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HomeMy WebLinkAbout0016 WHITE OAK TRAIL - Health .6 WHITE OAK TRAIL, CENTERVILLE A= UUntecuc® � y� UPC 12534 ' No.2� 1_OR �,,, � HASTINGS,YN ,DATE;_-/24/00----- PROPERTY ADDRESS:• 6_White RECEIVED ----------------- MAY 0 4 2000 TOWN OF BARN On the above date, I Inspected the septic ,system at tha E �9-d���BLE This system consists of the following: 1 . 2-6 'x8 ' block cesspools. Based on my Inspection, I certify the following conditions; 2 . This is not a title five septic system. © �� 3 . This is a sewage system. The sewage system is in proper working order at the present time. Both cesspools are dry. The house is used seasonally. SIGNATURE: N a m e:_,L�3.�jUs.stakgLr- ire__---- Company' Jo3e2h_P_ HkSomber_b Son , Inc . Address,- Box----66---- ---------- __Centerville Hay_02632-0066 Phone'___508 775_3338_______ THIS CERTIFICATION ODES NOT CONSTITVTLI A OVARANTY OR WARRANTY JOSEPH P. MACOMBER & SON, INC. Tanks-Cos:pools•LoachfIsIds PVmpsd � Instjllsd Town Sewer Connlotlons P.O. Box 66 Contarvlllo, MA 02632.0066 775.3338 775.6412 Cora Devine 16 White Oak Trail Centerville,Mass. _ 02632 System Consists of; 2-6 'X8 ' block cesspools in series. �� w� �� ®�� i era 1 G.��►-�e,��r:�l-c i `t dear o� ��Ugf 1��Y� �' � � �� � � — — �5� ��� 1 ' 1 � i }, 4.. i COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET, BOSTON MA 02108 (617) 292-5500 TRUDY CORE Secretary ARGEO PAUL CELLUCCI DAVID B. STRUHS Governor Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION ProPenyAdd►ess: 16 White Oak Trail Name of0 rplCora Devine Centerville,Ma s. 02632 Address of Owner: ' x= r e e t Date of inspection: 4/2 4�0 0 B e r i n,Mass. 01503 Name of Inspector: (Please Print) Joseph P.Macomber Jr. I am a DEPepproved system inspector pursuant to Section 15.340 of This 5(310 CMR 15.000) Company Name: J.P.Macomber & Son Inc Maav,gAddresa: ox 66 Centerville,Mass_ 02632 Telephor»Number: 5 0 8—7 7 5-31-1 8 CERTIFICATION STATEMENT 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: LIPasses Conditionally Passes _ Needs Further Evaluation By the Local Approving Authority _ Fails /� Inspector's Signature: d!(6' Date: The System Inspect shall submit a copy of this Inspection report to the Approving Authority(Board of Health or DEP)wkNn thirty 130)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 orfnvironmental Protection. The original should•be sent tovw system owner and copies sent to the buyer, if applicable, and the approving authority. NOTES AND COMMENTS revised 9/2/98 Page Iof11 C,Printed on Recycled Paper i SUBSURFACE SEWAGE Dt3POSAL SYSTSA INSPECTION FORM • PART A E , CFRTU34A,10N (oor timed) Ptop..rtyAddr.a,; 16 White Oak Trail Centerville,Mass. Dwr+«: Cora Devine Dww Of w4 "60n: 4/2 4/0 0 NSP£C'nON SUMMARY: ch r-h a e, C, or D. A. SYST PASSES: -k- I have not found any Information which Indicates that any of the faAurs oondt(om described In 310 CMR 14.303 exist. Any tsaw criteria not evaluated ue Indicated below. COMMENTS: B. SYSTEM CONDITIONALLY PASSES: � One or more system components as described to the 'CorA%Iwal Pass'section need to be replaced or repaired. The system, upo completion of the replacement or repair,as approved by the Board of Health, will peas. Indcat s, no, or not determined(Y, N. or NO). Describe basis of determination In all Instances. If 'rot deter►Nned% explain why not. The septic tank Is metal, urJ•aa the owner Of opuator has provided the system Irtspeotor with a oopy of a Cerditcate of Compliance (ettsched)Indicating that the tank was Installed wltNn twenty(20)years prior to the date of the Inspectlon: the septic tank, whether or not metal, Is oraoked,struewrally unsound, shows substantial Infiltration or extuo•stion. or ta failure Is Imminent. The system will pass Inspection If the existing septic tank Is replaced with a complying sapdc tuts s approved by the Board of Health. vQAlQr Sewage backup or breakout or high static water level observed In the distribution box Is due to broken or obstrucud pips ` or due to a broken. settled or uneven distribution box. The system will pass Inspection If(wtth approval of the Bond of Health). broken pipes) are replaced obstruction Is removed distribution box Is levelled or replaced The smern required pumplripmw ti t mn-four'efines-wyeardus%o broKen•or obstmoted plpe(s). The•Y*Nm ww -pvws-- Irupection If(with approved of the Board of Heedth): broken plps(s) we replsc'od obstruction Is removed revised 9/2/98 Page 2ofIt ' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (co►rtinued) Property Address: 16 White Oak Trail Centerville,Mass. Owner: Cora Devine Date of Inspection: 4/2 4/0 0 C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: -IL Conditions exist which require further evaluation by the Board of Health In order to determine If the system Is falling to protect the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 16.303(1)(b)THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH.WU.PRQTECT THE PUBLIC HEALTH AND SAFETY AND THE BMSONMENT 4d Cesspool or privy Is within 60 feet of surface water DCesspool 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 ANY)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 of 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. The system has a septic tank end soil absorption system and the SAS is within 60 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less then 100 feet but 60 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 prase ce of*mmonla nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine distance .�� (approximation not valid).• 3) OTHER • revised 9/2/98 Page 3ofIt SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FARM PART A CERTIFICATION (continued) Property Address:16 White Oak Trail Centerville,Mass. owner: Cora Devine Date of Inspection: 4/2 4/0 0 D. SYSTEM FAILS: You must indicate either "Yes" or "No" to each of the following: _Vb I have determined that one or more of the following failure conditions exist as described 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 , Backup of•eewage into feciBty"or.•syster+r+component-duo tto an overloaded or�clegged-Sr4Sor•cesspod. -j--'• ' " Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. ' IlA.fl 4t� 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 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 a. 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-then 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" to each of the following: The following criteria apply to large systems in addition to the criteria above: A& 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 _ a the system is within 400 feet of a surface drinking water supply _ J the system-is•witl in 200 feet of•e-tributary-We oucf000•dfkJ409�w+t 4uPPly - 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 upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional office of the Department for further information. revised 9/2/98 Page 4of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM tNSPECTIQN FORM ' PART B CHECKLIST PropertyAddress:16 White Oak Trail Centerville,Mass. owner: Cora Devine Deto of Wwoctlon: 4/2 4/0 0 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 systemtornpoaents kawbwn pu n sod4w4vtj"st two•awaaka awdtha'systam hasVaaowcaiaiag"a BMW}tow 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 wit /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 j 4beluding the Soil Absorption System have been located on the site. _41AI i__ 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 orrthe site has been determined based on: Existing Information. For example, Plan at B.O.H. _ 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)1 The facility owner(and.o•r,-a.nl-,lf differaot rhn SubSurfece Disposal Systems. revised 9/2/98 page sorn i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION PropertyAdd,.as: 16 White Oak Trail Centerville,Mass. Ownw: Cora Devine Data of kwlPoctton:4/2 4/0 0 FLOW CONDMONS RESIDENTIAL: Design flow: alo _g.P•d./bedr m. dd Number of bedrooms desig 1: Number of bedrooms(actual):) Total DESIGN flow Number of current residents: Garbage grinder(yes or no): Laundry Iseperate system) s or�_, If yes, aeparataJnspectlon•r.quir.d Laundry system Inspected or