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HomeMy WebLinkAbout0072 STERLING ROAD - Health 72 Sterling Road, Hyannis U 1 o h TOWN OF BARNSTABLE ✓ G LOCATION 7 �-- L't^-e .G« SEWAGE # 7 L1 VILLAGE - ^JL-n ASSESSOR'S MAP &LOT 3 A L ,1pL INSTALLER'S NAME&PHONE NO. ` b2 "v SEPTIC TANK CAPACITY t 0 6 .:t - 3 Sr 2- (r LEACHNG FACILITY: (tyre) (size) NO.OF BEDROOMS 221 BUILDER OR OWNER U e-0 fA- 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) /,,l,�--Feet Edge of Wetland and Leaching Facility(If any wetlands exist � � within 300 feet of leaching facility) �� � Feet Furnished by �JJ � oz (/U Ap r� I � 11 lad , . .. No. 1 Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer. Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS ZippYtcatiou for Migaar *pztem Cow5tructiou Permit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) El Complete System O Individual Components Location Address or Lot No. Owner's Name,Address and Tel.No. Assessor's Map/Parcel �h -GZ4-6. sue' `e Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size e a sq. ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 3 3 y gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank CJ Type of S.A.S. L Description of Soil Nature 4 Repairs or Alterations(Answer when applica le) .j .� X Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of isle 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by t s oard of Hoth. q Signed c Date Application Approved by Date Application Disapproved for the following reasons Permit No. Date.Issued 'i�yn. r.•Y3. r. 1'j 3 -.{t, �f- .�`+'` 4 4 . }'....,„,'v .s 'Vry t�_r". _ 1 w ... -. r No. 97 Fee ; THE COMMONWEALTH.OF MASSACHUSETTS \ Entered in computer: 1� Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS ZIppfication for Mi5 aar *p.5tem Construction J)ermit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components f Location Address or Lot No. Owner's Name,Address and Tel.No. Assessor's Map/Parcel 111 01w, Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. j a Type of Building: Dwelling No.of Bedrooms _ Lot Size sq. ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) l Other Fixtures a Design Flow 3 - � gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date .t Title i Size of Septic Tank /�GfJ U Type of S.A.S. Description of Soil Nature oS Repairs or Alterations(Answer when applicable) � p 1 � :3 6, X �— Date last inspected: is Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certify- cate of Compliance has been issued by t s,, oard of Huth. q Signed Date ` s APplication.Approved by- Date Application Disapproved'for the following reasons N Permit No. Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance,' THIS IS TO CERTIFY, that the On-site Sewage Disposal.System Constructed( )Repaired�pgraded( ) Abandoned( )by at led has been constructed in accordance with the provisions of Title 5 and the for Disposal System Constniction Permit No. dated ." ~* Installer `i P Designer The issuance of this permit shall not be construed as a guarantee that the system will function as designed. Date rl r, rn~'7 Inspector No. �-il' -------Fee , THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS e Migw6al *pgtem CongtructiorifVermit Permission is hereby granted to Construct )Repair( `j'IJpgr de ) bandon System located at and as described in the above Application for Disposal System'Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided: Con truction must be completed within three years of the date of this permit. Date: 2 -Il Approved by TOWN OF BARNSTABLE G LOCATION 2— t'�-C P�J SEWAGE # VII,LAGEI�,�.�—!1 ASSESSOR'S MAP & LOT 1��I dOL INSTALLER'S NAME&PHONE N0. 1 SEPTIC TANK CAPACITY I b v LEACHING FACILITY: (type) 3 �- (size) NO.OF BEDROOMS 3 BUILDER OR OWNER �L U PERMITDATE: �1- 1-L{ n 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) `"'''-1 Feet Edge of Wetland and Leaching Facility(If any wetlands exist �l6.1 within 300 feet of leaching facility) Feet Furnished.by NOTICE: This Form is to be used for the Repair of Failed Septic Systems Only CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANS) hereby certify that the application for disposal works construction permit signed by me dated 2 — 2 Y-/ 7 , concerning the property located at meets all of the following criteria: • There are no wetlands within 300 feet of the proposed septic system • There are no private wells within 150 feet of the proposed septic system • The observed groundwater table is 14 feet or greater below the bottom of the leaching facility • There is no increase in flow and/or change in use proposed • There are no variances requested or needed. SIGNED : DATE: /0 �LICENSED S4YSTEMSTALLER IN THE TOWN OF BARNSTABLE NUMBER [Attach a sketch plan of the proposed system.Also if the licensed installer posesses a certified plot plan, this plan should be submitted]. jxert �'J r �S Q �� • J 'l 1 ,, I�\ C `�, 1 Vn" V� i ova DATE: _ 1 /29/97 PROPERTY ADDRESS: :72 Sterling- Road. Hyannis ,Mass . 02601 On the above date, 1 inspected the septic system at the above address. This system consists of the following: 1 . 1 -1000 gallon septic tank. 2: 1 -1000 gallon precast pit. Based bn my Insrwctlon, I certify the following conditions: 1 . This is a title five septic system. ( 78 Code. ) .2. The septic system is in failure . 3 . . The leaching_pit is more__than,.j,,,full at the ,3 present. 5he..tisystemYwa,s •puhp_ d, in Auglust�of y1996.; Six-monthd� later=tthe p '•t .is, more than half' full. There is je ly one occupant: TYierfore we must fail the system and' ommend that the existing system upgrad � . " "``-` SIGNATURE: Name: J. P.Macomber Jr.. i C6mpany: J. P_MacoMber & Son-Inc .. , Address:_ _�g______3___,__ Cente�rvi11e LMass__02-632 Phone:---54& 7J5_333a------- - I THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY FFECEIVED F E B 7 199Z JOSEPH P. MACOMBER & SON, INC. Tanks-Cesspools-Leachflelds HEAM DZPT. . Pumped & Installed TOWN OF BARNSTABLE Town Sewer Connectlons P.O. Box 66' Centerville, MA 02632-0066 775.3338 775-6412 T Ul Commonwealth of Massachusetts ExecufNe Office of Environmental Affairs Department of nvironmental Protection Trudy Cox* e«��r David 13. Struhs u taowr... Cgrtve�ialoner e SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A . CERTIFICATION PropertyAddre..: 72 Sterling Road Hyannis ,Mass . Address of owner. Date of loapectlon.1 /29/97 (It different) Name ofI-PactorJoseph.P.Macomber Jr. Company Name,Address and Telephone Number. J.P.Macomber & Son Inc. Box 66 Centerville ,Mass . 02632 508-775-3338 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 u of the time of inspection. The inspectoo my training and experience in the proper function and mainwns.n of on•aite dis a system: s Conditionally Passes �No*ds_Further Evaluation By the Local Approving Authority FatL Iaspecto 9ignat Date.- The System Inspector bmit a Dopy of this inspection report to the Approving Authority thirty(30)days of completing this inspection. If the eystem is a s m or has a design flow of 10,000 gpd or Brea a inspector and the system owner shall submit the report to the appropriate regional office of the Dep rotsctiOn. The original should be sent to the system owner.wd copies sent to the buyer, if applicable and the approving authority. VNSPECTION SUMMARY: Check A, B. C, or D: A) SYSTEM PASSES: I have not found arty information which indicates that the system violates say of the failure criteria at in 310 CUR 15.303. 'C�LT�Any failure criteria not evaluated are indicated below. B) SYSTEM CONDITIONALLY PASSES: ,�'n One or more system components used to be replaced or repaired. The system,upon completion of the replacement or repair, passes inspection. Iodtests 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, cra:ked, structurally unsound, shows substantial infiltration or exiiltration,.or task failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by tL. Board of Health. (revised 11/03/95) 1 One Winter Street a Boston, Massachusetts 02108 a FAX(617) SW1019 a Telephone (617)292.5soo t'3 Pam„ied on R"Wd Pao.. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) PropertyAddresa: 72 Sterling Road Hyannis ,Mass . Owner. Mary Chuculate Date of Inspection: 1 /2 9/9 7 B)SYSTEM CONDITIONALLY PASSES(continued) �i Sewage backup or breakout or huh static water level observed in the distribution boat is due to broken or obstructed pipe(s) or due to a broken,settled or uneven distribution boat. The system will pass inspection if(with approval of the Board of Health): broken pipes)are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four times a 9 _due.to:bro4n or,obstr ucted,pips(s). The system will pass inspection if(with approval of the Board of Health):f� loir� (0 broken pipe(s)are obstruction is removed Cl FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: All? 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 60 feet of a bordering vegetated wetland or a salt marsh. 3) 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 water supply or to a surface water supply. �Q The system has a septic tank and soil absorption system and is within a Zone I of a public water supply well. t` The system has a septic tank and soil absorption system and is within 60 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 that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 6 ppm. S) OTHER (revised 11/03/95) 2 • 1 . SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Owner. Date of lnspeotion: f D) SYSTEM FAILS I have determined that the system violates one or more of the following failure criteria as definsd in 310 CMA 15.303. The basis for this determination is ideatiSed 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. A20 Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or �� cesspool. +�wJ-',Static liquid laystin the4istribution box above outlet invert due to an overloaded or clogged SAS or cesspool. wit tq�r Liquid depth is leas than 6"below invert or available volume is Is"than U2 day flow. RequirW pumping more than 4 times in the last_year_NOT_due to clo r_obsrtructed-pipe(s).,.._l—, Number of times pumpedt� /yy�u (S 19�i ! ' _—'�W r¢, _ - "t Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elsvation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. /2 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 60 feet of a private water supply well. Arty portion of a cesspool or privy is less than 100 feet but greater than 60 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 ooliform 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: NV The system Mrvw 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: A/9 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 U 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 6.00 and 6.00. Please consult the local regional office of the Department for!hither information.. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 72 Sterling Road Hyannis ,Mass . Owner. Mary Chuculate e Date of Inspection: 1 /2 9/9 7 Check if the following have been done: ZPumping information was requested of the owner,occupant,and Board of Health. None of the system compona4ts have been pumped for at least two weeks and the system has been receiving normal slow rates /during that period. Lame volumes of water have not been introduced into the system recently or as part of this inspeeti= �Y As built plans have been obtained and esaminsd. Now if they are not available with N/A. The facility or dwelling was inspected for signs of"wags back-up. The system does not receive non+anitary or industrial waste flow ZTh,site was inspected for sips of breakout. All,system components,9duding 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 bafn or tow material of construction,dimensions, depth of liquid,depth of sludge,depth of scum. '4 I'h.aim and location of the Soil Absorption System on the site has been determined based on edsting information or approximated by non-intrusive methods. ba facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of 3ub- Surfaa Disposal System. (revised 11/03/95) 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION PropertyAddreas: 72 Sterling Road Hyannis ,Mass . 02601 Owner. Mary Chuculate Date of Inspeotiow 1 /29/97 FLOW CONDITIONS RESIDENTIAL- Deep flow ns z'►''dpf Number of bedrooms: -Z 1 Number of current residents Garbage grinder(yes or no):I Laundry connected to system(,yes or no): Seasonal use(yes or no):jzjQ % Wate ,if availabls• 4l Je Last date of occupancy:��/ C O M M ERC L41/I ND US TRIAL Type of establishment: dzd Design flow: ns/dey Grease trap present: (yes or no)4,2 Industrial Waste Holding Tank present: (yea or no), Non-sanitary waste discharged to the Title 5 system: (yea or no)&* Water meter readings, if available: f Last date of occupancy: VA OTHER(Describe) A24 Last date of occupancy: A/J GENERAL INFORMATION PUMPING RECORDS d urge of information: & System pumped as part of inspection: (yes or no) If yea,volume pumped: /¢ ns Reason for pumping: TYPE 0 SYSTEM Septic taak/dislsi bcadsoil absorption system VL Single cesspool . . 00 Ovarilow Cesspool A)0 Privy Shared system(yes or no) (if yea, attach previous inspection records, if any) —d2et Other(explain) APPROIQMATE AGE of all components, date ia,talled(if known)and source of information: X;141 J)Aoxl Sewage odors detected when arriving at the site: (yes or no),&L[) (revised 11/03/95) 6 r r _ SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART G • ' SYSTEM INFORMATION (continued) Property Address: 72 Sterling Road Hyannis ,Mass . 02601 Owner. Mary Chuculate Date of Inspection: 1 /29/97 SEPTIC TANK:-z'Mp- 'V (locate on site plan) Depth below grade:�L ct io material of construn: &oncrete _metal _FRP _other(explain) Dimensions:_ ' Sludge depth: Distance from top oLiludge to bottom of outlet tee or baffle:z,. Scum thickness: Distance from top of scum to top of outlet tee or baffle: e �'Q Distance from bottom of scum to bottom of outlet tee or baffle. Comments: (recommendation for pumping, condition of inlet and outlet tees or baffle. depth of liquid level in relation to outlet invert, structural •rity, evidence of leakage, etc.) . Pump Septic lank every 3 SEPa_-rs ; tn,) el & —Qilt.l ArP i n p] a eP ;Tj =ui (i 1 PVPI nut i nvPr_t. ice_ 51,1�ShP t.arik lS GREASE TRAP. 4)4*f (locate on site plan) Depth below grade:.;V* material of cons(riini�-X—)'4:oncrete _metal _FRP —other(explain) Dimensions; Scum thickness: Distance from top vt scum to top of outlet tee or baffle:.JA Distance from bottom of srum in honnm of outlet tee or baffle:_ Comments: (recommendation for pumping, condi—n of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, struaural integrity, evidence of leakage, etc i��^� Grease zrap Is o (:.vlsed 1/15/9$) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(000tiaued) pr,p.rtyAd&..,. 72 Sterling Road Hyannis ,Mass . 02601 Olm"; Mary Lhuculate Data of Inspeotlon:1 /2 9/9 7 TIGHT OR HOLDING TANK.&(We (loafs ca sit.plan) Depth below grads: MaterW of construetioa: oaa+te_metal_FRP_othsr(=plaia) Dimensions: A1,,4 Capacit7: A)h sstlloaa Design flow ns/day Alarm levei: AM Commeate: (condition of inlet we,condition of alarm and aoat switch", etc.) Tight or holding tank arP not. =rP-,Pnt_ DISTRIBUTION BOX:A� (locate on site plea) Depth of liquid level above outlet invert:�� Comments: (note if level Lad diet*ution is equal,evidence of solids carryover,evidsacs of leeks Cato or out of bo:,stc.) Distribution box is not present PUMP CRAMBER:.AbVe— (louts on site plan) Pumps is working order.(y"or ao) L Commsats: (note condition of pump c),amber, condition of pumps sad appurtaaaaces,etc.) (revised 11/03/95) 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner. Date of Inspection: ,/ SOIL ABSORPTION SYSTEM(SASxL�d,Aa•L) Uocate an she plan,if possibL;excavation not required,but may be aPPradmated by non-intrusive methods) If not determined to be present,.:plain-.e Type. lemebi pits, _� Lachim chambers,number: 1 leaalring gallaiee,number: 7 leaching trenches,number,length: leaching tieW number,dime overtlow cesspool,number. Comments:(note condition of soil,alps of hydraulic failure,level of n�,conolt,on Medium sand to sand n_s o_ravel-No faun f =hy_drau�ii" aniolau , , _system was 'filled to capacity 8 15/96. Pit is 07e—rF luiiaz Tma TrogAn+ t.; mp. 7— n1 low water usea e ys' em s ou e ,:::�u radCESS _pit is in ovious failure. M.(locate an site plan) Number and configuration: �iJ1Q Depth-top of liquid to inlet invert: Depth of solids layer- rA Depth of scum layer. ) Dimensions of caspooL• Material-of construction: Indication of groundwater: 91/A inflow(oaspool must be pumped as part of inspection) AIA A),9 A) 4 Comments:(note condition of soil,signs of hydraulic faihuw,level of ponding,condition of vegetation,etc.) CPczgr)no1 R Ar.p not. present_ PRIVY-dE (loaf.an site place) Materials of constru Lion. AA Dimensions:_ Depth of solids: _ Commsnts (note condition of sell,aigms of hydraulic failure,level of pending;condition of vegetation,etc.) --pri" :s netprese1;t (revised 11/03/95). 8 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION ,PORM PART B SYSTEM INFORMATION continued SKETCH OF SEWAGE L'_SPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100 ' Hyannis Water Company 775-0063 0 J i i i -7 s re,< Al 6 d. DEPTH TO GROUNDWATER 141 + depth to groundwater r+pthod of determination orb r xim ti See 'P1�n-��h fil9 Berns �.�i�� ar : DIealth. 'V � I .•wr[fSTw.-n.-rtf'r7- swrarn•ntPrnr"nn rrRrRr:�•rTnrrrrRRnRlnsraftAr-n�strt I TOWN OF Barnstable BOARD OF HEALTH 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART D •- CERTIFICATION I �� �«.1..7«�...:.t-T.lif.«.�rr4ls T.'111'.,.1l11"!1T111i'.If1T•'1'I:r-.•.'I rsvin-7arRst-T�feRwllRt�'TR7 ,nn ..-.rer•r--1.-..A -TYPE OR PRINT CI.EARLY- PROPERTY INSPECTED STREET ADDRESS 72 Sterling Road Hvannis .Mass . 02601 ASSESSORS MAP, BLOCK AND PARCEL # OWNER' s NAME Mary Chuculate PART D - CERTIFICATION NAME OF INSPECTOR Joseph P.Macomber Jr. COMPANY NAME J.P.Macomber & Seon • Inc . COMPANY ADDRESS Box 66 Centerville ,Mass . 02632 Street Town or City State LIP COMPANY TELEPHONE ( 508 775 - 3338 FAX ( 508 ) 790 _ 1578 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: System PASSED The inspection which I have conducted has 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. :XXXXXXXXX System FAILED* The inspection which I have con -acted has found that the system fails to protect the public health and the environment in accordance with Title 5 , 310 CMR 15 . 303, and as specifically noted on PART C - FAILURE CRITERIA of this inspection form . V1 Inspector Signature Date 2/4•/97 One copy of this certification must be provided to the OWNER, the BUYER ( where applicable ) and the I30ARD OF HEAL1'il. +' If the inspection FAILED, the owner or "o«operator shall up grade pgrade ' the system within one year of the date of the inspection, unless allowed or required otherwise as provided in 3.10 Chjn 15 . 305 . partd .doc w f ti THE COMMONWEALTH OF MASSACHUSETTS DEPARTMENT OF ENVIRONMENTAL PROTECTION BE IT KNOWN THAT Joseph P. Macomber, Jr. Has satisfied the Department's qualifications as required and is hereby authorized to use the title CERTIFIED TITLE 5 SYSTEM INSPECTOR as provided in 310 CMR 15.340 and Section 13 of Chapter 21A of the General Laws. Issued by The Department of Environmental Protection. June 8, 1995 Acting Director of the ion of Water Pollution Control Commonwealth of Massachusetts Executive Office of Environmental Affairs Department of Environmental Protection OCT q 1996 VMlam F.weld HEALTH 1) Gxe cio�ma Argeo Paul Glluccl �OF i �•� U.Govemor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A ,� o ,/CERTIFICATION Property Address: ?Z s� L.c.® Address of Owner. Date of Inspection: "2�-4'(� (If different) Name of Inspector. Company Name,Address°'d Telephone Number. ,742 Te_g 120 C_&- Pei y t_kKu Si�AP�-e 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'aced maintenance of on-site sewage disposal systems. The system: e-iPasses _ Conditionally Passes _ Needs Further Evaluation By the Local Approving Authority F ,. Inspector's Signature: L% -�s. Date: The System Inspector shall mit 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: Al 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. B) SYSTEM CONDITIONALLY PASSES: One or more system components used 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 exfiltrstion,.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 11/03/95) I One winter Street a Boston,Massachusetts 02108 a FAX(617)SWID49 a T*Wphone(617)292-UN 0.1 P...d R.-WWd Paper i \ .t r ' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address:- Owner. Date of Inspeetioa: B)SYSTEM CONDITIONALL - A ISES (continued) Sewage backup reakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, ttled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health): , broken pipe(&)are replaced obstruction is removed distribution box is levelled or replaced The system required pump' more than four times inspection if(with approval o e Board of Heal ayyear due to broken or obstructed pipe(a). The system will pass b en pipe(s) placed obst ction is moved C) FURTHER EVALUATION IS REQUIRED B BOARD OF HEALTH: Conditions exist which require further aluation the Board of Health in order to determine if the system is failing to protect the public health, safety and the enviro ent. 1) SYSTEM WILL PASS BOARD OF HEAL DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL P OTECT THE PUBLIC H TH AND SAFETY AND THE ENVIRONMENT: Cesspool or pri is within 50 feet of a surface wate Cesspool or p vy is within 50 feet of a bordering vege ted wetland or a salt marsh. S) SYSTEM WILL F L UNLESS THE BOARD OF HEALTH PUBLIC WATER SUPPLIER,IF APPROPRIATE) DETERMINES T THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND 9AF1r"I'Y AND HE ENVIRONMENT: .. The system has a septic tank and soil absorption system and 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 is within a Zone I 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 that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or leis than 5 ppm. 3) OTHER (revised 11/03/95) 2 i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM I PART A CERTIFICATION(continued) Property Add s: "T Z Owner. Date of Inspection: —egg D) 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. Discha ge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or Cesspool. Static li�uid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid dep in cesspool is less than 6"below invert or available volume is less than 1/2 day flow. Required pum ' more than 4 times in the last year NOT due to dogged or o ructed pipe(s). Number of times umped Any portion of the ` Absorption System, cesspool or privy is bel the high groundwater elevation. Any portion of a cesspool r privy is within 100 feet of a ace water supply or tributary to a surface water supply. Any portion of a cesspool or i is within a Zone f a public well. Any portion of a cesspool or pri is within feet of a private water supply well. Any portion of a cesspool or privy is than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic mpo ds,ammonia nitrogen and nitrate nitrogen. El LARGE SYSTEM FAILS: The following criteria apply to ge systems in addition to a criteria above: The system serves a with a design flow of 10,000 gpd o ter(Large System)and the system is a significant threat to public health and safety-and environment because one or more of following conditions exist: the is within 400 feet of a surface drinking water zu ly the in is within 200 feet of a tributary to a surface drialda water supply system is located in a nitrogen sensitive area(Interim Wellhead Protection Area(IWPA)or a mapped Zone U of a public water supply well) The owner 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 11/03/95) 3 f ` SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ' PART B CHECKLIST Property Address: Opener. Date of Inspection: Check if the following have been done: ping information was requested of the owner,occupant,and Board of Health. one 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. built plans have been obtained and examined. Note if they are not available with N/A. vThe facility or dwelling was inspected for signs of sewage back-up. fi-The system does not receive non-sanitary or industrial waste flow he site was inspected for signs of breakout. "system components,excluding the Soil Absorption System,have been located on the site. ,_ a 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 sise and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods. C//_Thefacility owner(and occupants, if different from owner)were provided with information on the proper maintenance of Sub- - Surface Disposal System. (revised 11/03/95) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: Z Owner. Date of Inspecti • 15-29— tG RESIDENTIAL- FLOW CONDITIONS Design flow: 5=i4 sallow Number of bedrooms- 'Z— Number of current sr�w ;;id..