HomeMy WebLinkAbout0012 PINEY ROAD - Health 12 Piney Road
' � 4
Cotuit P
A = 034 025
i
TO F ARNSTABLE \'
LOCATION SEWAGE #
VILLAGE ASSESSOR'S MAP & LOT
O t
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type)
NO.OF BEDROOMS
BUILDER OR OWNER
PERMITDATE: COMPLIANCE DATE:
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
Furnished by
�����
��
� �3
�,
� � �g
# t
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
n f
DEPARTMENT OF ENVIRONMENTAL PROTECTION
n r
W
i
>ly TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FOR'" RECEIVED
PART A
CERTIFICATION
JUL 082002
Property Address: 12 PINEY'RD;COTUIT,MA 02635
Owner's Name: CHRISTOPHER THgMPSON
TOWN OF BARNSTABLE
Owner's Address: GROVERE&MCELHENY BUILDERS PO BOX 1080 COTUIT HEALTH DEPT.
Date of Inspection: 6/10/02
PARCEL
Name of Inspector: (please print)i, JOHN GRACI -
Company Name: SEPTIC INSPECTIONS LOT
Mailing Address: i';P O'BPX 2119 TEATICKET, MA.02536 .
Telephone Number: 508-564-6813,11TAX,508-564-7270 �"1►'� ���
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is
true,accurate and complete as of the time of the inspection. The inspection was performed based on my training and
experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system
inspector pursuant to Section'15.340,61',Title 5(310 CMR 15.000). The system:
X Passes _
_ Conditionall 'Passes
_ Needs Furth r aluation by the Local Approving Authority
Fails
Inspector's Signature:. ? ' ! Date: 6/10/02
The system inspector shall submit a c y 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 coplets sent to-the buyer, if applicable,and the approving authority.
Notes and Comments
SYSTEM PASSED TITLE V INSPECTION. RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE
SYSTEM'S USEFUL LIFE. REC,o,MMEND GETTING NEW COVERS.
""This report only describes condili4ills al Ilse lime of inspection and ou(let- the conditions ol'use al Mal lime.This
inspection does not address ho.w,the system will perform in the future under the same or different conditions of use.
;4 V.
Title 5 tncnrrtinn Pnrm A/1 5 11)00 l%: I
Page 2 of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
is PART A
,10 CERTIFICATION (continued)
Property Address: 12 PINEY RD COTU�IT,MA 02635
Owner: CHRISTOPHER TH,O,.MPSON
Date of Inspection: 6/10/02
Inspection Summary: Check'-;A',B,C,D or`,E/ALWAYS complete all of Section D
A. System Passes:
h ov f
X 1 have not found any informationtwhi;ch 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:
SYSTEM PASSED TITLE V INSPECTION. RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE
SYSTEM'S USEFUL LIFE. RECOMMEND GETTING NEW COVERS.
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'repaiij-as approved by the Board of Health, will pass.
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.ove026?years;old* or the septic tank(whether metal or not) is structurally unsound;exhibits
substantial infiltration or ekfiltift tion,•of'tai k'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 yeg s oldlis available.
ND explain: n/a {
.M
I . t
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 bo
Health): x. System will pass inspection if(with approval of Board of
!'y
_ broken pipe(s)'are replaced
_ obstruction`is removed
_ distribution boA is leveled or replaced
ND explain: n/a
.t t
n/a The system required pumping more thai 4 times a year due to broken or obstructed pipe(s). The system will pass
inspection if(with approval of the Board'ofrHPalth):
• r,
_broken pipe(§)are replaced
_obstruction is removed
ND explain: n/a
I.i .
Page 3 of 1 1 v.10
\
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 12 PINEY RD`COTOT,MA 02635
Owner: CHRISTOPHER THOMPSON
Date of Inspection: 6/10/02
C. Further Evaluation is Required'{by the Board of Health:
_ Conditions exist which requi're further:'evaluation by the Board of Health in order to determine if the system is failing to
protect public health,safety or the environment.
;',c
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`"anner which will protect public health,safety and the environment:
_ Cesspool or privy is4within 50 feet,of a surface water
Cesspool or privy is withini50 feet of a bordering vegetated wetland or a salt marsh
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 I of a public water supply.
_ The system has a septic`�tank and:SAS and the SAS is within 50 feet of a private water supply well.
.. Ilk F°
_ The system has a septic tank ariAAS and the SAS is less than 100 feet but 50 feet or more from a private water
supply well**. Method used to-rdetermine distance n/a
**This system passe0if the we'll water'analysis,performed at a DEP certified laboratory, for coliform bacteria and
volatile organic compo�inds 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:
n>
n/a h '
14.
E
t g,
Page 4 of I
OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACt SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
*: CERTIFICATION(continued)
Property Address: 12 PINEY RD COTUIT, MA 02635
Owner: CHRISTOPHER THOMPSON
Date of Inspection: 6/10/02(r^(
D. System Failure Criteria,applicable to all systems:
You must indicate"yes"or,'n'o''',to each of the following for alLinspections:
Yes No
_ X Backup of sewage into'facility&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 %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 n1a. ,
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 I 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. IThis 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 this7form. h
_ (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: The�system owner should contact the Board of Health to determine what will be
necessary to correct the failure;'=
s,
E. Large Systems:
To be considered a large system the system must serve a facility with a desibn flow of 10,000 gpd to 15,000 gpd.
You must indicate either"yes"or• 'no i to.each of the following:
(The following criteria apply to large,systerns-in addition to the criteria above)
yes no
X the system is within 400 feet of a surface drinking water supply
X the system is within 200 fectP.pf a tributary to a surface drinking water supply
X the system is located in a nitrogersensitive area(interim Wellhead Protection Area—IWPA)or a mapped
Zone II of a public water supply well
�44 -
If you have answered`,'yes,to aiiy 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 I;or failed under.SccliunI)shall upgrade the system in accordance with 310 CMIt 15.304. The syslciu owner
should contact the appropriate'region al`office of the Department.
i'{j d
Page 5 of I 1
u
f Y
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
S�. PART B
CHECKLIST
Property Address: 12 PINEY•R,I;COTI IT,MA 02635
Owner: CHRISTOPHER THOMPSON
Date of Inspection: 6/10/02
Check if the following have been done,..You must indicate"yes"or"no"as to each of the following:
Yes No 4
X _ Pumping information,was=.p.rovi'ded by the owner,occupant,or Board of Health
X Were any of thefsystem coml56n6nts pumped out in the previous two weeks?
D•
X Has the system received no"rmaf 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 systeni`obtained and examined?(If they were not available note as N/A)
X _ Was the facility-or,dwe(ling`inspected for signs of sewage backup?
X _ Was the site inspected;for signs of break out ?
X _ Were all system components,excluding the SAS, located on site
t ,
X _ Were the septic tank inanlibles uncovered,opened,and the interior of the tank inspected for the condition of the
baffles or tees,material of construe Mln';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:
Yes no
X _ Existing information,: For a sample,a plan at the Board of Health.
i
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)]
4;J
no
't
Page 6 of 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
' PART C
SYSTEM INFORMATION
Property Address: 12 PINEY RD CO.TUIT MA 02635
p Y
Owner: CHRISTOPHER THOMPSON
Date of Inspection: 6/10/02
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design) 4'�"Number of bedrooms(actual): 4
DESIGN flow based on 310 CMR 15`.203 (for example: 110 gpd x#of bedrooms): 440
Number of current residents-.,
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): NO ��g, z, . ,
Water meter readings, if available,(last 2 years usage(gpd)): n/a
Sump pump(yes or no): NO r
Last date of occupancy: 8/31/01
T' x .
COMMERCIAL/INDUSTRIAL
Type of establishment: n/a t
Design flow(based on 310 CMR,45.20�),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 disehafged to'dw Title 5 system(yes or no): NO
Water meter readings,' if a6ilable: it/a °
Last date of occupancy/use: n/a
OTHER(describe): n/a
9
fit' " i1
GENERAL INFORMATION
Pumping Records
Source of information:'n/a
r.
Was system pumped as pa&oPthe;inspection(yes or no): NO
If yes,volume pumped: nMgallons!1'L1 How`was quantity pumped determined? n/a
Reason for pumping: n/a'
TYPE OF SYSTEM
X Septic tank,distribution box;soil'i�bsorption system
_Single cesspool
_Overflow cesspool fr
_Privy
_Shared system(yes or no)(if yes,attach.previous inspection records, if any)
_Innovative/Alternative'technology.Attach a copy of the current operation and maintenance contract(to be obtained from
system owner) j
_Tight tank Attach a copy of the`'Dt approval
Other(describe): n/a '
«A �
Approximate age of all cAponeiitkl,dace;installed(if known)and source of information:
90 YEARS BY OWNER
Were sewage odors detected when arriving at the site(yes or no): NO
A
R t .
