HomeMy WebLinkAbout0010 COLONIAL FARM CIRCLE - Health lU C&onia-fT rmCir`cle(Barnstable)
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COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
LPt-EC101-:NDTITLE 5OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARYSUBSURFACE SEWAGE DISPOSAL SYSTEM
PART A '
CERTIFICATION ,
Property Address: 10 ( � '
fl', ! . ,
Owner's Name:
Owner's Address: T
Date of Inspection: c O\
Name of Inspector: (please print)_Kt C� QC- k
Company Name
Mailing Address:
Telephone Number: -' 1494a
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 CMR 15.000). The system:
Passes s
Conditionally Passes G
Needs Further Evaluation by the Local Approving Authority , ,
Fails
Inspector's Signature: *- , " Date: 5 0 1
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.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
DEP.The original 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 in the future under the same or different
conditions of use.
Title 5 Inspection Form 6/15/2000 page I :.
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Page 2 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Addiess:�1�
y o
Owner: ('
Date of Inspection:
Inspection Summary: Check A,B,C,D or E/ALWAYS complete a waf
A. S tem Passes:
-7I have not found any
information which indicates that any of the failure criteria described in 310 CMR •
15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below.
Comments:
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B. System Con ' ionally Passes: t
One or more sys components as described in the"Conditional Pass"s tion need to be replaced or
repaired.The system,upon mpletion of the replacement or repair,as approv d by the Board of Health,will pass.
Answer yes,no or not determined(Y, ND)in the for the following statements.If"not determined"please
explain.
The septic tank is metal and over 20 year old*or the selitic tank(whether metal or not)is structurally
unsound,exhibits substantial infiltration or exftltra. n or 'failure is imminent.System will pass inspection if the
existing tank is replaced with a complying septic tank a proved by the Board of Health.
#. *A metal septic tank will pass inspection if it is structure� sotmd,-not wing and if a Certificate of Compliance
indicating that the tank is less than 20 years old is av�ifable.
ND explain:
Observation of sewage backup or break out or High static waft el in the distribution box due to broken or
obstructed pipe(s),or due to a broken,set led.or uneven distribution box.S em will pass inspection if(with ;
approval of Board of Health):
?broken pipe(s)are npriaood ,
'obstruction is removed
distrib_ uticta.bmc its hweled or
ND explain: ,
The system quired pumping more than 4 times a year due to broken or obstructed pipe(s). he system will
pass inspection i with approval of the Board of Health):
broken-ope(s)are replaced
obstruction is removed
ND explain:
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Page 3 of 11 s
OFFICIAL INSPECTION FORM--NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address:
Owner
Date of Inspection: o '
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`the system
is failing protect public health,safety or the environment.
1. System ill pass unless Board of Health determines in accordance with 310 CMR'15`.303(1)(b)that the
system is t functioning in a manner which will protect public health,safet , nd the environment:
Cesspool o rivy is within 50,feet of a surface water
Cesspool or p 'vy is within 50 feet of a bordering vegetated wetland"o r a salt marsh
2. System will fail unless the Board o Health(and ublic Water Supplier,if any)determines that the
system is functioning in a manner that p tects t public health,safety and environment:
_ The system has a septic tank and soi b rption system(SAS)and the SAS is within 100 feet of a
surface water supply or tributary to a s face w r supply.
The system has a septic to and SAS and the S is within a Zone 1 of a public water.supply.
_ The system has a se p ' tank and SAS and the SAS is 'thin 50 feet of a private water supply well.
_ The system has septic tank and SAS and the SAS is less th 100 feet but 50 feet or more frodl a
private water sup y well".Method used to determine distance ;
"*This syst passes if the well water analysis,performed at a DEP certi d laboratory, for coliform
bacteria d volatile organic compounds indicates that the well is free from llution from that facility and
the pre nce of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 m,provided that no other
fail criteria are triggered:A copy of the analysis must be attached to this form.
