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Home My WebLink About0043 BLANID ROAD - Health EBlanid Road, Osterville Commonwealth of Massachusetts Executive Office of Environmental Affairs Department. of Environmental Protection William F.Weld Trudy Cox* saww K secw" Argeo�Paul Cellucci David B.Struhs LL r cane i..ionw SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOR a0 PART A �/M RECEI ® CERTIFICATION Property Address: (j 3T Address of Owner. AUG 8 1997 Date of Inspection: _ 2v _ Q •7 (If different) HEALTH DEPT. Name of Inspector. [ TOWN OF BARNSTADLE Company Name,Address and Telephone Number. CER ATRIOTV'S'I'ATEME /� � -C�� ` 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: -L'I'-Passes Conditionally Passes Needs Further Evaluation By the Local Approving Authority _ FZ -7 Inspector's Signature: r...: ba 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. i INSPECTION SUMMARY: � I %heck A,B, C,or D: i Al SYSTEM PASSES: �Ive t 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) ' he septic tank is metal, cracked,structurally unsound,shows substantial infiltration or exiiltration,.or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a yonforming septic tank as approved by the Board of Health. (revised 11/03/95) I One Winter Street • Boston,Massachusetts 02109 • FAX(617)556.1049 • Telephone(617)292-5600 Printed on Recycled Paper 1 �• .s SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: Owner. Date"of Inspection: 81 SYSTEM CONDITIONALLY PASSES (continued) backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) ry t.or du`e,to a,broken,settled or uneven distribution box. The m will pass inspection if(with approval of the Board of broken pipe(a)are replaced f obstruction is removed distribution box is leve ed or replaced —The systems pumping more than four • es a year due to broken or obstructed pipe(s). The system will pass inipection,if(wit proval of the Board of ealth): broken pipe(s are replaced obstruction ' removed C1 FURTHER EVALUATION IS REQUIRED B BOARD OF HEALTH: Conditions exist which require further aluation by a Board of Health in order to determine if the system is failing to protect the public health,safety and the enviro nt. 1) SYSTEM WILL PASS UNLESS ARD OF HEALTH D INES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PRO T THE PUBLIC HEAL AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is thin 50 feet of a surface water Cesspool or privy is 'thin 50 feet of a bordering vegetated wet d or a salt marsh:' 2) SYSTEM WILL FAIL S THE BOARD OF HEALTH (AND PUB WATER SUPPLIER,IF APPROPRIATE) DETERMINES THAT E SYSTEM 1S FUNCTIONING IN A MANNER T PROTECT THE PUBLIC HEALTH AND SAFETY AND THE RONMENT: The syste a septic tank and soil absorption system and is within 100 feet a surface water supply or tributary to a surface r supply. The in has a septic tank and soil absorption system and is within a Zone I of a blic water supply well. The m has a septic tank and soil absorption system and is within 50 feet of a private water supply well. The in has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water su p well,unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. 3) OTHER r (revised 11/03/95) 2 w f� • a SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: Owner. Date of Inspection: 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 i tified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Backup of sewage ' facility or system component due to an overload or clogged SAS or cesspool. Discharge or ponding of uent to the surface of the ground or ace.waters due to an overloaded or clogged SAS or cesspool. Static liquid level in the distri ion box above outlet inv due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less t 6"below invert r available volume is less than 1/2 day flow. Required pumping more than 4 tines the year NOT due to clogged or obstructed pipe(,). Number of times pumped Any portion of the Soil Absorption Sys sspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy ' 'thin 1 0 feet of a surface water Supply or tributary to a surface water supply. Any portion of a cesspool or pri is within a e I of a public well. Any portion of a cesspool or rivy is within 50 f of a private water supply well. Any portion of a cesspool r privy is less than 100 f but greater than 50 feet from a private water supply well with no acceptable water qua it analysis. If the well has been ed to be acceptable, attach copy of well water analysis for coliform bacteria,vola a organic compounds,ammonia 'trogen and nitrate nitrogen. El LARGE SYSTEM FAILS: ' The following criteria ap ly to large systems in addition to the criteria abo The system serves a cility