Page 7 of I I 3
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
;SYSTEM INFORMATION(continued)
Property Address: 12 PINEY RP COTUIT, MA 02635
Owner: CHRISTOPHER THOMPSON'
Date of Inspection: 6/10/02
bar' I�S
BUILDING SEWER(locate on site plan),
Depth below grade: 9"
Materials of construction:_cast'iron _`40 PVC Xother(explain): ORANGEBURG
Distance from private water supply well or suction line: n/a
Comments(on condition of joints, venting,evidence of leakage,etc.):
TOWN WATER
SEPTIC TANK: X(locate on site plan)
Depth below grade:3"
Material of construction:_Xconcrete metal fiberglass_polyethylene other(explain)n/a
If tank is metal list age: n/a Is d&;ld'onfirmM by a Certificate of Compliance(yes or no): NO(attach a copy of certificate)
Dimensions: 2' X 2' BRICK CESSPOOL"
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: 0"
Distance from bottom of scum to'1S6ttonvof outlet tee or baffle: 0"
How were dimensions determined:'lWll`ASURED
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related
to outlet invert,evidence of leakage,'etc.): y
CESSPOOL IS STRUCTURALLY.SOUND AND FUNCTIONING PROPERLY. RECOMMEND PUMPING EVERY
TWO YEARS TO PROLONG THE'SYSTEM'S USEFUL LIFE.CESSPOOL WAS EMPTY AT TIME OF
INSPECTION. RECOMMEND GETTING NEW COVER.
GREASE TRAP:_(locate on site an)''
Depth below grade: n/a
Material of construction: ,concrete_metal_fiberglass_polyethylene_other(explain): n/a
Dimensions: 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
Date of last pumping: n/a
Comments(on pumping recommVNdattons, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related
to outlet invert,evidence of le et'c`):
n/a
ill tilt
4,
t.
`:i•I` 9
1,
Page 8 of I l m
,(AN,
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
.SYSTEM INFORMATION(continued)
Property Address: 12 PINEY RD COTUIT, MA 02635
Owner: CHRISTOPHER THOMPSON
Date of Inspection: 6/10/02
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/days
Alarm present(yes or no): N/A` '.'; '
Alarm level: N/A Alarm in working order.(yes or no): NO
S
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 4 ,t
L `' '#
PUMP CHAMBER:_(locate on site plan)
Pumps in working order(yes or no)c NO
Alarms in working order(yes'or no):N'O
Comments(note condition of pump chamber,condition of pumps and appurtenances, etc.):
n/a
'lip •i,.'�. .,
.k.
'M
" R
Page 9 of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 12 PINEY RD COTUIT, MA 02635
Owner: CHRISTOPHER THOMPSON
Date of Inspection: 6/10/02
SOIL ABSORPTION SYSTEM (SAS):n X (locate on site plan,excavation not required)
,.j
If SAS not located explain why:
n/a
Type
n/a leaching pits, number: n/a
n/a �;,, leaching chambers, number: n/a
n/a teaching galleries, number: n/a
n/a leaching trenches, number, length: n/a
n/a leaching fields, number: n/a
8' X 6' BLOCK CESSPOOL°r overflow cesspool, number:
innovative/alternative system
T pe/name of technology: n/a
Comments(note condition of soil;tslps o:f hydraulic failure, level of ondin ,dam soil,condition of vegetation,etc.):
p g p g )
CESSPOOL IS STRUCTURALH!ZV SOUND AND FUNCTIONING PROPERLY.SYSTEM SHOWS NO SIGNS OF
FAILURE.CESSPOOL WAS EMTPY AT TIME OF INSPECTION. STAIN LINES INDICATE IT HAS NEVER
BEEN MORE THAN HALF FULL. BOTTOM IS AT 10'.RECOMMEND GETTING NEW COVER.
CESSPOOLS: (cesspool must lie pdmpedvs part of inspection)(locate on site plan)
y
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 inflow(yes or'no):'NO
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 soils signs of hydraulic failure, level ofponding,condition of vegetation,etc.):
n/a a Btr h F .
3
4
. Page 10 of I I
OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 12 PINEY RD COTUIT, MA 02635
Owner: CHRISTOPHER THOMPSO:N
Date of Inspection: 6/10/02
`
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.
Locate all wells within 100 feet. Locate wliere public water supply enters the building.
r .
tiZ I`
O
"J
;. AA
AG
1.
r i
tl:
ii
� , Y
` I Il
Page I I of
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 12 PINEY RD COTUIT,MA 02635
Owner: CHRISTOPHER THOMPSON
Date of Inspection: 6/10/02
SITE EXAM
_Slope
_Surface water
_Check cellar r
Shallow wells
Estimated depth to ground water 15+,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
YES 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)
NO Accessed USGS database=explain: n/a
You must describe how you established the high ground water elevation:
HAND AUGER- 15+ FT.; ..;
i
4 f
{
,