—.:ta: I Garbage grinder(yes or no):-AA'X' Laundry connected to system(yes or no):-92e Seasonal use(yes or no):A:2 Water meter readings, if available: Last date of occupancy: COMMERCIALANDUSTRIAL: Type of establishment- Design flow:_gall �dayGrease trap present: (yes Iadustrial Waste Holding t: (yes or no)_ Non-sanitary waste discharged to the Ti m: (yes or no) Water meter readings, if available: Last date of occupancy: — OTHER.-(Describe) Last date of a panty: GENERAL INFORMATION PUMPING RECORDS and source of information: System pumped as part of inspection: (yes or no)_ If yes,volume pumped:.4©C542 ¢allons ., Reason for pumping: r2 �J TYPE OF e taalddiatribution boslaoil 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)and source of information AQ 7/ ` Sewage odors detected when arriving at the site:(yes or no) Vtl;) (revised 11/03/95) 6 t � e r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C �+ 9 SYSTEM INFORMATION (continued) Property Address: —7 Ad Owner. f/ Date of Inspection: • / SEPTIC TANK (locate on site plan) Depth below grader Material of construction: 't-trnciete_metal_FRP_other(e:plain) Dimensions: 41 A to Sludge Distance from top of sludge to bottom of outlet tee or baffle: -1P Scum thickness: U �� Distance from top of scum to top of outlet tee or baffler Distance from bottom of scum to bottom of outlet tee or baffle: 6=7 Comments: (recommendation for pumping, can ' 'on of' et and outlet or baffles,depth of liquid level in 719tion to outlet invert,structural' tegri evide ce of leakage ) GREASE TRAP: -- - (locate on site plan_) Depth below grade: Material of construction: concrete_metal_FRP_other(explain) Dimensions: Scum thickness: Distance from top of scu5, condhition utlet tee or Distance from bottom ofom of out or baffle: Comments: _ (recommendation for pump' of inlet and outlet tees or baffles,depth o • •d level in relation to outlet invert,structural integrity, evidence of leakage, r (revised 11/03/95) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(oontinued) Property Addn aw 47 Z Owner. Mq4A4 Date Of Inspeotlon.Y TIGHT OR HOLDING TANK_ (locate on site plan) Depth below grade: Material of construction:_concrete_metal_FRP—other(explain) Dimensions: / Capacity: gallons • Design flow: %condhtionof / Alarm level: Comments: (condition of inlet tee, nd float switches ) DISTRIBUTION BOX— (locate(locate on site plan) Depth of liquid,level above outlet ' vert: Comments: (note if level and distnlmti is equal,evidence of solids carryover,a 7 'dence of leafage into or out of box,etc.) PUMP C ER_ \ (locate on plan) l Pumps wrrfiag order:(yes or no) �\ Comments: (note condition of pump chamber,condition of pumps and appurtenances,etc.) (revised 11/03/95) 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: -7 S Owner. Dane of Inspection: SOIL ABSORPTION SYSTEM (SAS): C� (locate on site plan,if possible;excavation not required,but may be approximated by non-intrusive methods) If not determined to be present,explain: leaching pits,number:-..,/— leeching chambers,number: v leaching galleries,number: leaching trenches,number,length: leaching fields,number, dimensions: overflow cesspool, number: Ii Comments:yiototcondition of soil, signs of hydraulic failure, level of po ding, condition Qf vegetation etcJ CESSPOOLS:_ (locate on ate plan) 1 Number and configuration: Depth-top of liquid to inlet b ert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater: inflow(cesspool must be pumped as of inspection) Comments: (note condition of soil, signs of h �fau�re, el of ponding,condition of vegetation,etc.) PRIVY:_ (locate on site p Materials construction: Dimensions: Depth solids' Ants:(note condition of soil,signs of hydraulic fadhire,level of pending, of vegetation,etc.) (revised 11/03/95) 8 • 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property.Address: "( �L- gta, d Owner: Date of Inspection. ` SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' l� 3Z DEPTH TO GROUNDWATER Depth to groundwater./-feet method of determi tion or approxi tion: s tsevlsed a/IS/95) 9 LZ.&- . N h.. • _ _ ,. n. "d'._ .::,~3 <. _,. .-.r,:"n'3�xw,...,.„.., �,_f .`.c<�;�"° ..'� ,vim