HomeMy WebLinkAbout0491 MAIN STREET (COTUIT) - Health 491 MAIN STA��-CT"��: cV C
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�°' C SEWAGE #
VILLAGE \_ " ' ASSESSOR'S MAP &
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) (size)
NO.OF BEDROOMS
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BUILDER OR OWNER
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PERMITDATE: COMPLIANCE DATE: _12 I�i'�00
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the 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
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LOCATION I,A I N �� _ SEWAGE # _
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VILLAGE `S��l� ASSESSOR'S MAP & LOT 7,1
INSTALLER'S NAME&PHONE NO.
SEP IC TANK CAPACITY 0
LEACHING FACILITY: (type)- - (size)
NO.OF BEDROOMS
BUILDER OR OWNER ��yl
PERMITDATE: COMPLIANCE DATE:
Separation Distance Between the: i
Mxximum Adjusted GrcundwaterTablet th
Private Water Supply Well and Leaching Facility (Lf any wells exist
on site or within 200 feet of leaching facility) Fez,
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) _ ►J Fc
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YOU WISH TO OPEN A BUSINESS?
For Your Information: Business certificates (cost$40.00.for 4 years). A business certificate ONLY REGISTERS YOUR NAME in town (which you
must do by M.G.L.-it does not give you permission to operate.) You must first obtain the necessary signatures on this form at 200 Main St., Hyannis.
Take the completed form to the Town Clerk's Office, 1 st FI., 367 Main St., Hyannis, MA 02601 (Town Hall) and get the Business Certificate that is
required by law.
X^t uy DATE: Fill in please:
Yk APPLICANT'S YOUR NAME/S. T? L
Ell. BUSINESS YOUR HOME ADDRESS::--- V \
&
TELEPHONE # Home Telephone Number 1::� c-D O 9
NAME OF CORPORATION v:v�
NAME OF NEW BUSINESS Y cz vim' TYPE OF BUSINESS A r�l 1. D-
IS.THIS A.HOME OCCUPATION? YES ` NO D�(,,
ADDRESS,OF.BU.SINE$S !1 - 1VI ARCEL.NUMBER_ 7.2 CJ Z [Assessing)
When starting anew business there are several things you must do in order to be in compliance with the rules and regulations of the Town of
Barnstable. This form is intended to assist you in obtaining the information you may need. You MUST GO TO 200 Main St. — (corner of Yarmouth
Rd. & Main Street) to make sure you have the appropriate permits and:licenses required to legally operate your business in this town.
1. BUILDING COM41
ION 'S OFFICE
This individu ha be forme of ype mit equirements that pertain to this type of busine
44
IUUST COMPLY WITH HOME OCCUPATION
`Aut ized Siana ur ** RULES AND REGULATIONS. FAILURE TO
CO MENT COMPLY MAY ARRWILT
I
2. BOARD OF HEALTH
This individual has een ed f the permit requirements that pertain to this type of business.
Authorized Signature*
COMMENTS:
3. CONSUMER AFFAIRS (LICENSING AUTHORITY)
This individual has been informed of the licensing requirements that pertain to this type of business.
Authorized Signature**
COMMENTS: i
7/��l2
YOU WISH TO OPEN A BUSINESS?
=MainStreet,
formation: Business certificates.(cost$30.00 for-4 years). A business certificate O
Youo by M.G.L.- it does not give you permission to operate.) Business Certificates are available at the Town Clerk's
Hyannis, MA 02601 (Town Hall) ONLY REGISTERS YOUR NAME in town (which
k s Office, 1" FL., 367
ff
flcY � APPLICANT'S Fill in please:
BUSINESS YOUR NAM � �,r I� j� bJA-TS p ti�
YOUR HOME ADDRESS �{ R V\/1
err ' TELEPHONE # Home Telephone Number
NAME:OF CORPORATION:
.NAME OF NEW.BUSINESS
,IS:THIS A HOME OCCUPATION- f r TYPE OF.BUSINESS
ADDRESS OF BUSINESS ::.
-- —YES NO
S i c v�� c C o.1
'I/1 MAP/PAR CEL:NUMBER_(0. .'. 0 a
(Assessing) ;
When starting a new business there are several things you must do in order to be in compliance with the rules and regulations of the Town of
Barnstd'ble. This form is intended to assist you in obtaining the information you may need. You MUST GO TO 200 Main St.
