Loading...
HomeMy WebLinkAbout0093 KELLEY ROAD - Health 93�Kel ey"Koaa tiyan�<<s�-� ,.�- i e A—„ _ - _ _, , __ ___- - - - __� � - C _ � -� �� � � �� ���� - Pj o ,i � o f � i o o � i �� o ���, o I,' t �� ��' ,� . � e ! � � � o "� t i � o a �� o 11 0 � _ _� _ COMMONWEALTH OF MASSACHL'SETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFF, .Is j>! DEPARTMENT OF EN MEN PRO IO\ ONE WINTER STREET. BOSTON. NIA 02108 617-292.5r0 row F y�OtiggNST WILLIAM F.WELD �Fnr9Rl, TRL'D�i. 0?T Govemc. c etar5 ARGEO PAUL CELLUCCI �' �jD STRUHS Lt.Govemor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM commission PART A CERTIFICATION Property Address: u e. a Address of Owner: (4:'.l� Date of Inspection: OS Cr (If different) Name of Inspector: l I am a DEP approved system spector pursuant to Section !�15.340 of Title 5 (310 CMR 15.000) Company Name: �"//Cc t c/-r'r �I.0 r'�n 1, 1, y.77�—u - Mailing Address: G A�7� ? 3� _ /` d-SN/�Q /`rho Telephone Number: �& _C7 CERTIFICATION STATEMENT I certih- 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: Passes _ Conditionally Passes tieed_ Further Evaluation By the Local Approving Authority _ Fads Inspector's Signature: cJra`s���►ail `1�V 'Ko Date: The Svstem Inspector shal' 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: Check A, B, C, or D: AI SYSTEM PASSES: _X I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 C:MR 15.303. Any failure criteria not evaluated are indicated below. COMMENTS: t4t) 1�y•,uLx.kw ate-%(+tx.y_rsuT't BI SYSTEM CONDITIONALLY PASSES: One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. 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, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection; or the septic tank, whether or not metal, is 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 04/25/97) Page 1 of 10 DEP on the World Wide Web http.Invww.magnet.state.ma.us/dep > Printed on Recycled Paper, ) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A ) ; t.. ' CERTIFICATION (continued) ` ti Property Address: `q� �� I�G/ - yc/ec Le•_• ` Owner: Date'of Inspection: r©Slh B] SYSTEM CONDITIONALLY'-PASSES (continued d Se�,%ag ybackup or breakout or high static water level observed in the distribution box is due to broken or obstructed �a .."pipelsror due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the , .,Board of Health). Describe observation's, r- broken pipe(s) are replaced: obstruction is removec. distribution box is levelled or replaced a The system required pumping more than four time a year',due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of He It _ broken pipe(s) are replaced obstruction is removed r C) FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by th Board of Health in order to determine if the system is failing to protect the public health, safer`• and the environment. t 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH ETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH A.N SAFETY AND THE ENVIRONMENT: _ Cesspool or privy is within 50 feet of a su ace water Cesspool or pri%)- is within 50 feet of a b rdenng vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF H ALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNE THAT,PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soi absorption system (SAS) and the SAS is within 100 feet to 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 1 of a public water supn1v well. a The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and soil'absorption system and the SAS is less than 100 feet but 50 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 presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine distance (approximation not valid). 3) 'OTHER (revised 04/25/97) p Pais 2 of 10 , i i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A "� CERTIFICATION (continued) Property Address: q.� �eliCl/ Owner: Date of Inspectionp D) SYSTEM FAILS: You must indicate either "Yes" or "No" as to each of the following: I have determined that the system violates one or more of the following failure criteria as defined 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 sewage into facility or.system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. Static liquid level in the distribution boa abo/,eutlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6" belovert or available volume is less than 1/2 day flow. Required pumping more than 4 times in the year NOT due to clogged or obstructed pipets;. Number of times pumped_. Any portion of the Soil Absorption System, Cesspool or privy is below the high groundwater eievation. i I Any portion of a cesspool or privy is w•ith.i 100 feet of a surface water supply or tributary to a surface water supply. Any pcnion of a cesspool or privy is within a Zone I of a public well. Any portion of a cesspool or privy is w.it6 in 50 feet of a private water supply well. Anv 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. 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. - j E] LARGE SYSTEM FAILS: You must indicate either "Yes" or "No" as to each of tht following: The following criteria apply to large systems addition to.the criteria above: The system serves a facility with a design fl of 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety and the environmer)t because one or more of the following conditions exist: Yes No the system is within 400 feet of a surface drinking 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 ll of'a public water supply well) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 04/25/97) Page 3 of 10 A SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ;j PART B CHECKLIST Property Address: 9j3 1�2G�y Owner: �/ovG G Date of Inspection: r' Check if the following have been done: You must indicame 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 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 not been introduced into the system recently or . f as part of this inspection. D - l� 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-sanitar• or industrial waste flow., ' The site was,inspected for signs of breakoit. _ All system components, excluding the Soil Absorption System, have been located on the site. 4 •.. _ -The septic tank manholes were uncovered, opened. and the interior of the septic tank was inspected for condition of baffles or tees, material o'construction, dimensions, depth of,liquid, depth of sludge, depth of scum. The size and location of the Soil Absorption System on the site has been determined based on: • _ The facility o%.•ner tand occupants, if diffe-ent from owner) were provided with information on the proper maintenance of Sub-Surface Disposal System. :. . r A Existing information. Ex. Plan at B.O.H.' } u _ Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) [t 5.302(3)(b)) ;E W - E �g (revised 04/25/97) Page 4 of 10 - ty , SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Properh Address: < 3 K� G(e� /Z�/ _ ��/« c� -� • , -Owner: G , C/ovG4' Date of Inspection: FLOW CONDITIONS RESIDENTIAL: Design flow: 3 J p.d./bedroom for S.A.S. Number of bedrooms: n?, Number of current residents: gLI Garbage g,,:der (yes or no': wa:-, Laundry corrected to system (yes or no): � Seasonal use ryes or no): t� Water meter readings, if available (last two (2) year usage (gpd): Sump Pump Ives or no):_�tJ Last date of occupancy:Z?! _ COMMERCIAIJINDUSTRIAL: Type of establishment: Design flow: sallons/day Grease trap present: (yes or nol_ Industrial %,N`aste Holding Tank present: (yes or no'._ Non-sanitary waste discharged to the Title 5 systerrn: (yes or no,,— Water meter readings, if available Last plate of o cupancv OTHER: :Describe Last date of occuoancv. GENERAL INFORMATION PUMPING RECORDS and source of information: NX-e-&. O�U1n fJ.nl n System pumped as part of (nipecuon: (yes or'no NO If yes, volume pumped: eallons Reason for pumping TYPE OF SYSTEM Septic tank/ soil absorption system Single cesspool Overflow cesspool Pri\,y Shared system (yes or no) (if yes, attach previous inspection records, if any) I/A Technology etc. Copy of up to date contract? Other APPROXIMATE AGE of all components, date installed (if known) and source of information: 'k' AQu:4" N)ewea,\.ro,r0 p�t Sewage odors detected when arriving at the site: (yes or no) NO (revised 04/25/97) page 5 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART-C ' SYSTE:vt •.INFORMATION (continued) Property Address: T:! XC4 /Y V6, u t, 1 Owner. G to t/G-ti /• Date of InCtion:: S / BUILDING SEWER: IJ (Locate on site plan) 1 Depth below grade: Material of construction: _cast iron _40 PVC _other (explain) Distance from private water supply well or suction li-t 6 Diameter a Comments: (condition of joints, venting, evidence of leakage, etc.) SEPTIC TANK: tS (locate on site plan) Depth below grade: T-3(-qA1>0— Material.oi construction: concrete _metal _Fiberglass _Polyethylene _other(explain) If tank is metal, list age _ Is age confirmed by Certificate of Compliance _(Yes"No: Dimensions %k=$PA Sludge depth: 'A" Distance from top of sludge to bosom of outlet tee or ba 6 31�t Scum thickness: 1N Distance from top of scum to top of outlet tee or baf'le. I Distance from bottom of scum to bottom of outlet tee or barie: %01_ How dimensions were determined: ►1�wDvn.a . 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.) :kxilJl �tlrn�N� '�` 2t< �r„ ► r�.av�� 4�.►te9 >• wl c GREASE TRAP: NO (locate on site plan) Depth below grade: Material of construction: _concrete _metal _Fiberglass _Polyethylene _otheir(explain) Dimensions: Scum thickness: , Distance from top of scum to top of outlet tees or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments: (recommendation for pumping, condition of inlet and outles tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) (revised 04/25/97) Page 6 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 93 /lt?Ll Y /Zcl • ��« a �� Owner: C Cje, Date of Inspection:�s���/%� TIGHT OR HOLDING TANK: t-SG (Tank must be pumped prior to, or at time,'of inspection) (locate on site plan) Depth below grade: Material of construction. _concrete _metal _Fiberglass _Polyethylene —other(explain) Dimensions: Capacrn•: gallons Design floes: gallonsida\ Alarm level. Alarm in working order _ Yes; _ No Date of previous pumping Comments: (condition of inlet tee. condition of alarm and float switches, etc.) DISTRIBUTION BOX:r�)c7 (locate on site plan: Depth of liquid level above outlet invert Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) PUMP CHAMBER: (locate on site plan; Pumps in working order: (Yes or Nol Alarms in working order (Yes or Not Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) (raviaad 04/25/97) Page 7 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM 1i PART C SYSTEM INFORMATION (continued) Property Address: 9j`'Axe G/c/ led k u c r_ Owner: Date of Inspection: f t SOIL ABSORPTION SYSTEM SAS): (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) k If not determined to be present, explain: k Type: i leaching pits, number:A.tVb leaching chambers, number:r leaching galleries, number. } leaching trenches, number,length: ' leaching fields, number, dimensions. overflow cesspool, number: Alternative system: Name of Technologv: II .. Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)' ���\� c� Igo �v��4trac�� oi- �Q,en.�o�T' 1J/O�S����w�� o-E h►.l�na,.��.c �.*1 �.� Q $° LA}� 'Pon�c��Ng ►T4 iL y W t U1r- �- S r 5•� �.sTRuca.4 aow. T N =N:rJM'r a CESSPOOLS: v� ' (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 (cesspool must be pumped as pan of inspection) Comments: (note condition of soil, signs of hydraulic failure, level oflponding, condition of vegetation, etc.) PRIVY: No (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments: (note condition of soil, signs of hydraulic failure, level of'pcnding, condition of vegetation, etc.) 1` (roviaed'04/25/97) Page a of 10 IE SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C a / SYSTEM INFORMATION (continued) Property Address: /3 ,2 4 .1 �d_ 1,1y, Owner. �r , G�ovG�► Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100'-(Locate where public water supply comes into house) 2 3 Q y -3k�' 83- 35'`' I ' (revised 04/25/97) Page 9 of 10 ^SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM 4 PART C `6 SYSTEM INFORMATION (continued) Property Address: / 5LI�J Owner: Glo �(i-�♦ I Date of Inspection: Depth to Groundwater *24eet u Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record r � Observation of Site (Abutting property, observation hole, basement sump etc.) t Determine it-from local conditions Check with local Board of health Check FEMA maps Check pumping records a Check local excavators, installers _.Use U SGS Data j Describe in vour own words how you established the High Groundwater Elevatio.n. (Must be completed) ,, rvlR,llno�l, o+- 9Q1,cam.Nhtlo.� V.s.�.� S�¢•�s� � 1�:��¢.o�>>;, �uve.6�'��.�'Rwl t �.A . b�Z, :i � • 1 I] (zaviaad 04/25/97) Page 10 of 10 ! } :7 C3. it zri i � F 3 J w✓ � z ; � ._..._._�......._ _.J/ i—..._-__•___•— ,):mot le+. ...._ _...__...........J�� �--_....� _�I._._�.....�_....._.__._._....-_ _� VI ZI loo :Z. ) i 1 �• I i ; �i 1 ,r. �A I. J'll I IN- 13 C .- lul f -- to. 4— ij I 16, 4 TOWN OF BARNSTABLE LOCATION )� �4\� SEWAGE #69� VILLAGE ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) NO.OF BEDROOMS BUILDER OR OWNER PERMITDATE: 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 Furnished by .'. . . � � ' � f. '� S a� i ,. i - .t ,. �• i. � � N v O ` ' ' i . _ - � .. � �, /'�, t �Ov/, I 'N, �_ -. t* - -. _ -� _ __ -_- -- -- _ - . �� � � r e � � � c � �P� �. � �I � ,•. � .Ga �''. i t i ._