with a design flow of 10,000 gpd or greater(Large ystem)and the system is a significant threat to public health and safety the environment because one or more of the following con 'tions exist: the m is within 400 feet of a surface drinking water supply the m is within 200 feet-of a tributary to a surface drinking water supp the system is located in a nitrogen sensitive area(Interim Wellhead Protection (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 f4u 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 1 s SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: Omer cpct Date of Inspection: 4�cq Check if the following have been done: l j f u ping information was requested of the owner,occupant,and Board of Health. .L-Ione 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. The facility or dwelling was inspected for signs of sewage back-up. {11�he system does not receive non-sanitary or industrial waste flow jJi'be site was inspected for signs of breakout. All system components,excluding the Soil Absorption System, have been located on the site. ZThe 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 existing information or approximated by non-intrusive methods. 'he facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of Sub- Surface Disposal System. (revised 11/03/95) 4 l F . SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: C�3 Owner. Date of Inspection: RESIDENTIAL: FLOW CONDITIONS Design flow: 33 V gallons Number of bedrooms: Number of current residents: Garbage grinder(yes or no):...eZ.0 Laundry connected to system or no):—V-S::7 Seasonal use(yes or no):- Water meter readings, if av#4&ble: Last date of occupancy: 1 COMMERC UIL/INDUSTRIAL: Type of establishment: Design flow:_gallons/day Grease trap p or no)_ Industrial Waste Ho no) Non-sanitary waste discharged to the Title 5 system: (yes or n Water meter readings,if available: Last date of occupancy: OTH date of occupancy: r GENERAL INFORMATION PUMPING RECORDS and source of informaJQn: System pumped as part of inspection: (yes or no)AII�j If yes,volume pumped: gallons Reason for pumping. TYP�TEM ptic tank/distribution boxlsoil 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: 1Ulsi1- :u Sewage odors detected when arriving at the site: (yes or no) (revised 11/03/95) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) (continued) Property Address: 3 V Owner. 1-ncrtb c� Date of Inspection: SEPTIC TANK:LJ (locate on site plan) Depth below grade: Material of construction:_�:0 crete_metal_FRP_other(ezplain) Dimensions: k Sludge depth: D s� Distance from top of sludge to bottom of outlet tee or baffle: Za Scum thickness: ?-- i•) Distance from top of scum to top of outlet tee or baffle: b r Distance from bottom of scum to bottom of outlet tee or baffle:_ Comments: (recommendation fof pumping, con 'tion of' t and outlet tees orjbaf1jps,depth of liquid level in relation to outl vert, structural fn grity, evidence leakage, etc1L. GREASE TRAP:_ (locate on site plan) Depth below grade: Material of construction:_ to_metal_FRP_other(ezplain) Dimensions: Scum thickness: Distance from top of scum to top of outl or Distance from bottom of scum to m of outlet tee or Comments: _ (recommendatio pumping,condition of inlet and outlet tees or baffles,dep f liquid level in relation to outlet invert,structural integrity, evidence of leakage,etc.) r (revised 11/03/95) 6 I a SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property AddresxK 3 3� Owner. Date of Inspection: TIGHT OR HOLDING TANK:_ (locate on site plan) Depth beiow_grade: Material of construction:_concrete_metal_FRP_other(explain) Dimensions: Capacity: aalloas .., , Design flow: pllona/day Alarm level: Comments: ° (condition of inlet tee ndition of alarm and float switches,etc.) . I DISTRIBUTION BOX: (locate on site plan) Depth of liquid level above outlet invert: Comments: (note if level and distnIrAion is equal, evidence of solids carryover,evidence of leafage into or out of box,etc.) PUMP CHAMBER:_ (locate on site plan) Pumps in working order:(yes or no) Comments: (note condition of pump chamber on of pumps and appurtenances,etc.) (revised 11/03/95) 7 , Il ' • 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ! PART C SYSTEM INFORMATION(continued) Property Address: t{7j Q Owner. Date 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: Type: leaching pits, number:—l COV O leaching chambers, number:_ leaching galleries, number: leaching trenches, number,length: leaching fields, number,dimensions: overflow cesspool,number: A/ c omme ts: (note edition of soil,signs of ydrauli vel of ponding, condition of ve tion, " C CESSPOOLS:_ (locate on site plan) Number and cor\nfigurttt' r Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: - Indication of groundwater: inflow(oesspoo] be pumped as part of inspection) Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation, etc.) PRIVY:_ (locate on site plan) - Materials of construction: Dimensions: Depth of solids: Comments: (note condition of soil, of hydraulic failure,level of po tion of vegetation,etc.) j (revised 11/03/95) 8 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: /1,76--2Z Date of Inspection: G SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' l � d - 33 DEPTH TO GROUNDWATER Depth to groundwater. feet O method of dete inati rt or app ximation: (revised 8/15/9S) 9 TOWN OF BARNSTABLE LOCATION �1.a4NO SEWAGE # VILLAGE6� ASSESSOR'S MAP & LOT INSTALLER'S NAME & PHONE NO.� �d� .f�/ SEPTIC TANK CAPACITY LEACHING FACILITY:(type) I (size) —�7)6 NO. OF BEDROOMS PRIVATE WELL O PUBLIC WATER- BUILDER OR OWNER DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No .__ .�_ _. ��- d i _ _ �.� � I ��_� � �� i ', � ` - i `r' _ � � i 1 � -- � �� , , Y } , i -7 THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF YaMOMH Appliration for Disposal Warks Tonstrudivit frrutit Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal, system at: 1,7zlelvo ............... ............................ ............................................................................................. L or Lot No. vRr J/�� '/7 .. . ........................................................... ......re------- ..................................................... -ner Address ........ .......J� ...................................................... .... ............................................... Installer Address Type of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms.......,2..........................Expansion Attic Garbage Grinder ( ) py Other—Type of Building ............................ No. of persons.........__-__-___-___-..... Showers Cafeteria ( ) Other fixtures ..............................................................................;...................................... ..........*--------------- Design,Flow...I/:4 uv--------------------gallons per person per day. Total daily flow..............................**...........-gallons. Septic Tank—Liquid capacity............gallons Length................ Width................ Diameter.......__..._._. Depth__._.._......... ....Disposal Trench—No..................... Width................... Total Length.............._..... Total leaching area...................sq. Seepage Pit No...................../ Diameter.-V-•th2l. Depth below inlet.....Y------------- Total leaching area..................sq. ft. Z Other Distribution box ( ) , Dosing tank ( ) aPercolation Test Results Performed by....,.................................................................... Date........................................ Test Pit No. I................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._....._........-_.._... -------------------------------------------------------------*...*........"..."--------------------------------------------------------------------' 0 Description of Soil........................................................................................................................................................................ W --------------- ---------*-----------**---------------------------"--------------------------------"---------------------------*----------------- -------*"*'"**.......... .............................................................................................. .. ............ ------------------------------ Answ Vr (e plic ' ........... ..................................................... U Nature of Repairs or Alterations n ap ......................................................................... .......__ . ... ........ ............................................................. Agreement: . The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of T I TL U 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 b the bo 1 of health. -Signed.. ....................... .......... Date Application Approved By......_:. ... ...D161611.14.��.........................0............. . ...... Date pplication Disapproved for the following reasons:................................................................................................................ Date Issued............... ..............................it No....... 40f----------------------- Date '4. f..r tif-rr...,,,., F. �.. y.. ' C�YCri'jr•."F-� r,T?C3�r�" j�r'r�''�'^•„�'tir•+�r�'+ti';F"f ib'^`�M+' rC'''-•rr- Lyr�"�"^r"+C.:.K�iMr..,.. �yyyr,,,� �p,� .;t-.'"...,�nx riry 1*Hii.,�*^r '"-.