HomeMy WebLinkAbout0414 OAKLAND ROAD - Health 4 1 4 Oakland Road
Hyannis F
A = 27I ' 616,
a2-21af�
CARL F. i
CAV®S�
Commonweatth.of Massachusetts �R-
Executive Office of Environmental Affairs
Department of
2 Palmer Avenue
_ Falmouth, MA 02540
a • • Telephone(508)540-3933
nvironm*enta' Pro' te.;-loll Fax(508)540-4753
William F.Weld
°owe"10f ' Trudy Cox*
Arpeo Paul Celluool r q
A
Do B.StrYhs •*r
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Rld/
r PART A co .
CERTIFICATION J U L 1 1997 f
Property Address: I'i� Oa►4aind Rd .� I4yann►s Address of.Owner. TO HEALiHDEP1ABLE
Date of Inspection: (y- ILi -q1j (If different) (91 166r) '4 Name of Inspector: C W l ', Ca c)s Sa r �� A
Company Name,Address and elephone Number: A
E
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 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 Evaluation By the Local Approving Authority .
— Fails
I nspector's Signature: /117 Date:
.. CPLW
The System Inspector shall subm' copy of this inspection
inspection. If the Into the Approving Authority within thirty(30)days of completing this
system is a shared system or has a design flow of 10,000 gpd'or`greater,the inspector and the system owner shaft 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) SYSTEM PASSES:
XI 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 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 roo
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) '
Ono Winter Strom o Boston,Massaehu8otts 02108 s FAX(617)US-1049 a Telephone(617)292-4W
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��Printed on Recycled Papa
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SUBSURFACE SEWAGE DISPOSAL`SYSTEM INSPECTION FORM
PART A
II� ( vaw Rd CERTIFICATION (continuer!)
Owner:erty ObQ ft U R bQ Ii I o � 4Y
Ow
Date of Inspection:
61 SYSTEM CONDITIONALLY PASSES (continued)
Sewage backup or breai:out or high static water level observed in the distribution box is due to broken or obstructed
Bipe(s) or due to a broken, settled or uneven distribution box:
Board of Health): The system will pass inspection if(with approval of the
broken pipe(s) are replaced
obstruction is removed,., ;
distribution box is levelled or replaced
The system required put"Ping more than four times a year due to broken or obstructed pipe(s). The system
inspection if(with approval of the Board of Health): Y will pass
broken pipe(s) are replaced
obstruction is removed
q FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
Conditions exist which require furher evaluation by the Board of Health in order to'determine if the system Y 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 PUi1LIC HEALTH AND SAFETY AND THE ENVIRONMENT: MANNER
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'PUBUC WATER
THE SYSTEM IS FUNCTIONING I SUPPLIER,IF APPROPRIATE) DETERMINES THAT
N A MANNER THAT P ROTECT THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
The system has a septic t nk and soil absorption system and is within 100 feet to a surface water supply or
surface water supply. pp y tributary to a
— The system has a septic t:,nk 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 hnk and soil absorption system and is less than 100 feet but 50 feet or more from a private water
supply well, unless a weli water analysis for coliform bacteria and Volatile organic compounds indicates that the well is
free from pollution from hat facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5
3) OTHER
-------------
(revised11/03/95)
2
SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION FORM
PART A
'/ CERTIFICATION (continued)
r
Property Add r �114 O r�\III,QL1�, ��i . • (�S
Owner:
Date of Inspection:
D] SYSTEM FAILS:
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.
— 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 box above outlet invert due to an overloaded or clogged SAS or cesspool.
Liquid depth in cesspool i; 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
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 I 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 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.
El LARGE SYSTEM FAILS:
The following criteria apply to larg, systems in addition to the criteria above:
The system serves a facility with a .lesign flow of 10,000 gpd or greater (Large System)and the system is a significant threat to
public health and safety and the en/ironment because one or more of the following conditions exist:
the system is within 400 1--et of a surface drinking water supply
the system is within 200 i-eet 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).
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 11/03/95) 3
SUP SURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B .
CHECKLIST
Property Addy ��� O k I
and PI ann►s
Date of.Inspection:
Owner: �ob:¢.r t � I '
bx�, I a
fo-19 - G7
Check if he following have been done:
Va no
n _Pumping information was re,;nested 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 not been introduced into the system recently or as part of this inspection.
As built plans have been obt:dned and examined. Note if they are not available with WA.
The facility or dwelling was inspected for signs of sewage back-up.
x _The system does not receive non-sanitary or industrial waste flow
_The site was inspected for si,.ns of breakout.
_All system components, excl.Iding the Soil Absorption System, have been located on the site.
x _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.