Other:
Page 4 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued) ;
Property Address:
Owner:
Date of Inspection: C (j
D. System Failure Criteria applicable to all systems: •3,
You must indicate"yes"or"no"to each of the following forall inspections:
Yes No
Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
Dischar or ponding of effluent to the surface of the ground or surface waters'due to an overloaded or
clogged S or cesspool //
Static liquid vel in the distribution box above outlet invert due to an overloaded or clogged.SAS or
cesspool
Liquid depth in ces ool is less than 6"below invert or available vo)dme is less than '/2 day flow
1_ Required pumping in e than 4 times in the last year NOT due todogged or obstructed pipe(s).Number
of times pumped ,
Any portion of the SAS,c spool or privy is below high ground water elevation.
Any portion of cesspool or p 'vy is within 100 feet of a surface water supply or tributary to a surface
water supply.
Any portion of a cesspool or pri is within a Zone 1/f public well.
Any portion of a cesspool or privy i within 50 fee yof a private water supply well.
Any portion of a cesspool or privy is 1 s than 1 Meet but greater than 50 feet from a private water
supply well with no acceptable water qu ity fialysis. [This system passes if the well water analysis,
performed at a DEP certified laborato or coliform bacteria and volatile organic compounds
'indicates that the well is free from poll io from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equa to or I than 5 ppm,provided that no other fadom criteria
are triggered.A copy of the analys' must be a cbed to this form.]
(Yes/No)The system fails.I have de rmined that one or ore of the above failure criteria exist as
described in 310 CMR 15.303 erefore the system fails.The system owner should contact the Board of
Health to determine what wi a necessary to correct the 'lure.
E. Large Systems: r
To be considered a large syste the system mast serve a facility with a desi n flow of 10,000 gpd to 15,000
gpd•
You must indicate either"yes' or"no"'to each of the following:
(The following criteria appl to large system.Liz md= )
yes no
_ — the system ' within 400 feet of a surface drinking water supply
the sys in is within 200 feet of a tributary to a st drinking water supply
_ — th system is located in a nitrogen sensitive area O&tterim Wellhead Protection Area—I )or a mapped
one I1 of a public water supply 1 well
If yo ave answered"yes"to any question in Section E the system is considered a significant threat,or wered
"y 'in Section D above the large system has failed. The owner or operator of any large system considered\a
si nificant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 lAR
15.304.The system owner should contact the appropriate regional office of the Department.
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Page 5 of 11 E.
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 1 l ,U' �dl,-
Owner:
Date of Inspection:
Check if the following have been done.You must indicate"yes"or"no"as to`each of the following:
Yes No
_ 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?
_ Has the system received normal flows in the previous two week period?
Have large volumes of water been introduced to the system recently or as part of this inspection?
r/ _ Were as built plans of the system obtained and examined?(If they were not available note as N/A),
Was the facility or dwelling inspected for signs of sewage back up
V _ 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
of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum?
Was the facility owner(and occupants if different from owner)provided with information on the proper
maintenance of subsurface sewage disposal systems?
The size and location of the Soil"Absorption System(SAS)
on site has been dete
rmined based on:
Yes no M -
y _ Existing information.For example,a plan at the Board of 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)]
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Page 6 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION ;
Property Address: t) _
Owner:
Date of Inspection: 1
RESIDENTIAL FLOW CONDITIONS
Number of bedrooms(design):_q_ Number of bedrooms(actual):"4-1
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): Ljq0
Number of current residents:
Does residence have a garbage grinder 0or no):_
Is laundry on a separate sewage system(yes oA95:_ [if yes separate inspection required]
Laundry system inspected(yes or no):_
Seasonal use:(yes o no :
` Water meter readings,if available(last 2 years usage(gpd)): ".Q 00 1 D'Z, OQ p
Sump pump(yes o no :— 1 clot
Last date of occupancy: v 5►0(x)
COMMERCIAL/INDUSTRIAL
Type blishment:
Design flow(ba 310 CMR 15.203): gpd
Basis of design flow(seats /sgft,etc.):
Grease trap present(yes or no):
Industrial waste holding tank present(yes or no):
Non-sanitary waste discharged to the Title em(yes or no):—
Water meter readings,if availabl
Last date of occupancy/us
OTHER t e):
GENERAL INFORMATION
Pumping Records
Source of information: fUA.11A,"
Was system pumped as part of the inspection(yes or _ U
If yes,volume pumped: gallons--How was.quantity plumed determined?