-.rrrX ,sldi,r.+��'1�'S �,/� �/ �� ,,..s. � •1�' '^al�i. No._!1..-_ .P ��s� J--- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF '`...� ... . ''''. Appliration for Ut-Sp asal ldaarks Tonstrnr#iaan f rrnti# Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: .�lh� _..._ - ........--- ... ----....._........... ....................._.......---- .........--------••-----...................-- l ... Y Lo ti or.Lot...................•-•--.............---..... ner Address w ....... .......:.��/ .. ......................................... ,/ r � ... ►a Installer Address Type of Building Size Lot............................Sq. feet aDwelling—No. of Bedrooms........2....•......•............:Expansion Attic ( i) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............_..........._`'. Showers ( ) - Cafeteria ( ) d Other fixtures -----••-----------------------•-••••.....---•- WW Design Flow_._ ...................gallons per person per day. Total daily flow_._.........__._....__._......,_F:........gallons. W. Septic Tank—Led 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.................. ft. Z Other Distribution box ( ) Dosing tank ( ) ra Percolation Test Results Performed by-•-----••-------•---•.......................•-•------••-••.............. Date........................................ Test Pit No. I................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......................... a ------------------•-•--•------•-•---.....---••---........----••-•----....._..._..--------......................................................... 0 Description of Soil.......................................................................................................................................................................... U .......... ............. ..-------------- ---..--•-- -•-----------.--------_-------•-----•--•-•--•------------•-------------•-----------------------------------•------------------------ x b/ U Nature of Repairs or Alterations—Answf r}�'}�'en/ap licabl _. .. ._ ................................................. .... .... --:. - ` X_.4... !-� = ...........'--•----•................•...........----•-•------------:... Agreement: ' The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITL1- 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 b the bo of health. r Signed •.-•---••-••••..............................................' � ...... . t T' Date Application Approved By.... - ---D ...... _ .................................... -Date APPlieatiot Disapproved for the following reasons:................................................................................................................ ..............................•-•--------•-•-•---...........------... .-......._.................-•-•-----•---•----•-•---.......------.....----........•....,--: D.---..---......... - - ----------- • .�� Dattee PermitNo...... -------... ------•--•=="-----.... Issued........................1................................ \�...-3=.:- L _ ha:�,y�e•. �a -., �..—.�.�.....n..r...�.-.!.+.,..w.-.� u�`'+�'�,.�"«"i"�..�..�r+-.,+:.'—+,,,-....�:..+�.w.�: �.....-...--..::6 - Date (/ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN of YfH ( rdifiratae of Taantplitturr THIS IS TO CERT , That the Individua Sewage Disposal System constructed ( ) or Repaired (11� by..................................... ....... . 'inec................_...... ........................................ ..•••--......... .......... at.......`-� ......�.4- -1..v--- -------------- .,s � . I ..... e...................---.......................-----............---... has been installed in accordance with the provisions of TIT 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No.._... ,1_-.... .__ _..6 .. _..... dated.....................:.........:............... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A ARANTEE THAT THE, SYSTEM WILL FUNCTION SAT S ACTORY. % � L DATE.......... - ( ::.. t. .............•--.. Inspector................................4,._.... ................ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN of YAH r No..,/ ." FEE 31J................ , . Zvi ns. tudi.ta.n�`f..... rmit ..... .....................................................•---------------•---....................Permission is hereby granted.. ..._.. r `ndividSewa e Diooto Construc or � p it ( n . System ..�.... ............at No............. Street as shown on the application for Disposal Works Construction Permit No._�� . . ��_ Dated.......................................... ............................. F .................................................... Board of Health DATE............//---."_�..•..._:...�_..-------