HomeMy WebLinkAbout0021 AMANDA COURT - Health 21. Amanda Court
COtUlt
A= 055-031 - - - -- - -- --- --- - -
Commonweaith of Massachusetts
John GradExecutive Office of Environmental Affairs
D.E.P. Title V Septic ItLspector
Department of P.o. Box
Environmental Protection Teatic 5 �
4-6s 13
REc�ivEn
SUBSURFACE SEWAGE DISPOOSAL RT ASYSTEM INSPECTION FORM to AUG 4 1997
CERTIFICATION _
TOIVNOFBARNSTABLE
S! HEALTH I)EPT.
Property Address: 21 Amanda Court Cotuit Address of Owner:
Date of Inspection:7131197 (If different) A
Name of Inspector:JohnGracl Dr.&Mrs.Robert Cronin:1304 Fairway Dr.Mldd o
Company Name,Address and Telephone Number:
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:
X Passes This inspection is based on criteria defined in Title V
Condition Ily P ses code 310 CMR 15.303.My findings are of how the system is
Needs
F 'rthe valuation B the Local Approving Authority performing at the time of the Inspection.My Inspection does
Y PP 9 tY , not Imply any warranty or guarantee of the longevity of the
Fails septic system and any of its components useful life.
Y
Inspector's Signature: Date: 7131197
The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this
inspections. 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] SYSTEM PASSES:
X I have not found any information which indicates that the system violates any of the failure criteria
defined as 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 not.)
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 11115195)
One Winter Street • Boston,Massachusetts 02108 e FAX(617)556-1049 • Telephone(617)292-5500
1
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 21 Amanda CourtCotuit
Owner: Dr.&Mrs.Robert Cronin:1304 Fairway Dr.Middletown R.I.02842
Date of Inspection:7131197
_ Sewage backup or breakout or high static water level observed in the distribution box is 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 leveled or replaced
_The system required pumping more than 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
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 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 MANNER 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) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE)DETERMINES
THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
The system has a septic tank and soil absorption system and is within 100 feet to.a
surface of water supply or tributary to a surface water supply.
The system has a septic tank and soil absorption system and is within a Zone 1 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 than 100 feet but 50 feet or more from a private
water supply well, unless a well water analysis for coliform bacteria volatile organic compounds indicates that the well is
free from pollution for that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal or less than 5 ppm.
3) OTHER
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 in 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
cesspool.
SAS is in hydraulic failure.
(revised 11115195)
' 2
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 21 Amanda Court Cotult
Owner: Dr.&Mrs.Robert Cronin:1304 Fairway Dr.Middletown R.I.02842
Date of Inspection:7131/97
D] SYSTEM FAILS(continued)
Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
Liquid depth in cesspool is 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).
Numbers of times pumped
Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation.
t
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 1 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.
E] LARGE SYSTEM FAILS:
The following criteria apply to large systems in addition to the criteria:
_ 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
public health and safety and the environment because one or more of the following conditions exist:
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 li 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.
g
(revised 11115195)
3
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECLIST
Property Add ress: 21 Amanda Court Cotult
Owner: Dr.&Mrs.Robert Cronin:1304 Fairway Dr.Middletown R.I.02842
Date of Inspection:7131197
Check if the following have been done:
x Pumping information was requested of the owner,occupant, and Board of Health.
x None of the system components have been pumped for at least two weeks and the 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.
n1aAs built plans have been obtained and examined. Note if they are not available with N/A.
x The facility or dwelling was inspected for signs of sewage back-up.
x The system does not receive non-sanitary or industrial waste flow.
x The site was inspected for signs of breakout.
x All system components,excluding 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.
x The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of Sub-
Surface Disposal System.
(revised 11115195)
4
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 21 Amand
a Court Cotult
Owner: or.&Mrs.Robert Cronin:1304 Fairway Dr.Middletown R.I.02842
Date of
f Inspection:7131197
FLOW CONDITIONS
RESIDENTIAL:
Design flow: 330 gallons
Number of bedrooms: 3
Number of current residents: 2
Garbage grinder(yes or no): No
Laundry connected to system(yes or no): Yes
Seasonal use(yes or no): No
Water meter readings,if available: n1a
Last date of occupancy: n/a
COMMERCIAL/INDUSTRIAL:
Type of establishment: rua
Design flow:U gallons/day
Grease trap present:(yes or no) No
Industrial Waste Holding Tank present: (yes or no) No
Non-sanitary waste discharged to the Title 5 system: (yes or no) No
Water meter readings,if available: n1a
Last date of occupancy: n1a
OTHER: (Describe) nfa
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
System has not been pumped In the last year.
System pumped as part of inspection: (yes or no)No
If yes,volume pumped: 0 gallons
Reason for pumping: n1a
TYPE OF SYSTEM
X Septic tank/distribution box/soil absorptions system
Single cesspool
Overflow cesspool
Privy
Shared system(yes or no) (if yes,attach previous inspection records,if any)
Other(explain)
APPROXIMATE AGE of all components,date installed(if known)and source information:
1982
Sewage odors detected when arriving at the site:(yes or no) No
(revised 11115195)
5
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 21 Amanda Court cotult
Owner: Dr.&Mrs.Robert Cronin:1304 Fairway Dr.Middletown R.I.02842
Date of Inspection:7131197
SEPTIC TANK: X
(locate on site plan)
Depth below grade:4'
Material of construction:X concreate_metal_FRP_other(explain)
Dimensions: L 8'6'H 5'7'W 4'10'
Sludge depth:3'
Distance from top of sludge to bottom of outlet tee or baffle: 24"
Scum thickness:V
Distance from top of scum to top of outlet tee or baffle:6'
Distance form bottom of scum to bottom of outlet tee or baffle: 17•
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.)
Septic tank and all components are structurally sound.Recommend pumping system now and then maintained every year.
GREASE TRAP:
(locate on site plan)
Depth below grade: n1a
Material of construction: _concrete_metal_FRP other(explain)
Dimensions: n1a
Scum thickness:rda
Distance from top of scum to top of outlet tee or baffle:nfa
Distance from bottom of scum to bottom of outlet tee or baffle:n1a
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.)
n1a
•(revised 11115195)
6
Ia 3
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 21 Amanda CourtCotult
Owner: Dr.&Mrs.Robert Cronin:1304 Fairway Dr.Middletown R.I.02842
Date of Inspection:7/31/97
TIGHT OR HOLDING TANK:
(locate on site plan)
r •
Depth below grade: nla
Material of con struction:_concrete_metal_FRP_other(explain)
Dimensions: nla
Capacity: nla gallons
Design flow: nla gallons/day
Alarm level: nla
Comments:
(condition of inlet tee,condition of alarm and float switches, etc.)
nla
DISTRIBUTION BOX: X
(locate on site plan)
Depth of liquid level above outlet invert: Liquid level with bottom of pipe.
Comments:
(note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box etc.)
Dtox is structurally sound.
PUMP CHAMBER:
(locate on site plan)
Pumps in working order:(yes or no)
Comments:
(note condition of pump chamber,condition of pumps and appurtenances, etc.)
Na
(revised 11/15195)
7
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 21 Amanda Court Cotult
Owner: Dr.&Mrs.Robert Cronin:1304 Fairway Dr.Middletown R.I.02842
Date of Inspection:7131197
SOIL ABSORPTION SYSTEM (SAS):x
(locate on site plan,if possible: excavation not required,but may be approximated by non-intrusive methods)
If not determined to be present, explain:
n1a
Type:
leaching pits.number: 1,000 gallon leach pit
leaching chambers,number:n1a
leaching galleries, number: n1a
leaching trenches,number,length: n1a
leaching fields,number, dimensions:n1a
overflow cesspool,number:n1a
Comments:(note condition of soil, signs of hydraulic failure,level of ponding,condition of vegetation, etc.)
The overflow is structurally sound and functioning properly.lt was empty at the time of the Inspection.Plt has not been more than 314 full.
