HomeMy WebLinkAbout0250 FAWCETT LANE - Health 250 Fawcett Lan +
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COMMONWEALTH OF 1�
• MASSACHUS ETT
S
01 EXECUTIVE OFFICE OF ENvIRONMENTAL AFFAIRS
> DEPARTMENT OF ENVIRONMENTAL PROTECTION
ru1AP �7 O
PARCEL � 3
LOT :
TITLE 5
OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTENI FORM
PART A
CERTIFICATION
Property Address:_ok
(�/" RECEIVE®
Owner's Name:
f/f CN
Owner's Address: c4 i" 0 ` F JUL 0 1 2003
Date of Inspection: t- TOWN OF BARNSTABLE
HEALTH DEPT.
Name of Inspector. (please print)
Company Name- /jar /
btailine Address: t t
—
Telephone Number.L-ve) ) 7 4
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 CiNIR 15.000). The system:
11 Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature:' �l
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. Lf 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 on final 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
conditions of use in the future under the same or different
rage 1. of L t
OFFICIAL INSPECTION FORNI- NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTENf INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:
Owner G l V01V 4
Date of Inspection: 6 7 p
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. Syst asses:
-Z, e not found an '
y information which indicates
15.303 or in 310 CNN 15.304 exist. Any failure criteria not evaluated are indicated below.
in 310 CI✓tFt
Comments:
Bi7vstor
Conditionally Pauses:
more syste m components as described in the"Conditional Pass"section need to be replaced or
repaired.The system, upon completion of the replacement or repair,as appro,-ed.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
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally
unsound,exhibits substantial infiltradon or exfiltration or tank failure is imminent. System--ill pass inspection if the
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 out or high static water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken,settled or uneven distribution box System will pass inspection if(with
approval of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system--ill
pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain:
OFFICIAL INSPECTION FORD[ - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
f�
Property Address:
c /��/f` 6 C/
Owner:
Date of Inspection: j
C.�jFu�rther Evaluation is Required by the Board of Health:
Conditions exist which require further evaluation by the Board of Health in order to determine if the system
is failing to protect public health safety or the environment.
I. Svstem will pass unless Board of Health determines in accordance with 310 CNIR 15.303(1)(b) that the
system is not functioning in a manner which will protect public health,safety and the environment:
— Cesspool or privy is within 50 feet of a surface water
_ 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 any) determines that the
system is functioning in a manner that protects the public health,safety and environment:
_ The system has a septic tank and soil absorption system(SAS)and the SAS is within !00 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'within a Zone I of a public water supply.
_ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
_ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a
private water supply well". Method used to determine distance
"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.
3. Other:
C.a�G � va •a .
OFFICIAL INSPECTION FORM— NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORINI
PART A
CERTIFICATION (continued)
Property Address. Cc
7d ;..�
Owner:
Date of Inspection: Gl
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no" to each of the following for all inspections:
Yes �_,Ou
ckvp of sewage into facility or system co,tponent due to overloaded orclogged SAS or cesspool,
scharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
i/
/logged SAS or cesspool
Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
squid 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
.Af times pumped
r/ y 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 Writer supply or tributary to a surface
water supply.
_ v portion of a cesspool or privy is within a Zone 1 of a public well.
�y portion of a cesspool or privy is within 50 feet of a private water supply well.
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,
perfonr.c•: DEP certified laboratory,for coliform bacteria and volatile organic compounds
indicates u.". :ne well is free from polludon from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than S ppm,provided that no other failure criteria
arc 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 a design flow of 10-WO gpd to 15,000
gpd•
You must indicate either"yes" or"no" to each of the following:
(The following criteria apph• to lame systems in addition to the criteria above)
yes no
the system is within 400 feet of a surface drinkng water supply
the system is within 200 feet of a tributary to a surface drinking water supply
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
If you have answered"yes' to any question in Section E the system is considered a significant threat. or answered
"yes" in Section D above the lam;e 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 Clot
15.304.The system owner should contact the appropriate regional office of the Department.
Page 5ofII
OFFICIAL INSPECTION FORINt-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address j G'
6101
Owner: G?C4 e
Date of Inspection: (�
Chcck if the following have been done. You must indicate`yes" or"no"as to each of the following:
Yes o
_ /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
tz Has the system received normal flows in the previous two week period
-v v
Have large
o 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?(l:f 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
_ Were the septic tank manholes uncovered.opened,and the interior of the tank inspected for the condition
es or tees, material of construction,dimensions,depth of liquid,depth of sludge and depth of scam
o�%/Mll
Was the facility owner(and occupants if different from owner)provided aith 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
a
,Existing information. For example, plan at the Board of
p p 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))
gage b of t t
OFFICIAL MSPECT71ON FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTENI INFORMATION
Property Address:
Owner. l tU'l ,?v�
Date of Inspection:
OW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): Number of bedrooms (actual):
DESIGN flow based on 310 CMR 13.203 (for example: 110 gpd x#of bedrooms):
Number of current residents: 4---
Does residence have a garbage grinder(yes or no):AL-O
Is laundry on a separate sewage system Lves or no). -0 (if yes separate inspection rcquiredl
Laundry system inspected(yes or no): Z110
Seasonal use: (yes or no):
Water meter readings, if available(last 2 years usage(gpd)): ,err
Sump pump(yes or no):
Last date of occupancy;
CONVYIERCIALANDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 13.203): and '
Basis of design flow(seats/persons/sgfl etc.):
Grease trap present(yes or no):_
Industrial waste holding tank present(yes or no):_
Non-sanitary waste discharged to the Title S system(yes or no): _
Water meter readings,if available:
Last date of oc^lpancy/use:
O'T I ER t: ac):
GENERAL LNFOWNUTION
Pumping Records
Source of information:
Was system pumped as part of the inspection(yes or no):
If yes,volume pumped:_gallons—How was quantity pumped determined?
Reason for pumping:
T OF SYSTEM
_Septic tardr,distribution box,soil absorption system
_Single cesspool
_Overflow cesspool
_Privy
_Shared system(yes or no) (if yes, attach previous inspection records, if anv)
_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):
Approxamarft_e_age of all components, date installed(if known) d source of informah�(yn/+� �j�/ /`��
Were sewage odors detected when arriving at she site(yes or no):,:vo
Page 7 of t t
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM LYFORNIATION(continued)
Property Address: ;c
FGi G'r Z
vi h vn
Owner:
Date of Inspection=
BUILDING SEWER(locate on
f/bite plan)
Depth below grade: 17
Materials of construction: cast iron _ 0 PVC_other(explain):
Distance from private water supply well or suction line:
Comments(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK:_(� -Dante on site lam
�� plan)
Depth below grade:_L �
Material of construction:_concrete metal fiberglass_polyethylene
_other(explain) _ —
If tank is metal list age:_ Is age confirmed by a Certifig
certificate) te of Compliance(yes or no):_(attach a copy of
Dimensions:
Sludge depth-
Distance from top of sludge to bottom of outlet tee or baffle: oZ a �
Scum thiclatess: �'
Distance from toP bf scan to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or e: G
Flow were dimensions determined. g�
Comments(on pumping recommendations, inlet and outle tee or baffle condition,structural integrity,as fated to outlet invert,evidence of leakage, .):, liquid levels
T.):,
°"" � �' ✓� -ems. �-
GREASE TRAP:�(to on site plan)
Depth below grade:_
Material of construction:_concrete_metal fiberglass_polyethylene other
Dimensions:
Scum thicknc-si
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle;
Date of last pumping:
Comments(on pumping recommendations,inlet and outlet tee or baffle condition, structural
as related to outlet invert,evidence of leakage,etc.):
Page $ of 1 I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTE�ti1 INSPECTION FORiti1
PART C
SYSTEM INFORMATION(continued)
Property Ad'drz9a j L 'v
Owner. 0" C' ,
Date of Inspection:
TIGHT or HOLDING TANK (tank must be pumped at time of inspection)(locatc on site plan)
)
Depth below grade:
Material of construction: concrete metal fiberglass_polyethylene other(eeplain):
Dimensions:
Capacity: gallons
Design Flow: gallons/day
Alarm present(yes or no):
Alarm level: Alarm in workingorder
Date of last pumping: (Yes or no):
Comments(condition of alarm and float switches, etc.):
D15T RIB(, (if present must be o n 1
pe ed)(ocate on site plan)
Depth of liquid level abo%-_ invert /
Comments (note if box is Ic•.el ar:d distribution to outlets
leakage • to or out of bo. etc.): any evidence of solids carryover,any evidence of
PUMP CHADMER: locate on site plan)
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.):
Page 9 of 11
OFFICIAL INSPECTION FORNI—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTENI INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
r
Property Address: • ��1 �GU�
Owner.
Date of Inspection:
SOIL ABSORPTION SYSTEM (SAS): (locate on site plan,excavation not required)
Q )
If SAS not located explain why:
Type
leaching pits,number.
leaching chambers,number.
leaching galleries,number.
leaching trenches,number,length:
leaching fields,number,dimensions:
overflow cesspool, number
innovativelalternative system Type/name of technology:
Comments to condition of soil, signs of hydraulic failure, level of nding,darhp soil,condition of vegeta on,
etc.):
40 0 f, C�' C
CESSPOOLS: l (cewpool must be pumped as 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 inflow(yes or no):
Comments(note condition of soil,signs of hydraulic failure, level of pondiag,condition of vegetation etc.):
PRIVY:4 (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.):
I
rage ►v vL i
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address
-:�;O/
Owner. ("Tc-Z�c iv "m.'.
Date of Inspection:
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sc%vage 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.
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Page I t of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
• SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: j(J f I
Owner.
Date of Inspection:
SITE EXAINI
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:
Ob erved site(abutting property/observation holes 150 feet of SAS)
✓Checked with local Board of Health-explain: Lf �,� 5--
Checked with local excavators, installers-(attach documentation)
Accessed USGS database-explain: .•
/ 0F
You must d "' ?how you established the high ground water elevation-
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L !� 7- b j TOWN OF BA.RNSTABLE
LGCATION._��✓'� ►.OLD T-r t a SEWAGE # �1' LI
VTLLAGE-'. ASSESSOR'S�M-AP & LOTS rI4
INSTALLER'S NAME&PHONE NO.? K C,f)i ik i�i��, to .
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type)a 'r I aka$ (size). X la
NO, OF BEDROOMS,
BUILDER OR OWNER
PERMITDATE: 12`20 ` 5 1 COMPLIANCE DATE:
-Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Weiland Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility). Feet
Edge of Wetland and Leaching Facility(1f any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
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No. ! Fee
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THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: ✓
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
01ppricatiou for �Digpoe;ar *p5tem (tottgtruction Permit
Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System O Individual Components
Location Address or Lot No. lkfo? r Owner's Name,Address and Tel.No.
1�5p ak") &VAIQ(�rL 0 ct j
Assessor's Map/Parcel )
C,ka 0ni,PvjsT_ A,d}dA)/KA 04 0a1
Installer's Name,Address,and Tel.No,
Designer's Name,Address and Tel.No.
Type of Building:
Dwelling No.of Bedrooms 0_ Lot Size I-',Q0� sq. ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow 1 ��� �'4 gallons per day. Calculated daily flow 3• gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank �[(j U 0 1- Type of S.A.S. w r-, Inn,
Description of Soil /9 T°PStj 00 /Y'e,4 /5-111� w/A 1'-1
Nature of Repairs or Alterations(Answer when applicable) ! e '
Date last inspected: w = 1
Agreement:
The undersigned agrees to ensure the construction and maintenance of e afore described on-site sewage disposal system
in accordance with the provisions of Title a vironmenta de a of to place system in operation until a Certifi-
cate of Compliance has bee issued by t is B lth"
Sign : ���� Date x�
Application Approved by Date
Application Disapproved for the following reasons
Permit No. Date Issued
14 0
0
No. .7 _— Fee
fb THE COMMONWEALTH OF MASSACHUSETTS -'"`Entered in computer:
Yes
PUBLIC HEALTH`DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
01pprication for Miopozal *proem Construction hermit
Application for a Permit to Construct( )Repair( )Upgrade( )Abandon,.(- ) ❑Complete System ❑Individual Components
Location Address or Lot No. 4PP 7 Owner's Name,Address and Tel.No. -7 p
Assessor's Map/Parcel o Y4W
1 C kA MPNjj. (nJA-A)MA nao.41.
Installer's Name,Address,and Tel.No,
Designer's Name,Address and Tel.No.
Owe
Type of Building:
Dwelling No.of Bedrooms Lot Size l-"Inoa sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures ji
Design Flow ��� �c Ca gallons-per-da3%._.Calc_illated daily fl�bw a a' gallons.
Plan Date Number of sheets Revision Date
Title l
Size of Septic Tank l o o o &•5. 7- Type of S.A.S. .`iv %,o a✓�S/
Description of Soil D / T°PSa ?f? /'LO /110 /-S�°� WA�.n as
i
Nature of Repairs or Alterations'(Answer when'applicable) `2
/ I
Date last inspected:
i
- I
Agreement:
r The undersigned agrees to ensure the construction and maintenance of e afore described on-site sewage disposal system
in accordance with the provisions of Title e vironmenttl de a of to place t system in operation until a Certifi-
cate of Compliance has bee 'sued by t is B itj
Sign / Prea Date
Application Approved by i Date
Application Disapproved for the following reasons
Permit No. --26 1 Date Issued
—————————————————————=—————————-- ------
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of (Compliance
THIS IS TO CEaTIFY,that the On-site Sewage Disposal System Constructed( �)Repaired( )Upgraded( )
Abandoned( )b P.k- to -,IN C.
at S ) W( h- a constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. ated
Installer Designer
The issuance of this ermit shall not be construed as a guarantee that the system will function as designed.
Date �a.0,19 w - K lam Inspector
_
No.---�- �7 ------------------------- _
!( THE COMMONWEALTH OF MASSACHUSETTS Fee
PUBLIC HEALTH DIVISION - BARNSTABLE}MASSACHUSETTS
30igozal *p$tem Con.5truct on Permit
Permission is hereby granted to Construct( )Repair(Upgrade( )Aba o )
System located at 5 U aw
r
and as described in the above Application for Disposal System Construction Permit. The applicant ecogn'zes his/her duty to
comply with Title 5 and the following local provisions or special conditions.
Provided:Construction must be completed within three years of the date f s p rmit. % m e
Date: �a U ' Approved by/ "! r✓' /✓//`---
r—,
116199
NOTICE: This Form Is To Be Used For the Repair Of Failed
Septic Systems Only. -
CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL
WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANS)
I, :,fA hereby certify that the application for disposal works
construction permit signed by me dated ` y concerning the
property located at ago cc,j at4 meets all of the
following criteria:
" • The failed system is connected to a residential dwelling only. There are no commercial or business
uses associated with the dwelling.
The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch.
f• There are no wetlands within 100 feet of the proposed septic system
Y1'• There are no private wells within 150 feet of the proposed septic system
�• There is no increase in flow and/or change in use proposed
�• There are no variances requested or needed.
✓'• The bottom of the proposed leaching facility will not be located less than five feet above the
ma..dmum adjusted groundwater table elevation. (Adjust the groundwater table using the Frimptor
method when applicable]
✓ If the S.A.S. will be located with 250 feet of anv vegetated wetlands, the bottom of the proposed
leaching facility will not be located less than fourteen(14) feet above the maximum adjusted
groundwater table elevation,
Please complete the following: �
A) Top of Ground Surface Elevation(using GIS information)
B) G.W. Elevation =the NfA , High G<<W djustmeat
C IF'r c .'CE _ ( IN.�are
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SIGN ,. �ED : DATE..
(Sketch proposed plan of system on back].
q:health Colter:cert
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