no) Seasonal use(yes or no): Water meter readings,if vailable(last two year's usage(gpd): 'p Sump Pump(Yes or no): I wr� 645 v~ �7 Last date of occupancy:A�_ COMMERCIALIWDUSTRWL: Type of establishment: AIA Design flow: d ( Based on 15.203) Basis of design flow Grease trap present: (yes or no) Industrial Waste Holding Tank present: (yes or no)." Non-sanitary waste discharged to the Title 6 system: (yes or no)" Water meter readings,if available: AIW Last date of occupancy: N14 OTHER:(Describe) Last date of occupancy: f GENERAL INFORMATION PUMPING R CORDS an ourc o infor atio System/pumped as part of ins action: (yes or no) If yes, volume pumped: gallons Reason for pumping: — TYPE OF SYSTEM �Q 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) 4)4 1/A Technology etc. Attach copy of up to date operation and maintenance contract _4& Tight Tank J,,o—Copy of DEP Approval Other /vo APPROXIMATE AGE of all components, data Installediif known)-and sours.of.iwformation: -• � � � Sawa oe odors detected when•arriving at the site: (yes or no) revised 9/2/98 Page 6of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPEC'ION FORM PART C SYSTEM INFORMATION(continued) P►oportyAddress: 16 White Oak TRail Centerville,Mass. Ownw: Cora Devine Date of ktspection: 4/2 4/0 0 BUILDING SEWER: (Locate on site plan) Depth below grade: d Material of construct Cos iron /�40 PVC other(explain) n.,af1r� »� p1DR Distance frompriv to watef s pp y well or suction line S;IL' Diameter V Comments: (condition of joints, venting, evidence of teakage,-otc.) Joints appear System is vented through SEPTIC TANK: (locate on site plan) Depth below grade: Material of construction V concreteA*netaLeAFiberglass*4Polyethylene44ODther(explain) 4 If tank is Instal, list age d)A is.age.confirmed by Certificate of Compliance 4M(Yes/No) Dimensions: Sludge depth: Distance from top of sludge to bottom of outlet tee ortmffle_,d,?& -' Scum thickness:X/1 Distance from top of scum to top of outlet tee or baffle: 4W Distance from bottom of scum to bottom of outlet tea or baffler How dimensions were determined: 4V Comments: (recommendation for pumping, condition of inlet and outlet tees or-baffles,depth of liquid level in relation to outlet invert, structurst4ntegrity, evidence of leakage,etc.) Selptic tank i-c; nc)t- prtzSPnf- r evrey 2 years GREASE TRAP: (locate on site plan) Depth below grade Material of constructionj kconcreteA/RmetaWf FiberglassWAPolyethylenooElother(explain) & Dimensions: .L Scum thickness: Distance from top of scum to top of outlet too or baffle: ,d2d Distance from bottom of scum to bottom of outlet tee or baffle: 4 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 =rPGPnf- revised 9/2/98 Page 7of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C 0 SYSTBA INFORMATION(condnuad) ProponyAddrea4: 16 White Oak Trail Centerville,Mass. OMrn«: Cora Devine °"Insp.otlon: 4/2 4/0 0 TIGHT OR HOLDING TANK:IL4'ee-(Tank must be pumped prior to, or at time of, Inspection) Ilocats on site plan) Depth below grads: Material of constructlon;&concrete i&#netal4MMberglass4Polyethylone4daother(explain) Ale AJA _ Dimensions: n1,4 Capscity: gallons Design flow: gallons/day Alarm present Alarm level: Alarm in working order:YssJjH Nom Date of previous pumping: As Comments: (condition of mist tee, condition of alarm and float switches,etc.) 1 D1.STR18UT1ON BOXA69w— ilocato on site plan) Depth of liquid level above outist Invert:., .(�A Comments: (note If level and distribution Is equal, evidenoe of solids ca(ryover, evidence of leakage Into or out of►ox, etc.) - - D . PUMP CHAM8ER:.A'&V Ilocats on site plan) """"��1�,dddd Pumps in working order:(Yes or No) Alarms in working order(Yes or No) Comments: (note condition of pump chamber,condition of pumps and appurtenances,etc.) YumD C l C nnt- pr.Q& n{ revised 9/2/98 hgtIof11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM " PART C SYSTEM INFORMATION(continued) PropertyAddress:16 White Oak Trail Centerville,Mass. owner: Cora Devine Date of kw4mcticn: 4/2 4/0 0 SOIL ABSORPTION SYSTEM(SAS) (locate on site plan,if possible;excavation not required,.location may be approximated by non-intrusive methods) If not located, explain: Type: leaching pits, number: leaching chambers, number: leaching galleries,number: leaching trenches,number, length: leaching fields, number, dimensions: overflow cesspool,number: / Alternative system:_ Name of Technology: / Comments: (note condition of soil, signs of hydraulic failure,level of ponding, damp soil, condition of vegetation, etc.) Loamy sand to medium fine sand No signs Soi s Ve—cfettatl9L is normal, CESSPOOLS: (locate on site plan) Number and configuration: 01 Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: LLU Dimensions of cesspool: Materials of construction: ee Indication of groundwater: IUDdX— inflow (cesspool must be pumped as part of Inspection) 0 (�_P-,Sp nnl cz a-re dam, No evidence 4ater - nft -- - Comments: (note condition of soil, signs of hydraulic failure,level of pending,condition of.vegetation, etc.) Same as ahnv PRIVY:_eve (locate on site plan) Materjals of construction: y1� Dimensions: y/9 Depth of solids: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,)etc.) Privy is not —nscant revised 9/2/98 Page 9orn SUBSURFACE SEWAGE DISPOSAL SYSTDA INSPECTION 4ORJA PVT.0 3YSTDA INFORJ%ATION,(con "od) P„pwTYAd&1":1 6 White Oak Trail, Centerville,Mass. Ownw: Cora Devine Dou of kupectlon: 4/2 4/0 0 SKETCH OF SEWAGE DISPOSAL SYSTEM: Include tios to at least two permanent reference landmarks or bonchmmks locate all wells within 100' (Locoto whore publlo water supply coma Into house) s �hc�r oT �Tp�15'e I ` revised 9/2/98 Page 10ofIt SUBSURFACE SEWAGE DISP9M SYSTEM WSPECTION FORM 1 PART C �; y SYSTEM y1FORMATION(con*%jod) FropwtyAddra": 16 White Oak .Trail Centerville,Mass. Ownw: Cora Devine Deco of lnap.ctlon: 4/2 4/0 0 NRCS Report name Soll Type_ Typical depth to groundwater USGS Date websits visited Observation Wells checked Groundwater depth: Shallow Moderate Deep _ SITE EXAM Slope Surface water Check Cellar Shallow wells r Estimated Depth to Groundwater Feet Piesse indicate all the methods used to determine High Groundwater Elevation: _ Obtained from Design Plans on record bserved Si �conftflon, observation hole, basemeot sump etc.) Determined Checked with local Board of health _Checked FEMA Maps Checked pumping records .. Checked local excavators, Installers Used USGS Data Describe how you established the High Groundwater Elevation. (Must be completed) Used water contours map. Gahrety & Miller Model 12/16/94 revised 9/2/98 Paee11of11 a•..R15T.� �+—.T'1�aenrmr•nTrrrnn nnrerlrr.7+-r1.sr►t7rlrn+rm f.srM11Y/1s'�!'.�rtwV'1 .�. 7'n'Rrr�.arm--:.t-.r•••' TOWN OF Barnstable BOARD OF HEALTH S11IISURFACE SEWAGE DISPOSAL ,SYSTEM INSPECTION FORM - PART D .- CERTIFICATION •••T^1^T••,••:i—�..IT.^.�T.'a tS T111•.1.'1T.TT1lTafa'g1Ra:a�!'1a"70.'R�17R.af1"�.Ra�fl�l.e1�►7 7w1. •Aa1"'Pa—'T�.+• � -TYPE OR PRINT CI.EARLY- PROPERTY INSPECTED STREET ADDRESS 16 White Oak Trail Centerville,Mass. ASSESSORS MAP, BLOCK AND PARCEL # OWNER' s NAME Cora Devine PART D - CERTIFICATION NAME OF INSPECTOR Joseph P.Macomber Jr. COMPANY NAME J•P.Macomber & Sen' Inc. COMPANY ADDRESS Box 66 Centerville,Mass. 02632 Street Town or City state LIP COMPANY TELEPHONE ( 508 ) 775 - 3338 FAX ( 508 1 790 - 1578 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported is true , accurate , and omplete as of the time of .inspection . The inspection was performed and any recommendations regarding upgrade , maintenance , and repair are consistent with my training and experience in the proper function and maintenance of on- site sewage disposal systems . Check one : System PASSED 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 15 . 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 acted has found that the system fails to Protect the jiublic 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 �`Cl� ne copy of this certification must be provided to the OWNER, the BUYER ( where applicable ) and the 130ARD OF HEALTH. * If the inspection FAILED, the owner or""N _Perator shall u pgrade ' the system. within one year of the date of the inspection, unless allowed or required otherwise as provided in 3.10 CMR 16 . 305 . partd .doc