CESSPOOLS:_
(locate on site plan) i
Number and configuration: n1a
Depth-top of liquid to inlet invert: n1a
Depth of solids layer: n1a
Depth of scum layer: nfa
Dimensions of cesspool: n1a
Materials of construction: n1a
Indication of groundwater: nfa
inflow(cesspool must be pumped as part of inspection)
nla-
Comments:(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
n1a
PRIVY:_ {
(locate on site plan)
Materials of construction: n1a Dimensions: n1a
Depth of solids: n1a
Comments:(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
n1a
(revised 11115195)
8
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 21 Amanda Court Cotuit
Owner: Dr.&Mrs.Robert Cronin:1304 Fairway Dr.Middletown R.I.02842
Date of Inspection:7131197
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100'
I
4C 36
DEPTH TO GROUNDWATER
Depth to groundwater:12 feet
method of determination or approximation:
USGS Maps and Charts 12+Feet
(revised 11115195)
9
LOCATION SEWAGE PERMIT NO.
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VIIIAGE o 't . j n_1��
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IN�TA LLER'S NAME i ADDRESS
iUILDE R ' OR OWNER
D A T E P E R M I T I S S U E D / �-�-- 3
DATE COMPLIANCE ISSUED
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No.........= Fps... ®/
THE COMMONWEALTH.OF MASSACHUSETTS
-BOARD !=#-EAd-TH
............. Y
}. . ..-.OF..........
,� . .... .. ...-.----------__-__-•••------•----•-----------•-•-
�piiration for Uispaal Works Tonstrnr#inn Varad
r>b Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
} ... S"""......................................... - ra
6VjL ion- ess o No
�....
_...1...caner '_� ........ Addressl�
a ..............
.........�:__.�f3'r�r �ILC... .�....................
Installer Address (� (;
�W � ! F�
Type of Building ry Size Lot... .._..,}_ ...Sq. feet '
►-� Dwelling—No. of Bedrooms.................%3....................Expansion Attic ( ) Garbage Grinder ( )
�`4 Other—Type T e of Building
yp g ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( )
dOther fixtures ......................................................-----------•------------------------------------- -------
Design Flow...........110__'K... .............gallons per person per day. Total daily flow............................................gallons.
Septic Tank—Liquid capacityt.._______gallons Length................ Width................ Diameter................ Depth................ .
w Disposal Trench—No..................... Width.................... Total-Length.....................Total leaching area....................sq. ft.
x
Seepage Pit No.......f........_:._ Diameter____________________ Depth below inlet................... Total leaching area..................sq. ft.
Z Other Distribution box (f/) Dosing tank )
aPercolation Test Results Performed by_.___�_ a_ �__-.___ �:US4 . -_ Date._ . . __ .......
Test Pit No. 1...Z.......minutes per inch Depth of Test Pit____________________ Depth to ground water...
44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water....._..................
P� ...................................-........-............................_..
O Description of Soil_.._L+6 +•SvSDi�....% �._y....Z�_�_!3 �lcd = - - ..._._.. -
x
.................................
c., ------------------------------------------------------------- ------------------ ----------------------------------------------------------------------
w
U Nature of Repairs or Alterations—Answer when applicable...............................................................................................
---------------------------------------------------------------•-----•-•---•--.._._._..............__.......-•---•--•----••••--•--•....••-•-••----•-•--•-•--•--.......................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Dispos4l System in accordance with
the provisions of TITL U 5 of the State Sanitary Code—The undersigned further agr es not to place the system in
operation until a Certificate of Compliance ha een is ued by e r o health.
aAft
Si a __ •
' -"z.S
D t!
Application Approved By...... ___- ••••.---- --------__-••---•----------
Date
Application Disapproved for the following reasons---------------------•--------------------•-------------•-------------------------------.._....----._...-•_._.._
------•------•-•------------- ----------- •--------�------•___Date--------------
Permit No.........................•---•-----•-----•-------^-----• Issued...1�-:-L
� ----=��
Date
a -----....------
L
N10..................U.
