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HomeMy WebLinkAbout0261 SCHOOL STREET - Health 261 SCHOOL STREET, COTUIT A= 020 101 I i Z c TOWN OF BARNSTABLE LOCATION t' ✓�-�./a '° S� SEWAGE # VILLAGE C-v�/ r T ASSESSOR'S MAP&LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) C 4 5 a� � (size) C X �S� NO.OF BEDROOMS BUILDER OR OWNER r PERMTTDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and 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) p/ Feet Furnished by ( ( C. t3��c. . S � � � � s� � �� Town of Barnstable P# Department of Regulatory Services A•Rw�.A i Public Health Division Date 2a 4 s� 200 Main Street,Hyannis MA 02601, D ADate Scheduled Time Fee Pd.�f cfo cz� Soil Suitability Assessment,for,Sewage Disposal Performed By: P-c, Nk Ge e Witnessed By: I Gy/lip LOCATION&GENERAL INFORMATION ' Location Address Z�i sc{AZI04 ST� Owner's Name Address �� Assessor's Map/Parcel: -iCP 6 r Engineer's Name NEW CONMUCTION _X_ "REPAiIR Telephone# eSQ `A,7`7 S7j f Land Use I�S �tyl 7-t=q 1 t Slopes(%) 2- Surface Stones Distances from: Open Water Body,A, ffop ft Possible Wet Area ft Drinking Water Well ft Drainage Way /V ft Property Line f ft Other ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes) WuS11( Leo rc.i x 4 3 - 10 I �� 5" Parent material(geologic) 0.Gc C,_ ©Ut-w-q_J�'A Depth to Bedrock 7 Depth to Groundwater. Standing Water in Hole: f 2--0 Weeping from Pit Face l) A Estimated Seasonal High Groundwater t ° � `�S �� t q w ON DETERMINATION FOR SEASONAL HIGH WATER TABLE ., Method Used: y Depth Observed standing in obs.hole: cT- ` w- _ in. Depth to soil mottles: Depth to weeping from side of obs.hole: In, groundwater Adjustment Index Well# Reading Date: Index Well level Adj.factor— Adj.droun Ater Level C PERCOLATION TEST We 2 'e /1,.� cib > Observation Hole# 3 lime at 4" # - G� ? ^ t � 3 6 O �T Depth of Pere 3�D 5 `pp �Time aC 6,: Start Pre-soak Time of A 1�Ol I 71 ime(V-6") � r*t 1 � End Pre-soak / 0' S t,vl vs Rate MinJlnch \ 2 b 0 f 40 k'j Site Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(Y/N) Original: Public Health Division Observation Hole Data To Be Completed on Back----------- ***If percolation test is to be conducted within 100' of wetland,you must first notify the Barnstable Conservation Division at least one(1)week prior to beginning. Q:\SEVnCWERCFORM.DOC DEEP.OBSERVATION HOLE LOG Hole.# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones;Boulders. Consistency. Gravel) 2o C DEEP OBSERVATION HOLE LOG Hole#. Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency,%Gravel) -Z� 13 . Lems U -t c +"mod. S ;t 2. DEEP OBSERVATION HOLE LOG Hole# 3 Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency. Gravel) �-zg 6Cr�atn, sad �d Y�rl� c ►MLaI Sa,�d 2=SY�i ���-e DEEP OBSERVATION HOLE LOG Hole# 4- Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency, Lcfct s'aKc LO ` k-rj . Zq—l`ZV C Z1'5yb1 o.a� Flood Insurance Rate Man: Above 500 year flood boundary No_ Yes Within 500 year boundary No Yes Within 100 year flood boundary No—A— Yes Depth of Naturally Occurring Pervious Material. Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil absorption system? � -- If not,what is the depth of naturally occurring pervious material? Certi_ fication I certify that on (date)I have passed the soil evaluator examination approved by the Department of Environmental Protection and that the above analysis was performed by me consistent with . the required trai ' ,expertise and experience described in 3 10 CMR 15.017. Signature Date Z Ca C Q:WBPTI0PERCFORM.DOC 4 TROY WILLIAMS s �� SEPTIC INSPECTIONS Certified by MA Department of Environmental Protection 9,g /Q(506) 760-1819 40 Old Bass River Road �` • South Dennis,MA 02660 ru SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Address of property 02, G/ S 1 S f � C c,- u , -7L Owner's name& Al' Ike. f t- !� — Fo s d; c k Mailing address pU. �oX 57,5 100 0d y., 114 E. oyos y Date of Inspection PART CHECKLIST Check if the following have been done: Pumping 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. 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. V The site was inspected for signs of breakout. 1� All system components, excluding the SAS, 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 SAS on the site has been determined based on existing information or approximated by non-intrusive methods. ►� The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of SSDS. Page 1 of 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION FLOW CONDITIONS If residential 3 number of bedrooms D number of current residents NO garbage grinder, yes or no ES laundry connected to system, yes or no -4,lo seasonal use,yes or no If nonresidential, calculated flow: Water meter readings, if available: qo l o o v q a I . 93 = J9. � �� yGi. �u C CA A. / o , Last date of occupancy GENERAL INFORMATION Pumping reJc�orrds and source of information: ti ,,VO System pumped as part of inspection,yes or no If yes,volume pumped Reason for pumping: Type of system Septic tank/distribution box/soil absorption system -� Single cesspool Overflow cesspool Privy Shared system(yes or no) (If yes, attach previous inspection records, if any) Other(explain) Approximate age of all components. Date installed, if known. Source of information: 6)v-. q ku / '4 h0 ^ '- I.v ; I -/- U�.�ro SG �rc CA 4 o d am✓ �it � yt„� c� w LN ' Sewage odors detected when arriving at the site, yes or no Page 2 of 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION continued SEPTIC TANK: /✓t//f (locate on site plan) depth below grader 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 baffies,depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage,recommendations for repairs,etc.) DISTRIBUTION BOX:-eYL/1 (locate on site plan) depth of liquid level above outlet invert Comments: (note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box, recommendation for repairs,etc) PUMP CHAMBER: i9 (locate on site plan) pumps in working order,yes or no Comments: (note condition of pump chamber,condition of pumps and appurtenances, recommendations for maintenance or repairs,etc.) Page 3 of 7 r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION continued SOIL ABSORPTION SYSTEM(SAS): _j 1� (locate on site plan,if poss.;excavation not required,but may be approximated by non-intrusive methods) If not determined to be present,explain: Type: leaching pits and number leaching chambers and number leaching galleries and 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,recommendations for maintenance or repairs,etc.) CESSPOOLS (locate on site plan) : 1/' number and configuration O41 e- Al 0, C-<-s.S L06 o / depth-top of liquid to inlet invert 6 depth of solids layer ;f�A depth of scum layer N o n/ dimensions of cesspool 6 ' r t 0-��y L - " C,6, materials of construction C e s s ' o �. "-k . indication of groundwater inflow (cesspool must be pumped as part of inspection) Comments: (note condition of soil,signs of hydraulic failure,level of pon ' g,condition of ve etation,recommendations for maintenance or repairs,etc.) Z o., , s 6,- s c,h -A PRIVY: ^I 4Z (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,recommendations for maintenance or repairs,etc.) Page 4 of 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION continued SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' 5 d � Say DEPTH TO GROUNDWATER depth to groundwater — adjusted high groundwater level method of determination or approximation: &y 1 ti K O W cl Tf.✓ ✓ t.t� T� 7 c� v� 7 I I Page 5 of 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C FAILURE CRITERIA Indicate yes, no or not determined(Y,N, or ND). Describe basis of determination in all instances. If"not determined", explain why not) Backup of sewage into facility? JV Discharge or ponding of effluent to the surface of the ground or surface waters? A A Static liquid level in the distribution box above outlet invert? IV Liquid depth in cesspool<6"below invert or available volume< 1/2 day flow? Required pumping 4 times or more in the last year? Number of times pumped Septic tank is metal?cracked? structurally unsound? substantial infiltration? substantial exfiltration?tank failure imminent? Is any portion of the SAS, cesspool or privy: below the high groundwater elevation? Al within 50 feet of a surface water? I l� within 100 feet of a surface water supply or tributary to a surface water supply? /V within a Zone I of a public well? within 50 feet of a bordering vegetated wetland or salt marsh(cesspools and privies only, not the SAS)? N within 50 feet of a private water supply well? 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. Page 6 of 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART D CERTIFICATION Name of Inspector: Troy Williams Company Name: TROY WILLIAMS SEPTIC INSPECTIONS Company Address: 40 Old Bass River Road, South Dennis, MA 02660 Certification Statement I certify that I have personally inspected the sewage disposal system at this address and that the information reported is true, accurate and complete as of the time of inspection. the inspection was performed and any recommendations regarding upgrade, maintenance and repair are consistent with my training and experience in the proper function and maintenance of on-site sewage disposal systems. Check one: --\ZI have not found any information which indicates that the system fails to adequately protect public health or the environment as defined in 310 CMR 15.303. Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form. I have determined that the system fails to protect public health and the environment as defined in 310 CMR 15.303. The basis for this determination is provided in the FAILURE CRITERIA section of this form. Inspector's Signature, Date Original to system owner Copies to Buyer(if applicable) Approving authority PROPERTY ADDRESS: a6 i 5<- 4 11 . i slk Page 7 of 7