X The size and location of the Soil Absorption System on the site has been determined based on existing information or
approximated by non-intrusive methods.
J\ _The facility owner (and occui)ants, if different from owner) were provided with information on the proper maintenance of Sub-
Surface Disposal System.
(revised 11/03/95) 4
'i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART:C:;:
SYSTEM'INFORMATION .
Property Address: M 6V6and Rd Ny�nnls t.::
Owner: �� U pb rd I O /
Date of Inspection: -q 1r�
i
RESIDENTIAL: FLOW CONDITIONS
Design flow: 03Qgallons
Number of bedrooms:
Number of current residents:
Garbage grinder(yes or no): �(Yesfor
Laundry connected to system no):�tv�t'y nnQ Q(� -�.. jQI VLya,Q x 31
Seasonal use(yes or no):�� ' 1 /
Water meter readings, if available:_
Last date of occupancy:
COMMERCIAUINDUSTRTL
Type of establishment:
Design flow: gallons/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:
'.ast date of occupancy:
OTHER: (Describe)
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source ifinformation:
f
System pumped as part of inspection: (yes or no) 1/�
If yes, volume pumped: 1 OU tzalions T
Reason for pumping: Qt(1_Q1'1(A Y1r Q_
TYPE OF SYSTEM
Septic tank/diedibnfisa4wjsoil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system (yes or no) (if yes, atta h previous iJr spection records, if any)
Other(explain) — L X cl'W x 3 i D
r
APPROXIMATE AGE of all mponents, date installed (if known)and source of information:<< —' �Q Cc f�nr1 I
Leach;(� PIE
►� yP rs t
Sewage odors detected when arriving at the site: (yes or no)
(revised 11/03/95) $
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C ;. ' .-
SYSTEM INFORMATION (continued)
Property ess o�►� b 1C I n�. P�, -, 4y ann�
Owner: bt
Date of Inspection;
SEPTIC TANK:_&.y
(locate on sit
e plan)
)
Depth below grade: ��►
Material of construction:&concrete _metal _FRP--other(explain)
Dimensions:
Sludge depth: (p
Distance from top of sludge to bottom of outlet tee or baffle:���
Scum thickness: "
Distance from top of scum to top of outlet cee or baffle:
Distance from bottom of scum to bottom o outlet tee or baffle:_r
Comments;
(recommendation for pumping, condition (f inlet a d outlet tees or baffle , depth,of liquid level in relation to outlet invert, stru ural
integrity,evidence of I e, etc.)
J �
GREASE TRAP:-&
(locate on site plan)
Depth below grade:
Material of construction: _concrete_mc tal _FRP—other(explain)
Dimensions:
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:
(recommen
dation for pumping, condition c f inlet and outlet 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 Address:
Owner: Robe-& U r
mb ello
Date of Inspection: 4` q
7
TIGHT OR HOLDING TANK:-do
(locate on site plan)
Depth below grade:
Material of construction: _concrete _metal _FRP other(explain)
Dimensions:
Capacity: gallons
Design Flow: gallons/day
Alarm level:
Comments:
(condition of inlet tee, condition of alarm aid float switches, etc.)
DISTRIBUTION BOX:-A/D
(locate on site plan)
liquid Depth of I'p i level above q 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:�D
(locate on site plan)
Pumps in working order:(yes or no)
Comments:
(note condition of pump chamber, condition of pumps and appurtenances, etc.)
(revised 11/03/95) 7
SUBSURFACE SEWAGE DISPOSAL SYSTEM,INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: r 1.� a�+r, _I U
Owner: �h� WIr,Z 'W f71,$
Date of Insp 0b rt ombr&o
(,P- / I - �7
SOIL ABSORPTION SYSTEM (SAS):fie 5
(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 trenches, number,length:
leaching fields, number, dimensions: ' L X 3'13
overflow cesspool, number:
Comments: (note condition of soil, ns of hydraulic Hu e, level.of pon ing,,co�dition gf tado n etc.)
3
r
CESSPOOLS: /Y 11
(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 gruundwater:
inflow (cesspool must be pumped as part of inspection)
Comments: (note condition of soil, signs of hydraulic failure, level of
ponding, condition of vegetation, etc.)
PRIVY:
(locate on site plan)
Materials of construction:
Depth of solids: Dimensions:
Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition-of vegetation, etc.)
(revieed.11/03/95) 8
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: ,�� Oak I arid Vd,
Owner
Date of In ton r� Umbr��lr7
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100'
kear
�avndr '
rya:- q Sa= Is0
A 3= Q-1 I .B 3=50, �
��
DEPTH TO GROUNDWATER
Depth to groundwater-�—A�feet
me f determipatip or approximation. S
VLF "
(revised 11/03/95) 9