........................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD Off HEALTH
W
.................. .. .)-----.OF.......... . .... .
Appliration for Disposal Works Tonstrurtiola Frrutit/-
Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal
System at:
.........Cr� A
A—t
A . *.A.+.0..................................... ................................. Q. ........'...I.P..
1.
..N...4..
......O.
T0 ..
... . . Vt..........oW -4
... .
Owner Addr L
C
. . ............................... ...k V...... ............. .............. . ................
Installer Address
Type of Building Size Lot.._ ----Sq. feet
Dwelling—No. of Bedrooms................_......._.......__.._.Expansion Attic Garbage Grinder
Other—Type of Building ............................ No. of persons............................ Showers Cafeteria
P-4 Other fixtures ..........................................................................................................
ell
Design Flow.._......... 0 X ...... --------*----------------
W ......................... _gallons per person per day. Total daily flow--------------------------"-".............._gallons.
--**.............gallons.
9 Septic Tank—7 Liquid capacityP ..gallons Length................ Width................ Diameter.........___.__. Depth................
W
01 Disposal Trench—No. .................... Width............__...... Total Length___................. Total leadhing area....................sq. ft.
Seepage Pit No..._.. �"Diameter.................... Depthbelow inlet.- ... Total leaching area..................sq. f t.
,
Z Other Distribution box Dosing tank
0-4
Percolation Test Results Performed b- Date_._._._'.---- ----------------- -......
V - ---
1.4 Test Pit No. I..... .......minutes.......minutes per inch Depth-of jest Pit.................... Depth to ground water...Ajp.��&IIFR
44 Test Pit No. 2................minutes per inch Depth of Test Pit_.__.__............. Depth to ground water........................
..............................
-----f--------.............................r.............
0 Description of Soil......... ... ... Su bzo; �Z0 , 2-, -/'3 ft.Ye WSAAf 0----*........*-------------**---------------
..... .. ....................................p-........................................... ............................................................
U .......................................................................................................................................................................................................
W
�4 ........................................................................................................................................................................7----------*---------
U Nature of Repairs cr Alterations—Answer when applicable.......................... ...............................................................
................. .....................................................................................................................................................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Sanitary Code— The undersigned further agr es not to place the system in
operation until a Certificate of Compliance ha--,-�-ee�n 7iued by he �f Do health.
e -Z 56-,
Si ....................... �,,(.(........ A
...................... ................... ............................
Application Approved BY. ..... .....
.......................... ......
Date
Application Disapproved for the following reasons:............................................................................
..................................
...........................v............................................................................................................................................................................
Date
PermitNo.......................................................... IssuedL.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD HEALTH
......... OF...... aP
........... .............Tatifiratr of Toutplitturr
Is L0,CERTIF at the, Sewage Disposal System constructed or Repaired
S T .... . . ... . .
5/p
T ... ......
by..'. ....... . ...... ....... ........ .....................------------------- .......... ......
Inst 4r A-
.... .......
at ..... ...a
--- --- -- ------------
f�16T),431 5
has been installed in, accor J/witY t-ie provisions o o The State Sanitary Code as described in the
application for Disposal Works Construction N Permit yj........... dated- .............
`THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CON D AS,A GUARANTEE THAT THE
�Z
SYSTEM W LL FUNCTION SATI§.EACT Y.
DATE....._../!.
----- .........------------ Inspector ..................................... .......................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD
�F HEAL
. 0F.......... !4..k4.4 -_-. a ......................... FE 4
No........ �..............
Raposal Wor Ton-strudion Vprrmit
Permission is hereby granted. ----------;:;;;P,
....t*; . ��.0
............................................... ............
to Construct V-11--dr--Repa,�' _stem ,).�([�gan In Sewag posal S-y �0
5t * ........................
A S
at No.. a
Street
as shown on the application for Disposal Works Construction ',erfihit 7N ---.,- D
_e
.7". \4
Board of Health
DATE..,/ If................................
FORM 1255 HOBBS !k WARREN, INC.. PUBLISHERS
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