-z 74•✓ « w O o 1-Xz Owner: Date of Inspection: / D. System Failure Criteria applicable to all systems: You must indicate°fires"or"rib"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 — 4_1 Discharge or ponding of effluent,to the surface ofthe ground or surface-waters due to an overloaded or clogged SAS or cesspool — /Static liquid level m the distribution box above outlet invert-due to an overloaded or clogged SAS a- cesspool %Liquid depth in cesspool is less than 6'}below invert or available-volume is less than'/z 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. ZVAny portion of a cesspool or privy is within 50 feet of a private water supply:well. Any portion ofa cesspool or privy is iessthan 100 feet but greater than 50 feet from a private water supply well with no acceptable water-quality-analysis.['Thus system passes if the well water analysis, performed at a IDEP certified laboratory,for cohiform bacteria and volatile organic compounds indicates that the well"is free from pollution from that facility and the presence.of ammoniac nitrogen and nitrate nitrogen is equal-toorbmthm.-Sffznpvwvideddut no other f2dure eraktria are triggered.A copy of the analysismvst beattached.to-this fu rm j- i v (Yes/No)The system fails:]have deter that one or more of the above failure criteria exist as described in 310 CM -15.303,therefore-the system fails The system or%mer.shtZuld contact the Board of Health to determine what will be-necessary to correct the failure. E. barge Systems: To be considered a large system the system s -a w�:a+Resign: of 10,000 gpd to 15,000 gpd- You must indicate either`yes"or"no" each of the-fe wiag (The following criteria apply to larg s ems in n m the criteria above) yes no _ the system is within 400 fe of a dtiitlatig wafer supply — the system is within 200 f a tributary to a surface.drinking water supply — the system is located in gin sensitive area(Interim Wellhead Protection Area—IWPA)or a iittapped Zone II of a public w s ply well 4 If you have answered"y ' 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€ailed under Section D shall upgrade the system in accordance with 310 CIvIR 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:40 Owner: _ I�AN� TT=F �u/s�e-f Date of Inspection: z Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes o umping 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) ,4as the facility or dwelling inspected for signs of sewage back up? Was the site inspected for signs of break out? 1� Were all system components,excluding the SAS,located on site? Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the affles 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: /Yno _ 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)j Page 6 of 11 -- - OFFI- UL INSPECTION FORM-NOT-FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGKD S 0SAL-SYSTEM-RgSPEC7IO'N FORM-- RART-C SYSTEM INFORMATION' Property Address: 441m4/ Owner: A ai C-7-re v crJ�S' - Bate of Inspection: i o� FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): -3 Number.of bedrooms(actual): -3 DESIGN flow based on 310 CMR 15203(for-example:.110 gpd x#-ofbedmoms): 31� Number of current residents:_ Does residence have a garbage grinder(yes or no):-CV Is laundry on a separate sewage system{yes or no):Z_1 Zif yes separate inspection required] - Laundry system inspected(yes or no): Seasonal use:(yes or no): y Water meter readings,if available(last 2 years usage(gpd)): Sump pump(yes or no):_ Last date of occupancy: X/o COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 C 15203): - pd Basis of design flo (seats! ons/sgftetc.): Grease trap present es or o):_ Industrial waste hol ' g present(yes or no):_ Non-sanitary waste ged to the Title 5 system(yes or no): Water meter read' , 'f available: _ Last date of occup cy se: OTHER(describe): GENERAL INFORMATION Pumping Records _- Sourceofinformation: 4(,IAI�e 2 Was system pumped-as part of the inspection(yes orno): c� Ifyes,volume pumped:_gallons—How__was quantity:pump;ikdetrrmined?- Reason for pumping:P _...... - Sep on box,soil absorption system _Singh--cesspool Overflow-cesspool Privy _Shared system-(yes or no)(if yes,attaclrpreviaus inspectiowrecords;if any} _hmovativetAltetnativrtechnology.Attachxcopy ofthe current operation and maintenance-contract(to be obtained-from system owner) _Tight tank- _Attach a copy of theF DEP-approval _Other(describe): . Approximate age of all compon nts,da a installed(if known)and source of information: a oo d Were sewage odors detected when arriving at the site(yes or no):_ Page 7 of I I II O C INSPECTION FORIM--NOT FOR VOLUNTARY ASSESSI�1E�lT'S . S SURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM LIFORMATION(continued) Froperty dress:la u o."% �/2�✓^� Owner: E r-T.i' es;e �y Date of InspectsOn: BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction:_cast iron Z40 PVC other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage.etc.): SEnIC TANK: 'oo to on site plan) Depth below grade: � Material of construction. oncrete metal fiberglass_polyethylene _other(e;,plai�-t} if.ardk is metal list age:_ is age confirmed by a Certificate of Compliance(yes or no):^(attach a copy of certificate) Dimensions: �, s ^x 5 X S Sludge depth: ' Distance from top of sludge to bottom of outlet tee or baffler Scum thickness: 3 Distance from top of scum to top of outlettee or baffle. /4" Distance from bottom of scum to bottom of outlet tee or baffle: /l How were dimensions determined: /'!r As"_v e i 't. Comments(on pumping recommendations,inlet and outlet tee or baffle conditior,,structural integrity,liquid as related to outlet invert,evidence of.leak-age,etc.): GREASE Tom:(Iocate on site plan) Depth below grade:— Material of construction: concrete m _fiberglass polyethylene other (explain): Dimensions-- Scum thickness: Distance from top of scum to top of et tee or baffle: Distance from bottom of scum to tto of outlet tee or baffle: e of last Pumping Co mments(on pumping rec endati, ,inlet and outlet tee or baffle condition,structural integrity,liquid le. Is to outlet invert,evidence of leakage,etc.): Page aofII ()MCL41 INSPECTION FORM y-NOT FOR ViOLUN ARyASSESSMENTS SUBSPACE SEWAGE DISPOSAL SMEM INSPECnON FORM PART C STEM ORMA ON( rlttiutted) FMP"Address: /a oe f Owner. 4V 4/Q�',TT�oDate f Inspection: TIGHT ur H€ LDING TANK: (tam Mast be at time a.'�.. .. speetioat)(Iocate on site plaa?,_ - Depth below grade: Material of construction: c rete etal f bsrglass_�__gol3'eLhyle: other(explain): Dimensions: Capacity:-----__ a ns Design FIow: day ..'.arm present(yes or no): Alarm level: Alarm m i worlt,n . r Date of last um I}inaa: g (}+e5 0_no): Comments(condition of alarm and gloat switches,etc.): DIS 9MMOIJ Box._. �: (3f present must be o pened)(Iacate on site plan) Depth of liquid level above outlet invert; Comments(note if box is Ievel and distribution to outlets egw4 aat r e rtalgnce of solids carryon,any evidenca.of le..akage into or out of bo P etc.): Sox 'q w�-7 �. �� Ia C.-HAMBER: (Ioc on site an Pumps in working order(yes or o): Alarms in working order(yes or Ccmtnetits(mote condition of chamber,canditionff pumps and tppWtenantet,etc.): I • Page 9 of 1 I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY.ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property-Address:-42 e v6: 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. aching trenches,number,length:-llw ei gf'ys 4 S leaching-fie number;dimensions: ovetflcw-cesspool,number. innovative/alternative-systernr Type/name 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 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 in ow es or no): Comments(note condition of s ,signs ofhydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: . (locate on 'te plan} . Materials of construction: Dimensions: Depth of solids: Comments-(note.condition-of soil; s of hydraulic.failure,level of ponding;condition of vegetation,etc.): Page 10 of 11 -- - OFFICUILINSPECTI N.FORM-NOT FOR VOLUNTARY ASSESSMENTS- ___ S URFACE SEWAGEDIS-PO EM INSPECMN FORM PART-C SYSTEWINFORMATION(continued) Property Address: ! ��✓ wood /�'� Owner: Aw,,g'r z:�/ A v - Date of-Inspection:. ��( SKETCH OF SEWAGE DISPOSAL SYSTEM-- Provide a sketch of the sewage disposal system inc3uding-ties to arleast two-permanent-reference landmarks or benchmarks.Locate alrwells within-100 feet Locate where-public water-supply-enters-the-build-mg. O [7D > �� z7o� �. t zEe I I of I I 0j--HCjjAL INSPECTION FORM-NOT FOR VOLUh FAIRY ASSES rS SUBSURFACE SEWAGE.D1SP0SAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 1?-,We;ly Addr 4 L,0vca,� r d er:.AI,4mr7-76 /rsv Date of Win: S1 E EXA31 'Sipe Sur ace-law Chick cellar Shallow wells Es=ated depth to V mttnd vrAer'15 feet pleaseindicate(check)aL methods used to determine the high grotmd water elevation: Obtained from system desisn plans on:record-If rhekeed,date of design plan reviewed: site(abutting groper ytobservation hole within 150 feet of SAS) t/a with local Board of Health-explain: el,,470-1 Checked with local excavators_installers-(attach docunentatl0n) Accessed USGS database-explain: must describe:how you established the high ground water elevation: