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Home My WebLink About0189 ARROWHEAD DRIVE - Health -89 Arrowhead Drive A= 140=100 � a S i TOWN OF BARNSTABLE 4 I:.00ATION AQ U.aV&G1-6 SEWAGE # VILLASE AAA t1ob.12,)-c ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) NO.OF BEDROOMS r BUILDER OR OWNER YER-MM• itu� DATE: i COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and 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 1 9s � - � � �� - � � � � � o k� i t A� r v, N �' _ �. .. 4� � � , - _ 8 COMMONWEALTH OF MASSACHUSETTS 4)EXECUTIVE OFFICE OF ENVIRONMENTAL RECEIVE k9i DEPARTMENT of ENVIRONMENTAL PROTE NM A R 2 8 1997 ONE WINTER STREET,BOSTON MA 02108 (617) 292-5500 TOWN OF BAANSTAR HEALTH DEPT ` N WnJJAM F.WELD S Z XE Governor ARGEO PAUL CELLUCCI DAVM B. STRL'ES Lt.Governor Comm izs ones SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION /� J Property Address: y tqwar t9 r, Address of Owner: _`t O----Ce_s Date of Inspection: 03 /[�`�I�— (If different) o ✓'moo x �4 S Name of Inspector: am�l �2ci�cr�e. _ 7i Company Name, Address and Telephone Number: I�TLAf, ►�_ t_ 11P. CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported be!ow 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 Evalu ' n By the Local Approving Authority _ Fails 1 Inspector's Signature:. Date: 31 �►� e�"t The System Inspector shall 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: 1 Check A, 5, 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 C!v1R 15.303. Any failure criteria not evaluated are indicated 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, 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, 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. (revised 11/03/95) 1 r C� rnnd nn R•nrlyd Pcvr - SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A llt CERTIFICATION (continued) Property Address: C'C ot Owner: Date of Inspect n: SYSTEM �C-O DITIONALLY PASSES (continued) Sewage backup or breakout or high static water level observed in the dist ution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The cyst will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four times a year d to broken or obstructed pipets). The system will pass inspection if(with approval of the Board of Health): broken pipets) are replaced obstruction is removed C1 FURTHER EVALUATION 15 REQUIRED BY THE BOARD OF LTH: Conditions exist which require further evaluation by e Board of Health in order to determine if the system is failing to protect the public health, safety and the environment. SYSTEM WILL PASS UNLESS BOARD OF HEAL DE;ERMINES THAT THE SYSTEM 15 NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEkLT AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 fee of a surface water Cesspool or privy is within 50 f t of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLE55 THE BO RD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAI THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a sep 'c tank and soil absorption system and is within 100 feet to a surface water supply or tributary to a surface water suppl The system-has a ptic tank and soil absorption system and is within a Zone I of a public water supply we!l. The system has septic tank and soil absorption system and is within 50 feet of a private water supply we!I. The system ha a septic tank and soil absorption system and is less than 100 feet but 50 fee, or more from a private wati supply well, nless a well water analysis for coliform bacteria and volatile organic compounds indicates that the we!l is free from p lution from that facility and the presence of ammonia nitrogen and nitrate nitroven is equal to or less than ppm- 3) OTHER (revise 11/03/95) 2 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A / CERTIFICATION (continued) Property Address: Owner: / 6eLG4 Date of Inspecti6n:� DI SYSTEM FAILS: I have determined that the system violates one or more of the following failure riteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be co cted to determine what will be necessary to correct the failure. Backup of sewage into facility or system component due to an erloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the groun or surface waters due to an overloaded or clogged SAS or cesspool. Static liquid level in the distribution box above outlet i ert due to an overloaded or clogged SAS or cesspool. _ Liquid depth in cesspool is less than 6" below inve. or available volume is less than 1/2 day flow. Required pumping more than 4 times in the last ear NOT due to clogged or obstructed pipe(s). Number of times pumped _. Any portion of the Soil Absorption System, sspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is wit in 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is rthin a Zone I of a public well. Any portion of a cesspool or privy ' within 50 feet of a private water supply well. Any portion of a cesspool or pri is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality anal y is. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile or nic compounds, ammonia nitrogen and nitrate nitrogen. Ej LARGE SYSTEM FAILS: The following criteria apply to arge systems in addition to the criteria above: The system serves a facility ith a design Flow of 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety a the environment because one or more of the following conditions exist: the system is ithin 400 feet of a surface drinking water supply the system ' within 200 feet of a tributary to a surface drinking water supply the syste. is located in a nitrogen sensitive area (Interim Wellhead Protection Area (IWPA) or a mapped Zone II of a public ater supply well) The owner or operator f any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 R 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 11/03/95) 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: /�`j'. prvrsrio/Irl act f Dr - Hyu u e.« Owner: --/-. ILIccc G� Date of Inspection: 0V 1",/C7 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 at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have no: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, excluding 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 Systern on the site has been determined based on existing information or approximated by non-intrusive methods. The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of Sub- Surface Disposal System. (revised 11/03/95) 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 2)r u H Owner:--/- /zoe C-t t- - Date of Inspection: FLOW CONDIT10N5 RESIDENTIAL: Design flow:at) allons Number of bedrooms:_ Number of current residents: Garbage grinder(yes or no):_Q Laundry connected to system (yes or no):�Gj Seasonal use (yes or no):_O Water meter readings, if available: ►a go, Last date of occupancy: 9VAM iz� nc.�zec� COMMERCIAUINDUSTRIAL: Type of establishment: Design flow:�Pallons/day Grease trap present: (yes or no)_ Industrial Waste Holding Tank present: (yes or no)— Non-sanitary waste discharged to the Title 5 system: (yes or no)_ Water meter readings, if available: Last date of occupancy: OTHER: (Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: 20 2 System pumped as part of inspection: (yes or no)VuO If yes, volume pumped: gallons Reason for pumping: TYPE OF SYSTEM Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system (yes r no) (if yes, attach previous inspection records, if any) _ Other (explain) �c 1� oscrtT-Sd•.� �ncc_�oc��S APPROXIMATE AGE of all components, date installed (if known) and source of information: 3V uQS Sewage odors detected when arriving at the site: (yes or no) (revised 11/03/95) 5 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: /`* /�i^✓'��-v�a.� �v - �Ju �'"S Owner:--r-- It aC,'(,t Date of Inspection: O3//4i/ SEPTIC TANK:_ (locate on site plan) Depth below grade: Material of construction: _,,,concrete _metal _FRP —other(explain) Dimensions: Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Comments: (recommendation for pumping, condition of inlet and outlet tees o affles, depth of liquid level in relation to outlet invert, structural inte;riry, evidence of leakage, etc.) GREASE TRAP:_ (locate on site plan) Depth below grade: Material of construction: _concrete _metal P _other(explain) Dimensions: Scum thickness: Distance from top of scum to top of/outletor baffle: Distance from bottom of scum to botlet tee or bartle: Comments: (recommendation for pumping, conlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) (revi9ed 11/03/95) 6 i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: u„uS Owner: -77 Date of Inspection: TIGHT OR HOLDING TANK:_ (locate on site plan) Depth below grade: . Material of construction: _concrete _metal _FRP —other(explain) ! Dimensions: Capacity: eallons Design flow: ftallons/day Alarm level: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX:_ (locate on site plan) Depth of liquid level above outlet irivert: Comments: (note if leve! and distribution is equal, evidence/solidsover, evidence of leaka;e into or out of box, etc.) PUMP CHAMBER:_ (locate on site plan) Pumps in working order:(yes or no) Comments: o (note condition of pump chambe , condition of pumps and appurtenances, etc.) (revised 11/03/95) 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C ,erg SYSTEM INFORMATION (continued) Property Address: (Q r�i"t^ou,�.oct.�1 )r �'-�— Owner:71--/Z'.1CA-1 t Date of Inspection:O3//Lf/ - SOIL ABSORPTION SYSTEM (SAS):-U+e5 (locate on site plan, if possible; excava on not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: Type: leaching pits, number:_ leaching chambers, number:_ leaching galleries, number: leaching trenches, number,length: leaching fields, number, dimensions: overflow cesspool, number. mments: (note condition of soil, signs of hydraulic failure, level of pondirg, c i ' n of vegetation,etc.) CESSPOOLS: (locate on site plan) Number and configuration: ll Depth-too of liquid to inlet invert: A`Q1L Depth of solids layer: 1Z t Depth of scum layer. to Dimensions of cesspool: UX to Materials of construction: L ilie-A Tee Indication of groundwater: Q0 inflow (cesspool must be pumped as part of inspection) I Comments: (note condition of soil, signs of hydraulic failure, level of ponding, itic f aetation, etc.) G vJ ( zn PRIVY: (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) (revised 11/03/95) 8 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: q Owner: !o� Date of Inspection: 4/y�- SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' � 2 O DEPTH TO GROUNDWATER Depth to groundwater: :!l;20_feet method of determination or approximation: V.S, (revised 11/03/95) 9