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HomeMy WebLinkAbout0975 MAIN STREET (COTUIT) - Health 7975 Man Street, Cotsit ;. �i,1 77 �ti COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFF I 12 g DEPARTMENT OF ENVIRONMENTAL P CTION �1 ONE WINTER STREET. BOSTON, MA 02108 617-29 -0 �Qt a 0 .� •e c �e 0 /�F© w WIV �LIAM F.WELD rp��pFe99 � '1 �RUDS C XE ary Governor Ty�FAlTgB�F ARGEO PAUL CELLUCCI d) DAy D B.STRUHS Lt.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Commissioner PART A CERTIFICATION ° Property Address: 975 Main St, Cotuit Address of Owner: Lawrie Peirson Date of Inspection: o� `7'7 (If different) Jeff Higgins Name of Inspector: Wm E Robinson Sr I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000) Company Name: Wm E Robinson Septic Service Mailing Address: PO Box 1 089 , C _ntervi 1 1 E°, MA 02632 Telephone Number. 5 0 8Y 7 7 5—R 7 7 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: _V Passes _ Conditionally Passes Needs Further Evaluation By the Local Approving Authority Fails n Inspector's Signature: &U 1 1, Date: , The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (30) days of completing this inspection. If the system is a shared system or has'a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. INSPECTION SUMMARY: Check A, B, C, or D: AI SYSTEM PASSES: I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. COMMENTS: 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. Indi to 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 04/25/97) Page 1 of 10 DEP on the World Wide Web: http:/hvww.magnet.state.ma.us/dep Printed on Recycled Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 975 Main St, Cotuit Owner: Peirson/Higgins Date of Inspection: q 7 ] SYSTEM CONDITIONALLY PASSES (continued) 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). Describe observations: 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 C) FU THER 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. 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 PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet to a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and the SAS 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 presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine distance (approximation not valid). 3) OT ER (revised 04/25/97) Page 2 of 10 SUBSURFACE SEWAGE DISPOSALFSYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 975 Main St, Cotuit Owner: Peirson/Higgins Date of Inspection: ] SYSTEM FAILS: Y u must indicate ea!ier "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 of sewage into 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 SAS or cesspool. 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). Number 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 I 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] LARG SYSTEM FAILS: You must dicate either "Yes" or "No" as to each of the following: T e`following criteria apply to large systems in addition to the criteria above: T e system serves a facility with a design flow of 10,000 gpd or greater (Large System) and the system is a significant threat to ublic health and safety and the environment because one or more of the following conditions exist: Yes N 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 own or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requiremen of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 04/25/97) Page 3 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 975 Main St, COtuit Owner: Peirson/Higgins 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. _ 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. S _ 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: The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of Sub-Surface Disposal System. Existing information. Ex. Plan at B.O.H. Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) [15.302(3)(b)] (revised 04/25/97) Page 4 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 975 Main St, Cotuit Owner: Peirson/Higgins Date of Inspection: FLOW CONDITIONS RESIDENTIAL: Design flow: 330_g.p.d./bedroom for S.A.S. Number of bedrooms:,.L--2 Number of current residents:N Garbage grinder (yes or no):_ d , Laundry connected to system (yes or no):�'`3 Seasonal use (yes or no): Water meter readings, if a4ilable (last two (2) year usage (gpd): 19 9 4 — 1995 1 0 0, 0 0 0 g Sump Pump (yes or no): _ 1 9 9 5 — 1996 77, 000g Last date of occupancy: COM ERCIAUINDUSTRIAL• Type o establishment: Design ow:_gallons/day Grease t ap present: (yes or no)_ + Industri Waste Holding Tank present: (yes or no)_ Non-sa itary waste discharged to the Title 5 system: (yes or no)_ Water eter readings, if available: Last date of occupancy: + COT LER: (Describe) Lasof occupancy: GENERAL INFORMATION PUMPING RECORDS and ource of information: 1� �s� System pumped as part of inspection: (yes or no))-�- � If yes, volume pumped: Rallons Reason for pumping: TYPE OF SYSTEM Septic tank/distribution box/soil absorption system $iV rfl cesspool —b�/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 of information: R g + Sewage odors detected when arriving at the site: (yes or no) F I : (revised 04/25/97) Pago 5 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 