(corner of Yarmouth
Rd. & Main Street) to make sure you have the appropriate permits and licenses required to legally operate your business in this town.
1. BUILDING COMMISSIONER'S FFICE
This individual has be rmed o a y permit requirements that pertain to this type of businesY.
UST COMPLY WITH HOME OCCUPATION
Authorized Signature** RULES AND REGULATIONS. FAILURE TO
COMMENTS: C MPLY MAY RESULT IN FINES.
0
2. BOARD OF HEALTH
This individual h infor�aure
he p r i requirements that pertain to this type of business: .
Au orized Si *
COMMENTS:
3. ,CONSUMER AFFAIRS(LICENSING AUTHORITY)
This individual has been informed of the licensing requirements that pertain to this type of business.
Authorized Signature**
COMMENTS:
�V , _
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE�;OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
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TITLE 5 '
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 491 MAIN ST COTUIT,MA 02635 V a DL-
Owner's Name: LOUIS FAY C.O BELL ONE ATT.PHIL
Owner's Address: RT.28 MASHPEE MA.02649
Date of Inspection: 12/12/00
Name of Inspector: (please print) JOHN GRACI v
Company Name: SEPTIC.INSPECTIONS .
Mailing Address: P.O. BOX 2119 TEATICKET,MA.02536
Telephone Number: 508-564-6813 FAX 508-564-7270 9
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-tra ning an
experience in the proper function'and maintenance of on site sewage disposal systems. I am a DEP approved system
inspector pursuant to Section B.340 of Title 5(310 CMR 15.000). The system:
X Passes
_ Conditionally asses F
_ Needs Fu Evaluation by the Local Approving Authority
Fails :f
Inspector's Signature: Date: 12/12/00
The system inspector shall submit la 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 `5
THE SYSTEM PASSES TITLE V INPECT ION.RECOMMEND PUMPING_ THE EVERY ONE TO TWO YEARS TO
PROLONG THE SYSTEM'S USEFULL LIrE;
****This report only describes conditions at the time of inspection and under-the conditions of use at that time.I'lils
inspection does not address how the system will perform in the future under the same or different conditions of use.
Title 5 1ncnPrtinn Fnrm 6/1 500oo
Page 2 of la
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE`SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 491 MAIN ST COTUIT,MA 02635 y
Owner: LOUIS FAY C.O BELL ONE'ATT.PHIL
Date of Inspection: 12/12/00
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes: 4,t
X I 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:
THE SYSTEM PASSES TITLE V INPECTION.RECOMMEND PUMPING THE EVERY ONE TO TWO YEARS
TO PROLONG THE SYSTEM'S USEFULL LIFE.
B. System Conditionally Passes:`
_ One or more system components as'described in the"Conditional Pass"section need to be replaced or repaired.The system,
upon completion of the replacement orrepair,as approved by the Board of Health,will pass.'
s
Answer yes,no or not determined(Y,N,ND)in the for the following statements..if"not determined"please explain.
n/a The septic tank is metal and over 20 years old* or the septic tank(whether metal or not)is structurally unsound,exhibits
substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced
with a complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound_,not leaking and if a Certificate of Compliance indicating
that the tank is less than 20 years old is available...
ND explain: n/a ; #.
n/a Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed
pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of,
Health):
_ broken pipe(s)are replaced
_ obstruction is removed
_ distribution box is leveled or replaced
ND explain: n/a , >
n/a The system required pumping more than 4 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
ND explain: n/a
4
I
Page 3 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 491 MAIN ST COTUIT,MA 02635
Owner: LOUIS FAY C.O BELL ONE ATT.PHIL
Date of Inspection: 12/12/00 '
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 public health,safety or the environment.
1. System will pass unless Board"of1.Health determines in accordance with 310 CMR 15.303(1)(b)that the system is
not functioning in a manner which will protect public health,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
t
2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the
system is functioning in a manner that protects the public health,safety and environment:
_ The system has a septic tank and soil absorption system(SAS)and 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 SAS and the SAS is within a Zone 1 of a public water supply.
_ The system has a septic tankand SAS and the SAS is within 50 feet of a private water supply well.
