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Home My WebLink About0006 SCHOOL STREET - Health (3) FA SCHOOL STREET, COTUIT = 035 054 i i 1 M TOWN OF BARNSTABLE LOCATION SEWAGE # VILLAGE ASSESSOR'S MAP LOT INSTALLER'S NAME 6z PHONE NO. r c ,e, 1 i,r l v SEPTIC TANK CAPACITY LEACHING FACILITY:(type) (size) / NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER v BUILDER OR OWNER DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No C�� t ��{ � ' S _ �e� �- e� I . t V Commonwea h oj-Envir sochusettG `w ` Executive Office of orime Affairso Department of 166z Environmental Protection William F.Weld ONi�j�� Gowmor Trudy t oxe ,t Secretary,EOEA f� David B.Struhs Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: x/bol- ST 66rt,l �- - ac�sd° Address of Owner; Date of Inspect'it� `1'-q 5-• (If different) �'v r.. 1��: i«< 5 Name of Inspector: �,� ,e� p� 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: Ll-Passes Conditionally,Passes _ Needs Further Evaluation. By the Local Approving Authority _ Fails Inspector's Signatu e: I L Date; /, ,/_g 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 t(• the system owner and copies sent to the buyer, if applicable and the appro�ing au:hority. INSPECTION SUMMARY: Check A, B, C, or D: A) PASSES: 7have not found an information which indicates that the system violates an of the failure criteria as defined in 310 CMR 15.303. Y Y Y Any failure criteria not evaluated are indicated.below. B) SYSTEM CONDITIONALLY PASSES: One or more system components need-to be replaced or repaired. The system,upon completion of the replacement or repair, passes inspection. Indicate yes, no, or not determined (Y, N, or ND). -Describe basis of determination in all instances. If"not determined", explain why not) The septic tank is metal, cracked, structurally unsound, shows substantial infiltration or`exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as. approved by the Board of Health. (revised ll/1s/9s) 1 One Winter Street a Boston,Massachusetts 02108 a FAX(617)$56-1049 a Telephone(617)292-5500 i~�Printed on Recycled Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A. CERTIFICATION (continued) Property Address: L? c j CO,r Owner:r ✓, e� r1r�5��h� Date of Inspection:.•a_l -`� S 61 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): 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) 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: _ 1he systPm has a septic lanK anu soil absurptlun systeni anu is wilimi joV ieci to a �uiacc ,vziei suppi') o tributai)- to a surface water supply. ' _ The system ha! a septic tank.and soil absorption system and is within a Zone 1 of a public water supply well. _ The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well _ The system has a septic tank and soil'absorption system and is less than 100 feet but 50 feet or more from a private water supply.well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from thatfacility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm Dj SYSTEM FAILS: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct. the:failure, Backup of sewage 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. (revised 8/15/95) 2 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Co i5 'o U 57-, C.cvT v r Owner:�?v-" �i�,�l Date of Inspection: t : ° 1 --A C. j DJ SYSTEM FAILS (continued): Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow. Required pumping more than 4 times_ in the last year NOT due to clogged or obstructed pipe(s). _rr Number of times pumped d? 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. rq Any portion of a cesspool or privy is'within a Zone I of a public well �I Any portion of a cesspool or privy is within 50 feet of a private water supply well. (4 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. El LARGE SYSTEM FAILS: The following criteria apply to large systems in addition to the criteria above: 14 The design flow of system is 10,000 gpd or greater (Large System)and the system is a significant threat to public health.and safety and the environment because one or more of the following conditions exist: the system is within 400 feet of a surface drinking water supply the system is within 200 feet-of a tributary to a surface drinking water supply _ the system is located in a nitrogen sensitive area (Interim Wellhead Protection-Area (IWPA) or a mapped Zone 11 of a public water suppiy 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 8/15/95) + 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION, FORM PART B CHECKLIST Property Address: (0 DC,�06 - Owner:_' Vvi.ct- � r��..�C4.,,,._e Date of Inspection: Check if the following have been done: LZPumping information was requested of the owner, occupant, and 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. :1A5 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. ZThe system does not receive non-sanitary or industrial'waste flow 4 ✓ The site was inspected for signs of breakout. tXAII 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. T e size and location of the Soil Abdor Lion System on the site has'been determined based on existing ' _ P Y 8 p -information or prox:imated by non-intrusive methods. _The fa6!;.:, .o.;:i r ;ji .J occupants, if Vic-r— from ov.-ner'- „vere provided with information on the proper maintenance of Sub- Surface Disposal System. (revised 8/15/95) 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: �, J L a��L- 5 T- G o --L/; Owner:'�V'. 1-*a ' Date of Inspection: FLOW CONDITIONS RESIDENTIAL- Design flow: t-cDt) gallons Number of bedrooms: r`�L— Number of current residents: o� Garbage grinder (yes or no): r Laundry connected to systerrt (yes or no): / Seasonal use (yes or no): Water meter readings, if available: l`1 �- Last date of occupancy: COMMERCIAUINDUSTRIAL: Type of establishment: Design flow:. gallons/day 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: 01.:`vclate:of occupancy: OTHER: (Describe) " Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: System pumped as pan of inspection: (yes or no)_ If yes, volume primped. gallons Reason for pumping; TYPE OF SYSTEM „ Septic tank/distribution box/soil absorption system Z Single cesspool Overflow xesspot-7 i Privy Shared system (yes orno) (if yes, attach previous inspection records, if any) Other(explain): APPROXIMATE AGE of all components, date_installed (if known) and source of information: '/✓S / c�'S �/ i S, Sewage odors detected when arriving at the site: (yes or no) (revised 8/15/95) 5 II SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: (0 5T- GC,vZ Owner: Date of Inspection: SEPTIC TANK: (locate on site plan) Depth below grade: Material of construction: _concrete _metal FRP—other(explain) 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: 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.) GREASE TRAP: (locate on site plan) Depth below grade: Material of construction: concrete _metal _FRP —other(explain) Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle; Distance from. botlom er Sr1tm in tintlnrr o1 0!t11P1 1PP'.M ba!1ie- } 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.i (revised 8115/95) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM. PART C SYSTEM INFORMATION (continued) T— � 1� t��n cv� r. Property Address: to �� ' Date of Inspection: r `a_ ( TIGHT OR HOLDING TANK: (locate on site plan) Depth below grade: ' Material of construction: _concrete_metal FRP—other(explain) Dimensions: Capacity: gallons Design flow: gallons/day Alarm level: 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: i Comments: mote n ievei and distribuou.i. eyua:; e%;uvnce of sulid: ca;ryu er, e%�idence of leakage into or out of box, etc.) PUMP CHAMBER: (Locate on site plan) Pumps in working order.(yes or no) N , Comments: ' (note condition of pump chamber, condition of pumps and appurtenances, etc.) (revised'6/15/95) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: to -'JikUc)(-- L, Owner: �YvL�_•-1�.r1�, L y._� Date of Inspection: 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: /} ' Y�•i Type: leaching pits, number. leaching chambers, number._ leaching galleries, number: leaching trenches, number,length: leaching:fields, number,.dimensions: overflow cesspool, number: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,etc.) CESSPOOLS: ✓ ` (locate on site plan) Number and configuration: Depth-top of Liquid to inlet invert: Depth of solids layer. av j Depth of scum layer: `T Dimensions of cesspool: Materials of construction: \4 �c Indication of groundwater. inflow (cesspool must be pumped as part of inspection) 1-2 � Comments: (note condition of sorl, signs of hydraulic failure, level of ponding, condition of vegetation; etc.) PRIVY:�' (locate on site plan) e Materials of construction: Dimensions: Depth of solids: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,etc.) B (revised 8/15/95) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: (pkcc,(.�-- � Owner ✓�r.��,�: C4lF Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent refere ces landmarks or benchmarks locate all wells within 100' ,__�_ . <, Ivy ,• n , . Lt7UU I•�otJ�7�<< _ DEPTH TO GROUNDWATER I=r , Depth to groundwater: �� feet f�D �,yTre✓ .�5, j)'S��•ems method of determination or approximation: Sy y'' TV- (revised 6/15/95) 9