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HomeMy WebLinkAbout0049 SUOMI ROAD - Health (3) 55 SAUNA ROAD, HYANNIS A = 268 094 TOWN OF®BARNSTABLE LOCATION SS SPO-�' P A, V�� ► SEWAGE # VILLAGE k6 utn1NkS ASSESSOR'S MAP&LOT 2b INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) pjl- (size) ' NO.OF BEDROOMS BUILDER OR OWNER SATE: �21,JJ dj _COMPLIANCE DATE: Separation.Distance Between the: Maximum Adjusted Groundwater Table Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) 1 Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching ffaaciili ) Feet Furnished by W � c No c I o l vo 0 f /" ! N P _, N COMNIONE.- iLTH OF I L�SSACHt'SETTS \� EXECUTIVE OFFICE OF E\vIRO\MENTAL. DEPARTMENT OF ENVIRONMENTAL PRO _�TI© Y 8 1999 0\E WINTER STREET. BOSTO\ `.'_4 02106 l61 i i 29`L:i:itw Lr �+�t pHOgl(Bl f COXE Secretar D �rlD B STRLH: ARGEO PALL CELLliCCI Cotnrnissione Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM �� PART A V-` [ CERTIFICATION (;i►` Property Address: "� �t7�;.:�a.. �-A Name of Owner Vt AP+%�R 5ocv-1c,,t. t Address of Owner: �=tF4-yV` . Date of Inspection: y�b`��� / Name of Inspector:(Pie a Print)d •cA a r'L I am a DEP approved system inspector pursua t nt to Section 15.t340 of True 5(310 CMR 15.000) Company Name: 4�. t-r" Pk to-,'r� a. .... r i.' Cl& F o `7 µacing Address: ,^ • I VL145 N u 4- Te)eplum Number: �SQ LAC 7 r CE RTIRCATION 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 Approving Authority Fails Q L Inspector's Signature: Date: , - The System Inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)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. I NOTES AND COMMENTS revised 9/2/98 Page Iof11 ~� Printed on Recvc"Paper • i . I {'� 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A f ; CERTIFICATION (contirwed) 4operty Address:S'Si7'UNAP I —Jwner: '�` -- a Date of Inspection: INSPECTION'SUMMARY: Check A, B, C, or D: A f SYSTEM PASSES: -{ I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist. Any failure criteria not evaluated are indicated below. COMMENTS: Ss B. SYSTEM CONDITIONALLY PASSES: One or more system components onents as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon p 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 prigr 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 complying septic tank as approved by the Board of Health. _ Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled 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 box is levelled or replaced _ The system required pumping more then four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed revised 9/2/98 P2ge2of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Owner: Date of Inspection: C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of Health in order to determine if th system is failin_to protect the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 MR 15.303(1)(b)THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SA AND THE ENVIRONMENT: _ Cesspool or privy is within 50 feet of surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt mar h. r 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER PPLIER,IF ANY)DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND FETY AND THE ENVIRONMENT: _ The system has a septic tank and soil absorption system (SAS)a d the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. _ The system has a septic tank and soil absorption system and t SAS is within a Zone I of a public water supply well. _ The system has a septic tank and soil absorption system and a SAS is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system an he SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for c liform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the prese a 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 9/2/98 Page 3of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Owner: Date of Inspection: D. SYSTEM FAILS: You must indicate either "Yes" or "No" to each of the following: I have determined that one or more of the following failure conditions exist a described it 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted, o determine ovhat will be necessary to correct the failure. Yes No Backup of sewage into facility or system component due to an verloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground r surface waters due to an overloaded or clogged SAS or cesspool. Static liquid level in the distribution box above outlet invert ue to an overloadec or clogged SAS or cesspool. Liquid depth in cesspool is less than 6" below invert or av ilable volume is less man 1/2 day flow. Required pumping more than 4 times in the last year N / due to clogged or obstructed pipe(s). r Number of times pumped_. Any portion of the Soil Absorption System, cesspool r privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 fee of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zon I of a public well. Any portion of a cesspool or privy is within 50 f let of a private water supply well. Any portion of a cesspool or privy is less-than 00 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the wet has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compoun , ammonia nitrogen and nitrate nitrogen. E. LARGE SYSTEM FAILS: You must indicate either "Yes" or "No" to each of the foll ing: The following criteria apply to large systems in a dition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to publk health and safety and the environment becaus one or more of the following conditions exist: Yes No the system is within 400 feet of surface drinking water supply _ the system is within 200 feet f a tributary to a surface drinking water supply the system is located in a ni ogen 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 s all upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional office of the Department for further informa ion. revised 9/2/98 page 4of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST property Address: j j aUr•s Or Owner: Si4v-,.T . Date of Inspection: Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Yes No Pumping information was provided by the owner, occupant, or Board of Health. x _ None of the system components have been pumped for at least two weeks and-the system has been-receiving normal flow TC 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 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 System on the site has been determined based on: A Existing information. For example, Plan at B.O.H. Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) [15.302(3)(b)1 The facility owner(and occupants,if differeru from owner)'were provided with information on the propermaintananrs-of SubSurface Disposal Systems. revised 9/2/98 Page 5of11 ✓ =w SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM. PART C t C SYSTEM INFORMATION +roperty Address: ;J Owner:�+i Date of Inspecti8n:�kT4-r,t� J FLOW CONDITIONS RESIDENTIAL: _ Design flow: g.p.d./bedroom. Number of bedrooms (design):(^;` Number of bedrooms (actual):C33 Total DESIGN flow j C Number of current residents: Garbage grinder(yes or no):_ Laundry(separate system) s or no): ►V: If yes, separate inspection required Laundry system inscted ye or nol pe Seasonal use (yes or no): L3 Water meter readings, if available (last two year's usage(gpd): Sump Pump (yes or no): Last date of occupancy: :LiU1� COMMERCIAL/INDUSTRIAL: Type of establishment: Design flow: qpd ( Based on 15.203) { Basis of design flow Grease trap present: (yes or nol_ 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 in r�mati QVA 6il�ivZifiv System pumped as pan of inspect i n: (ye or no)��t� 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 or no) (if yes, attach previous inspection records,if any) I/A Technology etc. Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other APPROXIMATE AGE of all components, date installed(if known) and source of information: 1 t:4%W i:xf Sewage odors detected when arriving,at the site: (yes or no) revised 9/2/98 P2gc6ofIt SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) 'roperty Address: Owner: s•'i�V^t A`�, Date of Inspection: .Is BUILDING SEWER: '1 (Locate on site plan) Depth below grader Material of construction:_cast iron 140 PVC_other (explain) Distance fro p�rivate water supply well or suction line Diameter v Comments: (condition of joints, venting, evidence of leaks e, etc.) ` SEPTIC TANK:-44j (locate on site pl/dn)_ t Depth below grade: ILL Material of construction: concrete_metal_Fiberglass _Polyethylene other(explain) If tank is metal, list age_ Is age confirmed by Certificate of Compliance_(Yes/No) r Dimensions: , ' � Sludge depth: a ll_ Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: ^3't rl Distance from top of scum to top of outlet tee or baffle: l i �, Distance from bottom of scum to bottom of outlet tee or baffle:1� How dimensions were determined: 'omments: (recommendation for pumping, co ditio of inlet and outlet tees or baffles. depth of liquid level in relati_n to outlet invertstrruc,ur n tegrity, lam' :;� i� evidence of leakage,etc.) l 6ra. GREASE TRAP:�A� (locate on site plan) Depth below grade:_ Material of construction:_concrete_metal_Fiberglass _Polyethylene_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: Date of last pumping: 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.) revised 9/2/98 Page 7of11 Vr .h SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C S SYSTEM INFORMATION (continued) 'roperty Address:5 *C&J& Owner: C!;I 4it Date of Inspection: TIGHT OR HOLDING TANK: U (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: Capacity: gallons Design flow: gallons/day Alarm present 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:_ (locate on site plan) Depth of liquid level above outlet invert: Comments: _ (note if level and gistnbution s eq I, evidence of solids carryover, evidence of leakage i to or out of box, etc.) �s��rS� 0 kj PUMP CHAMBER:—�� (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.) revised 9/2/98 Pagc8of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) ,roperty Address: Owner: Date of Inspection: SOIL ABSORPTION SYSTEM ISSO S (locate on site plan, if possible: excav ion not required.location may be approximated by non-intrusive methods) If not located, explain: Type: leaching pits, number:—a leaching chambers, number:_ leaching galleries, number:_ leaching trenches, number, length: leaching fields, number, dimensions: overflow cesspool, number: Alternative system: Name of Technology: Comments: �I (not condition of soil, signs of hydraulic failure, level of ponding.,damp syoi a edition of vegetation, etc.) V CESSPOOLS: (locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: )epth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater: 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:20 (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 9/2/98 Page 9of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) 'roperty Address: Date of Inspection: ,y SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) t a � revised 9/2/98 Page 10of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) ;opertY Address: rj [; (4V Owner: C:. C.' Date of Inspection: i NRCS Report name --- Soil Type_ ------ — - Typical depth to groundwater_-_-_ _ _-_ USGS Date website visited Observation Wells checked Groundwater depth: Shallow Moderate Deep SITE EXAM Slope Flu i Surface wateriVC Check Cellar j)r Shallow wells virli i Estimated Depth to Groundwatert,2Lt feet I Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observed Site(Abutting property. observation hole, basement sump etc.) Determined from local conditions Checked with local Board of health Checked FEMA Maps t Checked pumping records Checked local excavators. installers Used USGS Data t Describe how you established the High Groundwater Elevation. (Must be completed) ` (( f { { revised 9/2/98 Page 11or11