HomeMy WebLinkAbout0351 MAIN STREET (COTUIT) - Health 351 Main Strut, Gohiit
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Commonwealth of Massac -U
Executive Office of Env' our ntal Affairs
Dept. 6f Environme Pr*68 vo
One winter Street,Boston, 12 .John Grad
2 1 D.E.P. Title V Septic Inspector
" 997 P.O. Box 2119
tftOF s E Teaticket,MA 02536
(508) 564-6813
WILLIAM RWELD
Governor
ARGEO PAUL CELLUCCI E y
Lt.Governor
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
Property Address: 351 Main St.Cotuit Address of Owner:
Date of Inspectibn:8/t3/97 (If different)
Name of Inspector-John Gracie Dr.Sooy:326 Matheison St.Hildberg Cal.95448
1 am a DEP approved system inspector pursuant to Section 15.340 of Title%.(310 CMR 15,000)
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
— Conditionally P sses code 310 CMR 16.303.My findings are of how the system is
performing at the time of the inspection.My inspection does
_ Needs Evaluation By the Local Approving Authority not imply am warranty or guarantee of the longevity of the
Falls septic system and any of its components useful life.
Inspector's Signature: Date: 8/27197
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.
COMMENTS:
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, 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 conforming septic tank
as approved by the Board of Health.
(revised 04/27/97)
One Winter Street • Boston,Massachusetts 02108 . FAX(617)556-1049 9 Telephone(617)292-5500
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 351 Main St.Cotuit
Owner: Dr.Sooy:326 Matheison St.Hildberg Col.9544E
Date of Inspection:86/97
_ Sewaae backuD or.breakout.or hiah.static water level obser.ved.in.the distribution box is due to a broken.
or obstructed pipe(s)or due to broken, settled or uneven distribution box.The system will pass inspection if
(with approval of the Board of Health). Describe observations:
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 pipets)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 watersupply 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 the SAS is less than 100 feet but 50 feet or more from a
private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that
the well is free from pollution from that facility and the presense of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm. Method usedto determine distance (approximation not valid)
3)Other
D] SYSTEM FAILS:
You must Indicate either"Yes"or"No"as to each of the following:
_ 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.
Yes NO Backup
Backup of sewage in facility or system component due to an overloaded or clogged SAS or
cesspool.
Discharge or pondinq of effluent to the surface of the ground or surface waters due to an overloaded or clogged
cesspool.
SAS is in hydraulic failure.
(revised 04127/97)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 351 Main St.Cotuit
Owner: Dr.Sooy:326 Matheison St.Hildberg Cal.95448
Date of Inspection:8/6/97
D] SYSTEM FAILS(continued)
Yes No
Static liquid level in the distribution box above outlet invert dice 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.
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:
You must indicate either"Yes"or"No"as to each of the following:
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:
Yes No
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 II of a
public water supply well)
The owner or operator of any such system shall bring the system.and facility into full compliance with the groundwater treatment program
requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.
(revised 04f27/97)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECLIST
Property Address: 351 Main St.Cotuft
Owner: Dr.Sooy:326 Matheison St.Hildberg Cal.9544E
Date of Inspection:8/6/97
Check if the following have been done-You must indicate either"Yes"or"No"as to each of the following:
— 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.
x As built plans have been obtained and examined. Note if they are not available with NIA.
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
The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of
Sub-Surface Disposal Systens.
x Existing information. Ex. Plan at B.O.H.
X Determined in the field('If any failure criteria related to Part C is at issue, approximation of distance is
unacceptable)(15.302(3)(b))
(revised 04/27197)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 351 Main St.Cotuit
Owner: Dr.Sooy:326 Matheison St.Hildberg Col.95446
Date of Inspection:6l6/97
FLOW CONDITIONS
RESIDENTIAL:
Design flow: 330 9 p d.lbedroom for S.A.S.
Number of bedrooms: 1
Number of current residents: 0
Garbage grinder(yes or no): No
Laundry connected to system(yes or no): No
Seasonal use(yes or no): No
Water meter readings, if available:(Iast two(2)year usage(gpd):
n/a
Sump Pump(yes or no): No
Last date of occupancy: Last Spring
COMMERCIAL/INDUSTRIAL:
Type of,establishment: n/a
Design flow:0 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: n/a
Last date of occupancy: nla
OTHER:(Describe) n/a
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: n/a
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)
I!A Technology etc. Copy of up to date contract?
Other:
APPROXIMATE AGE of all components,date installed(if known)and source information:
System was installed in 1094 by ABCO
Sewage odors detected when arriving at the site: (yes or no) No
(revised 04/27/97)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 351 Main St.Cotuit
Owner: Dr.Sony:326 Matheison St.Hildberg Cal.95448
Date of Inspection:W/97
SEPTIC TANK: X
(locate on site plan)
Depth below grade: 16'
Material of construction:X concreate_metal_FRP_Polyethylene_other(explain)
If tank is metal, list age 0 .. Is age confirmed by Certificate of Compliance No (Yes/No)
Dimensions: L 9'6'H 5'7'W 4'10'
Sludge depth:0
Distance from top of sludge to bottom of outlet tee or baffle: 0
Scum thickness:0
Distance from top of scum to top of outlet tee or baffle:2'
Distance form bottom of scum to bottom of outlet tee or baffle: 0
How dimensions were determined: Measured
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 septic system every two years for maintenance.
GREASE TRAP:
(locate on site plan)
Depth below grade: n/a
Material of construction: _concrete_metal_FRP_Polyethylene_other(explain)
Dimensions: n/a
Scum thickness:n/a
Distance from top of scum to top of outlet tee or baffle:A
Distance from bottom of scum to bottom of outlet tee or baffle: n/a
Date of last pumping,v,
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.)
A
BUILDING SEWER:
(Locate on site plan)
Depth below grade: 20'
Material of construction:_cast iron X 40 PVC—other(explain)
Distance from private water supply well or suction line�—
Diameter: 4'
tn/amments:(conditions of joints,venting,evidence of leakage,etc.)
(revised 0427/97)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 351 Main St.Cotuit
Owner: Dr.Sooy:326 Mathelson St.Hildberg Cal.95448
Date of Inspection:8097
TIGHT OR HOLDING TANK:
(locate on site plan)
Depth below grade: n/a
Material of con struction:_concrete_metal_FRP_Polyethylene_other(explain)
Dimensions: NO
Capacity: n/a gallons
Design flow: n/a gallons/day
Alarm level:_n/a Alarm In working order?_Yes_No
Date of previous pumping:
Comments:
(condition of inlet tee,condition of alarm and float switches,etc.)
n/a
DISTRIBUTION BOX:
(locate on site plan)
Depth of liquid level above outlet invert: n/a
Comments:
(note if level and distribution is equal,evidence of solids carryover, 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)yes
Comments:
(note condition of pump chamber,condition of pumps and appurtenances, etc.)
n/a
(revised 04/27/97)
I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 351 Main St.Cotuh
Owner: Dr.Sooy:326 Matheison St.Hildberg Col.95448
Date of Inspection:8097
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:
We
Type:
leaching pits, number: 1,000 gallon leach pit
leaching chambers,number:n/a
leaching galleries,number: n/a
leaching trenches,number,length: n/a
leaching fields,number,dimensions:n/a
overflow cesspool,number:n/a
Alternate system: n/a Name of Technology:_n/a
Comments:(note condition of soil,signs of hydraulic failure,level of ponding, condition of vegetation, etc.)
The overflow is structurally sound and functioning properly It was empty at the time of the inspection.
CESSPOOLS:_
(locate on site plan)
Number and configuration: n/a
Depth-top of liquid to inlet invert: n/a
Depth of solids layer: n/a
Depth of scum layer: n/a
Dimensions of cesspool: n/a
Materials of construction: n/a
Indication of groundwater: n/a
inflow(cesspool must be pumped as part of inspection)
n/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: We
Comments:(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
n/a
(revised 04/27197)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
351 Main St.Cotuit
Dr.Sooy:326 Mathelson St.Hildberg Cal.95448
8/6197
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references, landmarks or benchmarks
locate all wells within 100'(Locate where public water supply comes into house)
h
IL
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AC 3�
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pegs 9 of 10
(revised 0427/97)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
351 Main St.Cotuit
Dr.Sooy:326 Matheison St.Hildberg Cal.96449
816J97
Depth of groundwater 12,
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from design plans on record.
Observation of Site(Abutting property,observation hole, basement sump etc.)
Determine it from local conditions
Check with local Board of Health
Check FEMA Maps
Check pumping records
Check local excavators, installers
x Use USGS Data
Describe in your own words how you established the High Groundwater Elevation.(MUST be completed)
USGS Maps and Charts
(revised 04/27/97) tray 10 of 10
kSESSOR'S MAP NO. Dga PARCEL n
LOCATION SEWAGE PERMI a.
VILLAGE
Co-�LA-o
ST LLER'S NAME i ADDRESS
mom; S 1N�aS �eY Wjc D�Cogq
S U I L D E R OR OWNER
DATE PERMIT ISSD E D .r
DATE COMPLIANCE ISSUED
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No.aF. � Fes$.. ...... .D
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Applirntion for Dbripu ttl Warkii Towitrnr#inn runtit
Application is hereby made+Perm o Con ruct ( ) or Repair (4-<an Individual Sewage Disposal
System at
S
.A.
catiac-Ad e•ss - y-�r� or Lot N ,
...----- ® ---•-•._._ ---------- ...........
` O Address c �A
..- ........ _...k. �1. •1.�....w� ..�.__'ILX.\��?. e`C_.!'` �
Installer Address
UType of Building Size Lot............................Sq. feet
.� Dwelling—No. of Bedrooms-------------- `_ .-----------------------Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ---------------------------- No. of persons--------.............--..--- Showers ( ) — Cafeteria ( )
dOther fixtures --------------------------------------------------------------------------------------- -------------------------------------.......................
Design Flow---------------------------------------------gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity------------gallons Length---------------- Width-------_-----. Diameter--...--......... Depth................
x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No--------------------- Diameter...--...--...----... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date........................................
a
Test Pit No. 1................minutes per Inch Depth of Test Pit..---.--..---....... Depth to ground water...---------------------
G14 Test Pit No. 2................minutes per inch Depth of Test Pit-------------------. Depth to ground water..............--..--....
9 -- -----------------------------------------------------------•---------------•---•---------••••-•............
-....
•--------------------
..........
•--------
0 Description of Soil....._ _.
x �—
U ....•-•---•••••-••-••-•-•••----•••......--••---•••--•-
W ----
U Na re of Re airs o Alterations—Answer he applicab .------..-. -�.�. .�............4 S i -----e $5 ?
�?C
�4 . �,
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
.the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of'Coinpl' ric as b en issu d by the bo�ofh h.Signed . ........ ..... .. — as 7
._-- ....'........'.`------.....-------'----- ---"Dace.................
Application Approved B
a -�
.... t- ---------------------------- ----- ..�. ..
' Dare
Application Disapproved for the following reason.. ....................................... - ------...----------------------------------------..
�} Dace
Permit No. 1..��.'�..''.......�.:�. ---------------- Issued .--- ^"�a ^9..� ........
Date
P
No.f-., � � Fas..3.0......O.O
! THE COMMONWEALTH OF MASSACHUSETTS
=' BOARD OF HEALTH
;TdWWOF BARNSTABLE
Appliratiou for Diipooal Worko Tomitrurtiou Permit
Application is hereby, made r a Permit to Corl truct ( ) or Repair (1-<an Individual Sewage Disposal
System at
I:ocation-i\dd ess or Lot N—T f
{
^O\ neer Address (1 -
'� �C` �• - O", `lv" LS--------- `..... ..............
Installer Address
UType of Buildings A r r Size Lot............................Sq. feet
a Dwelling'-No. of Bedrooms..............r --------------Expansion Attic ( ) Garbage Grinder ( )
Q, Other—Type of Building ............................ No. of persons---------------------------- Showers ( ) — Cafeteria ( )
a' Other fixtures ___---------------------------------------------------
W Design Flow--------------------------------------------gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacitv............gallons Length---------------- Width---------------- Diameter_.------------ Depth................
x Disposal Trench—No. .................... Width-------------------- Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No______________________ Diameter-------------------- Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date........................................
0
Test Pit No. I................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........................
----------------------•--------------------------------------------•--•--------•-___............................................................
Descriptionof Soil------ I'`------�•-•-----•-•------------------------------------------------------------------------------------------------------------------------••-
x y�-�-
U Nature of Repairs o Alterations—Answer heft applicable.__--__-._._- -���.�___._._.?�.:.5_._ �� Sp} _
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Compliance as been issued by\the boa d of he IthDate.
'..a..� .
'
nel
Application Approved B a ��...` /...../......�'�1` 9'' '
Dare
Application Disapproved for the following reasons: -----------------------------
......................................................................................
Permit No. � r a' ^
,�,1 Q Dare
-- !��� .�7 .. Issued ------- --........................................................
Dale
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
TrrfifiratE of Complianre
77-H�S IS TO CERTIFK That the Individual Sewage Disposal System constructed or Repaired
09
...............)....................... --------------------------------------------------------
by ...... ........\. Instal lei
�
co --------
---------------------------
--'---------0- ------------- ---------- --------------------------------
at ....... .2-------------------------- ----—---------
has been installed in accordance with the provisions of TITL f ThyState Environmental Code as described in
the application for Disposal Works Construction Permit dated
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FU ION 7 TI FACTORY.
DATE....... 0' —�-1
.... ................ ------- ------------------------------------------ Inspector
------------------------------------------ -------------------------------
��- C) a r), THE COMMONWEALTH OF MASSACHUSETTS
03e' — 0 0 BOARD OF HEALTH
TOWN101 BARNSTABL 0
No......................... w r i
FEE........................
Mijimial Vorkii T, nntrwfivu rrbti
Permission is hereby granted................ --------- -------------------*-----------
to Construct or
. Repair n Ind* iduaI Sewage(DispotlSat
l eSysten
at No........OZ ........... .. . ............ A -r
. . ...............
as shown on the application for Disposal Works Construction Permi ate&... .......
........................................------- ........
� ...e...............................
�-c
DATE.. 4? Board of Health
-------------------
FORM 36508 HOBBS&WARREN.INC..PUBLISHERS