Elie
_ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water ..
supply well**. Method used to determine distance n/a
**This system passes if the'well`water analysis,performed at a DEP certified laboratory,for coliform bacteria and
volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia �.
nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy
of the analysis must be attached to'this form. .
3. Other: i}� •-
�
n/a
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Page 4 of I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
t CERTIFICATION(continued)
Property Address: 491 MAIN ST COTUIT,MA 02635
Owner: LOUIS FAY C.O BELL ONE ATT.PHIL
Date of Inspection: 12/12/00 '
D. System Failure Criteria applicable to,all systems:
You must indicate"yes"or"no"to each of the following for alLinspections:
s
by
Yes No
_ X Backup of sewage into facility or,system component due to overloaded or clogged SAS or cesspool
X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged
SAS or cesspool
X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool
X Liquid depth in cesspool is less than 6"below invert or available volume is less than '/2 day flow
X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times
pumped nLa. I 1
X Any portion of the SAS,cesspool or privy is below high ground water elevation.
_ X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
X Any portion of a cesspool or;privy is within a Zone 1 of a public well.
X Any portion of a cesspool or privy is within 50 feet of a private water supply well.
X 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. [This system passes if the well water analysis,performed at a DEP
certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free
from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be
attached to this form.]
(Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in 310
CMR 15.303,therefore the system fails.Tie.system owner should contact the Board of Health to determine what will be
necessary to correct the failure. +`
E. Large Systems:
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd.
You must indicate either"yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
yes no
X the system is within 400 feet of a surface drinking water supply
1.i'
X the system is within 200 fee1t of a tributary to a surface drinking water supply
`xi*n
X 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
If you have answered"yes"t6any question in Section E the system is considered a significant threat,or answered
"yes" in Section D above the large system has failed.The owner or operator of any large system considered a significant threat
under Section E or failed under Section D'shall upgrade the system in accordance with 310 CMR 15.304. The system owner
should contact the appropriate regional office of the Department.
A
I� :opt
Page 5 of 14
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OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 491 MAIN ST COTUIT,MA 02635
Owner: LOUIS FAY C.O BELL ONE ATT.PHIL
Date of Inspection: 12/12/00
Check if the following have been done.You must indicate"yes"or"no"as to each of the following:
Yes No
X _ Pumping information was prol vided by the owner,occupant,or Board of Health
_ X Were any of the system components pumped out in the previous two weeks
_ X Has the system received,normal flows in the previous two week period?
_ X Have large volumes of water been introduced to the system recently or as part of this inspection?
_ X Were as built plans of the system—obtained and examined?(If they were not available note as N/A)
X _ Was the facility or dwelling inspected for signs of sewage back up?
X _ Was the site inspected for signs of break out?
X _ Were all system components,excluding the SAS,located on site?
X _ 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?
X _ 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 the site has been determined based on:
ip ,
Yes no "as•
X _ Existing information.Foi"example,a plan at the Board of Health.
X _ 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)] s
{
Page 6 of 1.1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE'SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 491 MAIN ST COTUIT,MA 02635
Owner: LOUIS FAY C.O BELL ONE ATT.PHIL
Date of Inspection: 12/12/00
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design):2 Number of bedrooms(actual): 2
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms):220
Number of current residents: 0
Does residence have a garbage grinder(yes'or no): NO
Is laundry on a separate sewage system(yes or,no): NO [if yes separate inspection required]
Laundry system inspected(yes or no): NO
Seasonal use:(yes or no):YES `
Water meter readings,if available(last 2 years usage(gpd)): n/a
Sump pump(yes or no): NO
Last date of occupancy: n/a
COMMERCIAL/INDUSTRIAL
Type of establishment: n/a ""A
Design Design flow(based on 310 CMR 11203), n/agpd
Basis of design flow(seats/persons/sgft,etc.): n/a
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: n/a Q
Last date of occupancy/use: n/a
OTHER(describe): n/a 4.;.
GENERAL INFORMATION
Pumping Records
Source of information: n/a t`.
Was system pumped as part of the inspection(yes or no): NO
If yes,volume pumped: n/agallons--How'was'quantitypumped determined?n/a
Reason for pumping: n/a
TYPE OF SYSTEM
X Septic tank,distribution box,soil absorption system
_Single cesspool
_Overflow cesspool
_Privy
_Shared system(yes or no)(if yes,-, previous inspection records,if any)
_Innovative/Alternative technology:,Attach a copy of the current operation and maintenance contract(to be obtained from
system owner) -`
_Tight tank Attach a'copy of the�DEP approval
Other(describe): n/a _
Approximate age of all components,datte installed(if known)and source of information:
1958
cf
Were sewage odors detected when arriving at the site(yes or no):NO
4
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Page 7 of 1°1 '
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 491 MAIN ST COTUIT,•MA 02635
Owner: LOUIS FAY C.O BELL ONE ATT.PHIL
Date of Inspection: 12/12/00
BUILDING SEWER(locate on site plan)
Depth below grade:24"
Materials of construction:_cast iron =40.PVC Xother(explain): ORANGEBURG
Distance from private water supply,.w!ell or,suction line: n/a :
Comments(on condition of joints,venting,evidence of leakage,etc.):
TOWN WATER
F
SEPTIC TANK: X(locate on site plan)
e ,
Depth below grade: 18"
Material of construction: Xconcrete_metal_fiberglass_polyethylene other(explain)n/a
If tank is metal list age: n/a Is age confirmed by a Certificate of Compliance(yes or no): NO(attach a copy of certificate)
Dimensions:Y X 5' CINDER BLOCK';
Sludge depth: 0"
Distance from top of sludge to bottom of outlet tee or baffle: n/a
Scum thickness: n/a - -
Distance from top of scum to top of outlet tee or baffle: n/a
Distance from bottom of scum to bottom of outlet tee or baffle: n/a
How were dimensions determined: MEASURED
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels as related
to outlet invert,evidence of leakage,etc.):
MAIN CESSPOOL AND ALL COMPONENTS ARE STRUCTURALLY SOUND. RECOMMEND PUMPING
EVERY ONE TO TWO YEARS TO PROLONG THE SYSTEM'S USEFULL.THE CESSPOOL WAS EMPTY AT
THE TIME OF INSPECTION.
GREASE TRAP:_(locate on site plan),;
!
Depth below grade: n/a
Material of construction:_concrete_ metal_fiberglass polyethylene_other(explain): n/a
Dimensions: n/a
Scum thickness:n/at;)
Distance from top of scum to top of outlet tee or-baffle: n/a
Distance from bottom of scum to bottom of outlet tee or baffle: n/a
Date of last pumping: n/a w
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels as related
to outlet invert,evidence of leakage,etc.)-
n/a
Page 8 of 1-1 "sad
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued) a -
Property Address: 491 MAIN ST COTUIT,MA 02635
Owner: LOUIS FAY C.O BELL ONE ATT.PHIL
Date of Inspection: 12/12/00
TIGHT or HOLDING TANK: (tank must be pumped at time'of inspection)(locate on site plan)
Depth below grade: n/a
Material of construction:_concrete_metal fiberglass_polyethylene_other(explain): n/a
Dimensions: n/a
Capacity: n/a gallons
Design Flow: n/a gallons/day '
Alarm present(yes or no): N/A
Alarm level: N/A Alarm in working order'(yes or no):NO
Date of last pumping: n/a
Comments(condition of alarm and float switches,etc.):
n/a
DISTRIBUTION BOX:_(if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert:,n/a
Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into
or out of box,etc.):
n/a .
PUMP CHAMBER: (locate on site plan)
Pumps in working order(yes or no): NO
Alarms in working order(yes or no):NO
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
n/a .,
i.
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• .. 1.�,
Page 9 of 1.1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE_ DISPOSAL SYSTEM INSPECTION FORM
PART C I
SYSTEM INFORMATION(continued)
Property Address: 491 MAIN ST COTUIT,MA 02635
Owner: LOUIS FAY C.O BELL ONE ATT. PHIL
Date of Inspection: 12/12/00
SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required) .
If SAS not located explain why: -
n/a
Type
6'X 6' PIT leaching pits, number: 1
n/a ` " leaching chambers, number: n/a
n/a 4R.1 leaching galleries, number: n/a
n/a r ''leaching trenches, number, length: 'n/a
n/a leaching fields, number: n/a
n/a overflow cesspool, number: p
n/a {,innovative/alternative system
`. .Type/name of technology: n/a
Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation,etc.):
THE LEACH PIT IS STRUCTURALLY SOUND AND APPEARS TO BE FUNCTIONING PROPERLY.THE PIT
HAD 2' OF WATER IN IT AT THE TIME OF THE INSPECTION.THE PIT HAS NOT HAD MORE THAN T OF
WATER IN IT.
CESSPOOLS: (cesspool must be pumped as"part of inspection)(locate on site plan)
Number and configuration: n/a
Depth—top of liquid to inlet invert: n/a a
Depth of solids layer: n/a
Depth of scum layer: n/a r ;`
Dimensions of cesspool: n/a
Materials of construction: n/a
Indication of groundwater inflow(yes or no):.NO a
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
n/a
PRIVY: (locate on site plan)
Materials of construction: n/a
Dimensions: n/a
Depth of solids: n/a
Comments(note condition of soil,signs of,hydraulic failure, level of ponding,condition of vegetation,etc.):
n/a i x:,
I
Page 10 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 491 MAIN ST COTUIT,MA 02635
Owner: LOUIS FAY C.O BELL ONE ATT.PHIL
Date of Inspection: 12/12/00
F .
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal'. ystem 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 l l of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 491 MAIN ST COTUIT,MA 02635
Owner: LOUIS FAY C.O BELL ONE ATT.PHIL
Date of Inspection: 12/12/00
SITE EXAM
_Slopei,
_Surface water
_Check cellar
Shallow wells
Estimated depth to ground water 10+feet
Please indicate(check)all methods used to determine the high ground water elevation:
NO Obtained from system design plans on record-If checked;date of design plan reviewed: n/a
NO Observed site(abutting property/observation hole within 150 feet of SAS)
NO Checked with local Board of Health-explain: n/a
NO Checked with local excavators, installers-(attach documentation)
YES Accessed USGS database-explain: n/a
You must describe how you established the high ground water elevation:
USGS MAPS AND CHARTS- 10+FEET
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31
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CO.I.NIONWE.kLTH OF I�L�SS.�CHliSETTS
- 'E OFFICE OF E1'VIRONME:�TAi
EXECUTIVE
- DEPARTMENT OF ENVIRONMENTAL PRO MON t -INTER STREET. BOSTO\ MA 02106 (615) 292 1
ONE f �� �71�14jr
lift, ,� 0 Yoe T rY COX__
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ARGEO PALL CELLtiCCI 1 onunisS:•ne!
Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PM 0 — 0�Z PART A y
V�� -V- On � ^^-- - CERTIFICATION
Property Address: LAC'% �0,to,3 �� lS%�`��� Name of Owner
Address of Owner: h 4 0_5DCA:
Date of Inspection:. , �`y `` _-1 / i/U ��k wzoc_ I ��-1.(f4
Name of Inspector:(Please Pr' 1� C_!r a I D CC A/C-)
1 am a DEP approved system inspector pursuant to Section 5•f of Tide 5(310 CMR 15.0001
Company Name: rg tsty._. +'r tc L-,'jCe- F!- IYFF/9 4.5
MaSng Address: rn
Telephone Number: //5- — /L- • LG
CERTIFICATION STATEMENT
certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate
tion was performed based on my training and experience in the proper function and
and complete as of the time of inspection. The inspec
maintenance of on-suite sewage disposal systems. The system:
Passes
Conditionally Passes
_ Needs Further Evaluation By t Local pproving Authority
_ Fails
Inspector's SigrurCur
Date: (-1
The System Inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within thirty (301 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 ttre
system owner and copies sent to the buyer,if applicable, and the approving authority.
NOTES AND COMMENTS
�ew\ F -ss-e-s
WCVL*_lvu�l
revised 9/2/98 oru
q0 Preened on ReeyeW Paper
♦ J
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (contirwed)
4operrty Address:
Jwnef:
Date of Inspection:
INSPECTION SUMMARY-.* Check A, B, C, or D:
� Crry�hJ ti
r
A. SYSTEM PASSES:
1 have not found any information which indicates that any of the failure conditions described in 3.10 CMR 15.303 exist. Any failure
criteria not evaluated are indicated below.
COMMENTS: Cb
r tU
B. SYSTEM CONDITIONALLY PASSES:
One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon
completion of the replacement or repair, as approved by the Board of Health, will pass.
In'8icate 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 prior 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 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
_. sQ
revised 9/2/98 P>, e.2of11
r
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 the system is failing to protect the
public health. safety and the environment. r`
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 15.303(1)(b) 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 surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or efsalt marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUB C WATER SUPPLIER,IF ANY)DETERMINES THAT THE SYSTEM IS
FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC H LTH AND SAFETY AND THE ENVIRONMENT:
_ The system has a septic tank and soil absorption sy ern(SAS) and 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 ystem and the SAS is within a Zone I of a public water supply well.
_ The system has a septic tank and soil absorptio system and the SAS is within 50 feet of a private water supply well.
_ The system has a septic tank and soil absorpti n system and the SAS is less than 100 feet but 50 feet or more from a
private water supply well,unless a well wate analysis for coliform bacteria and volatile organic compounds indicates that the
well is free from pollution from that facility nd the presence of ammonia nitrogen and nitrate nitrogen is equal to or less
than 5 ppm. Method used to determine di ante (approximation not valid).
3) OTHER
revised 9/2 .98 page 3or11
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:
have determined that one or more of the following failure conditions exist as scribed in CMR 1 The basis for this
determination is identified below. The Board of Health should be contacted t determine whhatat will be necessary to correct the failure.
Yes No
_ Backup of sewage into facility or system component due toe overloaded or cogged SAS or cesspool.
_ Discharge or ponding of effluent to the surface of the gro d or.surface waters due to an overloaded or clogged SAS o
cesspool.
Static liquid level in the distribution box above outlet ' vert due to an overloaded or clogged SAS or cesspool.
Liquid depth in cesspool is less than 6" below inv t or available volume is less than 1l2 day flow.
_ Required pumping more than 4 times in the las year NOT due to clogged or obstructed pipe(s).
Number of times pumped_.
Any portion of the Soil Absorption Syste cesspool or privy is below the high groundwater elevation.
_ Any portion of a cesspool or privy is wi in 100 feet of a surface water supply or tributary to a surface water supply.
Any portion of a cesspool or privy is ithin a Zone I of a public well.
Any portion of a cesspool or priv is within 50 feet of a private water supply well.
Any portion of a cesspool or p vy is less than 100 feet but greater than 50 feet from a private water supply well with no
acceptable water quality ana sis. If the well has been analyzed to be acceptable, attach copy of well water analysis for
coliform bacteria, volatile or anic compounds, ammonia nitrogen and nitrate nitrogen.
E. LARGE SYSTEM FAILS:
You must indicate either "Yes" or "No" o each of the following:
The following criteria apply to arge systems in addition to the criteria above:
The system serves a facilit with a design flow of 10,000 gpd or greater(Large System) and the system is a significant threat to publi
health and safety and the environment because one or more of the following conditions exist:
Yes No
_ the syste is within 400 feet of a surface drinking water supply
the sy em is within 200 feet of a tributary to a surface drinking water supply
the stem is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA) or a mapped Zone 11 of a public
w er supply well)
The owner or oper or of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional
office of the Depa ment for further information.
revised 9/2/98 Page 4or11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address:
Owner: "V
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
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:
Existing information. For example. Plan at B.O.H.
Determined In the field (if an'y,of the failure criteria related to Part C is at issue, approximation of distance is unacceptable)
(15.302(3)(b)] _
�( The facility owner (and ocdupants,if different from owner) were provided with information on the propermaintera^^e-0f
T� SubSurface Disposal Systems.
Aly
l.
tFr
revised 9/2/98 eaecsoftt
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
l SYSTEM INFORMATION
'roFcrty Address: �1, Aw Vj f
Owner:
Date of Inspection:
FLOW CONDITIONS
RESIDENTIAL:
Design flow: g•p•d./bedroom.
Number of bedrooms (design):OZr Number of bedrooms (actual):CjZ
Total DESIGN flowe-;t-
Number of current residents:
Gerbage grinder(yes or no):—k,)
Laundry(separate system) ( es or6fs� : If yes, separate inspection required
Laundry system inspected e)or no)
Seasonal use (yes or no): 5
Water meter readings, if av ilable (last two year's usage(gpd):
Sump Pump(yes or no): AJJ
Last date of occupancy: GLV-c Lk k ws
COMM ERCIALfINDUSTRIAL: `
Type of establishment:
Design flow: qpd ( Based on 15.203)
Basis of design flow
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:
Last date of occupancy:
OTHER:(Describe)
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information-
System
������
pumped as part of inspection: ( es or not
If yes, volume pumped: gallons
Reason for pumping:
TYPE OF SYSTEM
—��— Septic tank/distri ution box/soil absorption system
Single cesspool k0UtiCGlo AJ f,(alcG �[
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: 4-��` S �►'�(� � 1
• ,,7� �IN`•Y�+ �L
Sewage odors detected when arriving at the site: (yes or no) "V
revised 9/2/98 Pop 6ofIl
f
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
►ropefty Address:
Owner:
Date of Inspection:
j
BUILDING SEWER: ;"
(Locate on site plan)
r
Depth below grade:_ �t
i
Material of construction: _cast iron_40 PVC_other (explain)
Distance from private water supply well or suction line
Diameter
Comments: (condition of joints, venting, evidence of leakage, etc.)
t
SEPTIC TANK:_,
(locate on site plan)
Depth below grade:_
Material of construction:_concrete _metal _Fiberglass _Polyethylene ther(ezplain)
If tank is metal, list age_ Is age confirmed by Certificate of Compliance (Yes/No)
Dimensions:
Sludge depth:
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 dimensions were determined:
;omments:
(recommendation for pumping, condition of inlet and outlet tees r baffles,depth of liquid level in relation to outlet invert, structural integrity.
evidence of leakage, etc.)
------------
GREASE TRAP:
(locate on site plan)
Depth below grade:
Material of construction:_concrete_metal_,Fiber lass _Polyethylene_,other(explain)
Dimensions-
Scum thickness:
.Distance from top of scum to top of outlet tee or affle:
Distance from bottom of scum to bottom of outl t tee or baffle:
Date of last pumping:
Comments:
(recommendation for pumping,condition o nlet and outlet tees or baffles,depth of liquid level In relation to outlet invert, structural integrity,
evidence of leakage,etc.)
revised 9/2/98 Pyfe7oftl
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
'roperty Address:
Owner:
Date of Inspection:
TIGHT OR HOLDING TANK: (Tank must be pumped prior to, or at time of, inspection)
pocate on site plan)
Depth below grade:_
Material of construction: _concrete _metal_Fiberglass _Polyethylene _other(ez ain)
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 distribution is equal, evidence of olids carryover, evidence of leakage into or out of box, etc.)
PUMP CHAMBER:_
(locate on site plan)
Pumps in working order:(Yes or No
Alarms In working order(Yes or N
Comments:
(note condition of pump chamb r,•condition of pumps and appurtenances,etc.)
revised 9/2/98 P.Fc Ill oru
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PAR
T C
SYSTEM INFORMATION (continued)
Toper Address:
Owner'.
Date of Inspection:
SOIL ABSORPTION SYSTEM(SAS):t/
(locate on site plan, if possible: excaXtion not required, location may be approximated by non-intrusive methods)
If not located, explain:
Type:
leaching pits, number:
leaching chambers, number:_
leaching galleries, number:_
leaching trenches, number, length:
leaching fields, number, dimensions:
overflow cesspool, number:
Alternative system:
Name of Technology:
Comments:
(n to c ndition of soil, signs of h draulic failure, level of ponding. damp so', co 'tion of vegetation, etc.)
CESSPOOLS:
S
(locate on site p an)
Number and configuration:
Depth-top of liquid to inlet invert:
Depth of solids layer: I
)epth of scum layer: no
Dimensions of cesspool: SDiN K kA
Materials of construction: Cn 'kaj�
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 o vege ation, etc.) I✓u It a`\
t
PRIVY:,(jW
(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:
Jwner:
Date of Inspection:
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)
revised 9/2/98 page iooril
.c
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
roperty Address: (J%C4Vt k{j 5
Owner:
Date of Inspection:
NRCS Report name V - --- ----- — --
Soil Type_ _ ---------- ------
Typical depth to groundwater____._
USGS Date website visited
Observation Wells checked
Groundwater depth: Shallow Moderate
SITE EXAM Slope �JC)
Surface waterr--3
Check Cellar OaS j
Shallow wells
fsof
Estimated Depth to Groundwater Feet
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
Checked pumping records
Checked local excavators, installers
Used USGStData
Describe how you established the High Groundwater Elevation. (Must be completed)
revised 9/2/98 Page 11of11