Reason for pumping:
TYKE OF SYSTEM 1
ti_/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)
_Innovative/Alternative technology.Attach a copy of they-mnt operation and maintenance contract(to be
obtained from system owner)
—Tight tank _Attach a copy of the DEP approval
—Other(describe):
Approximate age of all com onents,date ' stalled(if known)and source of information:
Were sewage odors detected when arriving at the site(yes orl ••_
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Page 7 of 11 t
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
Owner:
Date of Inspection: r
BUILDING SEWE- R—(io`t"a site plan)
Depth below grade:
Materials of construction: cast iron . 40 PVC xplai_n):
Distance from private water supply well or ti me:
Comments(on condition of jo' nting,evidence of leakage,etc.):
SEPTIC TANK:_(locate on site plan)
Depth below grade:jGL
Material of construction:_concrete metal fiberglass_polyethylene .
_other(explain)
If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of
certificate)
Dimensions: 1 fjCO
Sludge depth: 3^'
Distance from top of sludge to bottom of outlet tee or baffle:
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:
How were dimensions determined:
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels
as related to outlet invert,evidence of.leakage,etc.): '
GREASE T P:_(locate on site plan) x
Depth below grade:— • ;:;
Material of construction:_conc metal_fiberglass__polye ne_other
(explain):
Dimensions: .
Scum thickness:
Distance from top of scum to top of outlet tee aflle:
Distance from bottom of scum to botto outlet tee or baffle:
Date of last pumping:
Comments(on pumping r mmendations,inlet and outlet tee or baffle condition,strut tegrity,liquid levels
as related to outlet ' ert,evidence of leakage,etc.):
7 e
Page 8 of l l
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: i Q
Owner
Date of Inspection: i
i
TIGHT or OLDING TANK: (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:
Material of construction: rete metal fiberglass_polyethylene other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons/day
Alarm present(yes or no):
Alarm level: Alarm in working order r no):
Date of last pumping:
Comments(condition of alarm an at switches,etc.):
DISTRIBUTION BOX: (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert:
Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of
leak e into or out of box,etc.):
PUMP CHAMB locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no):
Comments(note condition of pump cham on of-pumps s,etc.):
ro,
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Page 9 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 16 ,lvv& , ci�_az
Owner: Sn LL.6
—
� -
Date of Inspection: r i
SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required)
If SAS not located explain why:
Type
leaching pits,number: . 6 CJ - .a,, Q�, �- .' t.'`� °pry. 21 4�ua
✓ _
leaching chambers,number:
leaching galleries,number:
leaching trenches,number,length:
leaching fields,number;dimensions:
overflow cesspool,number:
innovative/alternative system Type/name of technology:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,
etc.):
CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan)
Number and co�tf uration:
Depth-top of liquid let 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,lev f ponding,condition of vegetation,etc.):
PRIVY: (locate on site plan) _
Materials of construction:
Dimensions:
Depth of solids:
Comments"' de_condition of soil,signs of hydraulic,failure, level of ponding,condition of vegetation,et _"
Page 10 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: icp r1Qr l
Owner: �
Date of Inspection:
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage 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 11 of I .
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued).
r-
Property Address: � J4"' QXAr_P_�_ '
Owner: `QYC
Date of Inspection C)
SITE EXAM
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:'
7 Observed site(abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health-explain:
Checked with local excavators,installers-(attach documentation)
Accessed USGS database-explain:
You must describe how you stablished the high ground water elevation: