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HomeMy WebLinkAbout0017 LONGVIEW DRIVE - Health 17 Longview Drive Hyannis A= 252 — 077 r I i 1 II 1 c commonwealth of Massachusetts �9� 1ell , Executive Office of Environmental Affairs �a Department of. 9Nsr 998 Environmental Protection , Willlam F.Weld Ldy Cie GovernorTr Argeo Paul Celluccl s.c,, e U.Governor David B.Struhs Commleslow SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: ��,,,!�,p L&." � �s,vf�� of�!, f"A o Address of Owner. Date of Inspection: � / r I od<&3 2 (If different) Name of Inspector. Company Name,Address and Telephone Number. ", C W Sel aC, So CERTIFI3nJ 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' ion. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewaaisposal systems. The system: Passes Conditionally Passes Needs Further Evaluation By the Local Approving Authority Fails Inspector's Signature: r � Date: The System Inspector shall submit a copy of this inspection report to the Approving Authority wit 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: A] SYS ASSES: I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. B] SYSTEM CONDITIONALLY PASSES: One or more system com ts.need to be replaced or repaired. The ,upon completion of the replacement or repair,passes ir pection. \ In ;cats yeg, no,or not determined(Y,N,or ND). Descri is o determination in all instances. If"not determined",explain why not) The septic-tank is metal, cracked,structurally` d,shows substantial infiltration or exfiltration,-or tank failure is imminent. The stem will H pass ins on if the existing c tank is replaced with a gonforming septic tank as approved by the Board of Health. (revised �1/03/95) 1 One Wlnter Street.* Boston,Massachusetts 02108 a FAX(617)556-1049 a Telephone(617)292-WW i�J Printed on Recycled Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A r,[� CERTIFICATION(continued) Property Address: i�S�n/Co+ yli/°eW PA. CPa-,terill f(t°� 9l'li9= f�ol(v3 Z Owner. ISROCC K� L�/%/�I`l�'►-� Ft- Date of Inspection: � j�n C B)SYS CONDITIO ALLY PASSSSES(continued) Sewage backup or b Icout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken,sett or uneven distribution box. The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed distribution boa is levelled or replaced The system required pin aping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with app val of the Board of Health): broken pipe(s)are replaced obstruction is removed Cl. THER 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 the public health,safety and the environment. 1 SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A WHICH WILL PROTECT THE PUBLIC HEALTH AND 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) S STEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER,IF APPROPRIATE) ETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND TY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system and 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 is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and is less 100 feet but 50 feet or more from a private water supply well,unless a well water anal for coliform bacteria an olatile organic compounds indicates that the well is free from pollution from that facility and the resence of ammo trogen and nitrate nitrogen is equal to or less than 5 ppm. (revised 11/03/95) 2 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: LD.,/� f//C&t/ �/Qa C CP,&-74 rV 111ef Owner. 131?(/116- 7`' W/11%4 A--1 Date of Inspection: DI SYSTEM FAILS: I have determined that the system violates one or more of the following failure criteria as defined in 0 CMR 15.303. The basis for t ' determination is identified below. The Board of Health should be contacted to determine what be necessary to correct the Backup of sewage into facility of system component due to an overloaded or clogged AS or cesspool. ischarge or ponding of effluent to the surface of the ground or surface waters d to an overloaded or clogged SAS or 1. Static liq ' level in the distribution box above outlet invert due to an overl ded or clogged SAS or cesspool. Liquid depth in pool is less than 6"below invert or available volume ' less than 1/2 day flow. Required pumping m than 4 times in the last year NOT due to cl or obstructed pipe(s). Number of times pum Any portion of the Soil Abso tion System, cesspool or privy is ow the high groundwater elevation. Any portion of a cesspool or privy within 100 feet of a surf ce water supply or tributary to a surface water supply. Any portion of a cesspool or privy is wit a Zone I of a u'blic well. Any portion of a cesspool or privy is within 50 t of a'rivate water supply well. Any portion of a cesspool or privy is less than 100 f but greater than 50 feet from a private water supply well with no acceptable water quality anal PP y P q y analysis. If the well has n yzed to be acceptable, attach copy of well water analysis for coliform bacteria,volatile organic compounds, onia m gen-and= trate::nitrogen: El LARGE LYSTEM FAILS: 71 e following criteria apply to large systems in ad 'tion to the criteria above: e system serves a facility with a design flow o 10,000 gpd or greater(Large System d the system is a significant threat to public h th and safety and the environment beta one or more of the following conditions the system is within 400 feet of a ace drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nit gen sensitive area(Interim Wellhead Protection Area(IWPA)o a mapped Zone II of a public water supply well) The owner o operator of any such system s bring the system and facility into full compliance with the groundwater tment program requirements,of 314 CMR 5.00 and 6.00. PI ase 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 Adam: Lo•,.�vi ew /.�/1� C����s�v i �1 e� NIA= O Z&3 2 Owner. /31*1eE 7- kloliun( y/'e Date of Inspection V;.?/ Check if the foll have been done: information was requested of the owner,occupant, and Board of Health. _None of the system components have been pumped for at least.two.,wgeks_and„thg system has been receiving normal flow rates Lduring that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. As t p ve been obtained and examined. Note if they are not available with N/A.. " _TheAcility or dwelling was inspected for signs of sewage back-up. The sw m dot receive non-sanitary or industrial waste flow e i w ' pected for signs of breakout. All m com eats, excluding.the Soil Absorption System, have been located on the site. The se ' tank es were uncovered,opened, and the interior of the septic tank was inspected for condition of baffles or tees terial construction, dimensions,depth of liquid, depth of sludge,depth of scum. e a and location of the Soil Absorption System on the site has been determined based on existing information or ap ted 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 INFO/RMATION Property Address: S Ld. Y/[ic/ �/� < �'Pti�C�/` �P Owner. 13&11~[= 40, !si/��j c7®►,� F i�yl C�y j�Q o��P 3 Z Date of Inspection: RESIDE FLOW CONDITIONS Design flow: ons Number of mg: �/ / Number of current residents: L- Garbage grinder(pea or no): Laundry connected to systegm�or no): E S Seasonal use(yes or no): / Water meter readings, if available: Last date of occupancy: COMMERCIAL INDUST Type of establishment: Design flow:_gallons/da Grease trap present: (yes or n )T Industrial Waste Holding T nt: (yes or no)_ Non-sanitary waste disc o the Title 5 system: (yes or no)_ Water meter readings, if av b e: Last date of occupancy OTHER: (Descri Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: System pumped as part of ins ion: (yes or no) If yes,volume pumped: 0® ons Reason for pumping: "/1 t9 j I ! C I v& C, 5 S �0 Gl TYPE OF SYSTEM Sept tank/distnbution box/soil absorption system cesspool Overflow cesspool P ' hared system(Yes or o) (if yes, attach previous ins ion cords, if any) p Other(explain) 7 j D 0 TT- APPROXIMATE AGE of all components,date installed(if]mown)and source of information: Sewage odors detected when arriving at the site: (yes or no) (revised 11/63/95) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address 4. 3 2 Owner. Date of Inspection: 'yE / (locate on site plan) Depth below grade: Material of construction: concrete_metal_FRP other(explain) Dimensions: _ Sludge depth: l Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: 1 T&a / 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 pump' condition of inlet and outlet tees or baffles, depth f liquid level in lation to outlet invert�,/s-tructural in grity, evidence of leakage, etc.) t m V�I7 / E$ O® jJ e I �h U� !, !/fr GREASE TRAP:_ to on site plan) } Depth ow grade: Material o ruction:_concrete_metal_FRP—other(explain) Dimensions: Scum thickness: Distance from top of scum to of outlet tee or baffle: Distance from bottom of scum to bo m of outlet tee or baffle: Comments: (recommendation for pumping, condition of inlet an u tees or baffles,depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage,etc.) (revised 11/03/95) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Aaareas 0 2&3 2 Owner. Date of Inspection TI T OR HOLDING TANK:_ (loca on site plan) Depth be w grade: Material o constriction:_concrete_metal FRP—other(explain) Dimensions: Capacity: ons Design flow: ons/day Alarm level: Comments: (condition of inlet tee, condi 'on of alarm and float switches,etc.) DISTRIBUTION BOX (locate on site plan) Depth of liquid level above outlet invert: Comments: (note if level and distribution is equal, evidence f ds carryover,evidence of leakage into or out of box,etc.) PUMP CHAMBERZber, (locate on site plan) Pumps in working ord Comments: (note condition of pum of pumps and appurte s, etc.) (revised 11/03/95) 7 f . SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: �L G y�!i/e Gt/ �/le �P✓L//Q/'v!�!P� /Ll.9c a�(p 2 Owner. 13/2 06E- /e Date of Inspection: j// / SOIL ABSOR PTION SYSTEM (SAS):— S' cr P�d (locate on site plan,if possible;excavation 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 trench h: leaching fields, dimensions: =(note pool,num r: Cotion of soil,signs of hydraulic failure, level of ponding, condition of vegetation etc.) CESSPOOLS:_ (locate on site plan) Number and configuration: C'*C 55 Poo Depth-top of liquid to inlet in ert: Depth of solids layer: If Depth of scum layer: A 5 ry / Dimensions of cesspool: Materials of constriction: Indication of groundwater: inflow(cesspool must be pumped as part of inspection)_ "/n hd Co e : (note condition of soil, signs of hyliraulic failure, el of po nditionsof ve to ' b�fc PRIVY:_ (locate on site plan) Materials of construction: ensions: Depth of solids: Comments: (note condition of soil,signs of hydraulic failure, level of ponding, tion getation,etc.) (revised 11/03/95) 8 i I • V SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: �, Lis e/jew Owner. Date of Inspection: 31101 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' \ v dui y � O d©: �' �° oo I r5 o� � A fr/Du DEPTH TO GROUNDWATER ® / 00 ` D v Depth to groundwater 3, feet C method of determination or approximation: ✓ Ina (revised 11/03/95) 9 d TOWN OF BARNSTABLE LocATION AGE # VILLAG __J ES.SO' 'S MAP& LOT C? INSTALLER'S NAME&PHONE NO. ✓ l� ��� '" ��°7 SEPTIC TANK CAPACITY S S bvg LEACHING FACILITY: (type) NO.OF BEDROOMS BUILDER OR OWNER sZ PERMTTDATE: COMPLIAN 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 a /" � 0 � � � � hod a � �a� �' �� ��ss ��01