975 Main St, Cotuit Owner: Peirson/Higgins Date of Inspection: �? BUIL ING SEWER: (Local on site plan) Depth be ow grade: Material f construction: _cast iron _40 PVC_other (explain) Distance rom private water supply well or suction line Diamet Comm ts: (condition of joints, venting, evidence of leakage, etc.) SEPTIC ANK:_ (locate on ite plan) Depth bel grade: Material of construction: _concrete _metal _Fiberglass _Polyethylene _other(explain) If tank is etal, list age _ Is age confirmed by Certificate of Compliance _(Yes/No) Dime ions: Sludge the Distance fir top of sludge to bottom of outlet tee or baffle: Scum thickn ss: Distance fro top of scum to top of outlet tee or baffle: Distance fro bottom of scum to bottom of outlet tee or baffle: How dimen ions were determined: Comments: (recomme dation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, idence of leakage, etc.) GREASE RAP: (locate on si plan) Depth below rade: Material of c nstruction: _concrete _metal _Fiberglass _Polyethylene other(explain) Dimension Scum thi ness: Distanc from top of scum to-,op of outlet tee or baffle: Distance fir bottom of scum to bottom of outlet tee or baffle: Date of last umping: Comments: (recommen ton for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evid nce of leakage, etc.) (revised 04/25/97) Page 6 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 975 Main St, Cotuit Owner: Peirson/Higgins Date of Inspection: g �Q TIGHT OR HOLDING TANK: (Tank must be pumped prior to, or at time, of inspection) (locat on site plan) Depth low grade: Material of construction: _concrete _metal _Fiberglass _Polyethylene —Other(explain) Dimensi ns: Capaci gallons Design low: gallons/day Alarm evel: Alarm in working order_Yes; _ No )at of previous pumping: Com ents: (condit n of inlet tee, condition of alarm and float switches, etc.) DISTR TION BOX:_ (locate on ite plan) } Depth of li uid level above outlet invert: l Comments• (note if le I and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) PUMP C BER:_ (locate on site plan) i Pumps in wo ing order: (Yes or No) Alarms in w rking order (Yes or No) _ t _ Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) (revised 04/25/97) Page 7 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 975 Main St, COtuit Owner: Peirson/Higgins. Date of Inspection: '7 SOIL ABSORPTION SYSTEM (SAS):_ (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: Type. /_ �6 g �' leaching pits, number: r leaching chambers, number:_ leaching galleries, number: leaching trenches, number,length: leaching fields, number, dimensions: overflow cesspool, number:_' Alternative system: Name of Technology: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) ,L _ l/n Q2. !e/w i dD '�-' (� 4 A B DL G, t� �n t. �i 2 A 6 V CESSPOOLS: _ (locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: $ ' Depth of solids layer: 3—�l ' Depth of scum layer: '�L` Dimensions of cesspool: G >r T Materials of construction: flu/0 c .4c� j Indication of groundwater: inflow (cesspool must be pumped as part of inspection) Comments: (note condition of soil, signs of hydraulic failuw, level of ponding, condition of vegetation, etc.) / ' ss - S 46e� t'Cas7 c9 ate/ P (locate o site plan) Materials f construction: Dimensions: Depth of solids: Comme ts: not ndition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) (zevieed 04/25/97) Page 8 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) I Property Address: 975 Main St, Cotuit ^ Owner: Peirson/Higgins Date of Inspection: 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) r 1 ♦ 1 L r (revised 04/25/97) Page 9 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 97.5 Main St, Cotuit Owner: Peirson/Higgins Date of Inspection: Depth to Groundwater �5' Feet 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.) '1/ Determine it from local conditions Check with local Board of health Check FEMA Maps Check pumping records Check local excavators, installers Use USGS Data 1 � Describe in own words how you established the High Groundwater Elevation. (Must be completed) �.e x s 7-6 J I i (revised 04/25/9')' ' Peg* 10 of 10 l �\ v 3o�is ZcyY� G u • I S GtJh/ /AXIS%s A-5No.33253 Ohl JAN ►�1 fMOOREE OITI LOCATION SEWAGE PERMIT NO. VILLAGE INSIAL L E R'S NAME ADDRESS BUILDER OR OWNER NS DATE PERMIT ISSUED DATE COMPLIANCE ISSUED • �� • d� c:� 1 �. s �'� F a\'.� / s r � � ' . � _ ��h � N'. __ �, �_ � � -� i d J �/ � No.... Fps.. _.-......... THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH .......... .v ..........OF.......L.Sl / / - /�C /...................... App iratiou for Disposal Works Tonstrnrtiun Errant Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: ....-• - . ✓✓ice..--::� 7.�.... G'�Z '¢� ...... ..... -• •--•-- � >Location.Address o. Lot No. ��'' O ner Address r— .......!.!�� . .r' .....I ...../----•-- -c............................................................................................ Installer Address Type of BuildmV Size Lot............................Sq. feet U Dwelling No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building No. of persons............................ Showers — Cafeteria Other fixtures .................................. W 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........................................ aTest Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ fro Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ O Description of Soil............ ---.. .. .... .._ x �., W ••-•-•---- .. ............. --- ---------------------•---•------ . ------ ----•-•-• --•------•------- V Nature of Repairs or Alterations—Answer when applicable.____ __ ________��� �__ lO .14.Q ................ -- -------------•----------------------------------..._..--...._. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of iITIU 5 of the State Sanitary Code— The undersigned.further agrees not to place the system in operation until a Certificate of Compliance has been issued Py.4th, board of healt Si ne p� Date Application Approved By.................-- •--- --•• -•--------+� Date Application Disapproved for the f o o ing reasons----------------•--.....-----•-------•--•-------------....---------------------------------------------•-------- Date Permit No........ ......�...�'�-------------------• - Issued ...................... ---- g Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH �,�r Appliratiun for Disposal Works Tonstrurtiun Vrrmit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal Systemat r - ..................................... .� - ... fye # > Location Address or Lot No. ........................ ---'-� � a�Nner --------------------------------Address W .f O !/ J �✓+r gf iy ? FY 1 f ............ Installer Address d Type of Buildin�° Size Lot...........................Sq. feet Dwelling ' No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) < Other fixtures ------------------------•-----------------------------.-•----••---•••---••--•-=-•••••-------••--•-•-••--•---•---•----••••--••--•-••••......---•-----•• W 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........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water----------------_----- Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ -. - f•-•----•-•••----•-••--•-••-•••_..._....-•-•.:_.._--••••..._....----•.........---•....................•--••--•......-•••-------•-- ODescription of Soil a ------•-----------•----------•-•-------•--------- -------------------•---•---------------------.....-------•-----•-•-•--• �C U == x Nature of Repairs or Alterations—Answer when applicable _ ?� ._ ________________ U P PP 1 -----------------------------•-•--•-----------------------•------------•--•--------•-•-•----•-•------------•-••----------------------•------`---------•------•------------------------.._........------ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLL 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health: ....................... Application Approved By..............-- .... 44 --_,Date Application Disapproved for the of owing reasons:--------------••------••---...--••----------•---------------••-••-----------••......----•-Date •---.•------- --••-•--•---•-••--•-•..........................••---•••--.........--- --------••-------------•------...--•--------•---...-•----.....----•-•----•---•--••---••--••--••--•------•••......------••-------- Date Permit No........9S.--- 30 0 -- Issued-------`.7 Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..... ...................O F......... J ........ ................................................ Trrtifiratr of hum fianrr THIS%IS, TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired �"� by `-- `l9•• =.. �.- ' k....... `......... ' .......... '' ' r................................................................................-------- .✓',��,""` � C! ✓�' t"r,� F�A".. Installer at.............- ..........................................• -•--- .. ....----••--------•--•...................•--•--- has -,installed P'nstalled In accordance with rovisions `of TITLE 5 of The State Sanitary Code as described in the Y . application for Disposal Works Construction Permit No.;...... '.:•!' l___G~?_.__._.___ dated_. __ _-_ .'..V-S................. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT-BE CON TRIBE® AS A GUARANTEE THAT THE SYSTEM WIL 7 NCT1 N SATISFACTORY. DATE .._:.. ................................. Inspector.......... .. . �..•--•-•.....--•--•---.............--. .•....... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH y a`A ,< ' N FEE:_......."........... Disposal rkv Tuns#riun rrmit Permission is hereby granted........: '' ................................................,r ...f t _ ................................... to Constru t, Pr R7air ( )"an Individual Sewage Disposal System Street as shown on the application for Disposal Works Construction Permi Dat ... ..1__ _ �.................. •.' 0 7Y � U ................•---......_... ... ...................................- t5ardrf Health DATE................................................................................ j (( FORM 1255 A. M. SULKIN, INC., BOSTON I I I ` I i I, it It n I 1 C •1 I .J Q 1 - 17 ii r i i I � " 1il nil n 41 I 71 II I f i 1 Z. A \ \ a z o I � 3 ; I I rn I ILI i-A-------- it - i i I-.i I PI �I V O I b h UJI ! rq ems- gab M ' a • tj LLL ;' LA o r \ \ r LqCD w41 I - z If _ m rn ci IF-IF E ft N � L J x i r 0 W ri i r r r j•J - a r I 1 , 44 i I !I f•y y !\ 1 d . - j � � o O N r o � N D Ga (M -C c -ZGl Ln Z ri I d Z f' / J v r o gi