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Home My WebLink About0010 CROSSWAY PLACE - Health 10 Crossway Place, Osterville , J " f I r TOWN OF BARNSTABL'E LJCA+ION 0 �`2oJ�Gv z 3/ 4 ce SEWAGE #.1 VILLAGE ASSESSOR'S MAP& LOT 165 ®.' INSTALLER'S NAME&PHONE NO.��« SEPTIC TANK CAPACITY c � LEACHING FACEL=: (type) /�'r C C�7-��/ (size) 4000 6&1, NO.OF BEDROOMS �Z BUILDER OR OWNER h5 ��(tin Si n-tr�a��S PERMTTDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility 33 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 f leachin facility d,90 Feet Furnished by ✓Ge'.�1 � 1 �. ""2=CL�v 9'1 d�+'tA�s e I`� � �s 0 0 �y aye . . � o Commonwealth of Massachusetts Executive Office of Environmental Affairs Department ®f FRECEIVro-In Environmental Protection SEP 9 1996 William F. Weld Governor - HEAL T,t Trudy Coxe 7Owt C,T S.,..y,EOEA David B. Struhs Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION f1 •y O11-,rN S.my -\a z S \O Cc ss ,a��RCCAddress of Owner: Property Address: ' �S \N,., �IIG Date of inspection: }'��•;S,kLt \� � (If different) Name of Inspector: '�C.,C e �lc,.c'-.kli,''} Company Name, Address and Telephone Number: S�o,2e\ C0+1 S SCE C — CERTIFICATION STATEMENT s \e ry. t e l`(A= I6s S . • 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: Passes Conditionally Passes _ Needs Further Evaluation By the Local Approving Authority Fails +` Inspector's Signature: 17 Date: C/ 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 :ne system ov.ner anci copies sent to the buyer, if applicable and the approving authority. INSPECTION SUMMARY: Check A, B, C, or D: AI 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. BI 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 8/15/95) 1 One Winter Street • Boston, Massachusetts 02108 a FAX(617)556-1049 • Telephone(617)292-5500 `a Printed on Recycled Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A q'r""'"' CERTIFICATION (continued) Property Address: j,,�`A�c Owner: C>S��t,,,;l�e Date of Inspection: lgItf�, B) SYSTEM CONDITIONALLY PASSES((continued) _ Sewage backup orbreakout 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 Cl 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 safer 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: _ The sysiem has a septic tank antl soli absorption system and is within 100 feet to a surface water iuppi) of tribulaiy iG o 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 less than 5 ppm. DI 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 a PART A CERTIFICATION (continued) Property Address: CroSst..,ra Owner: 1"ts, �Q11 S nt rv`u r�S Date of Inspection: DI 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). Number of times pumped 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. 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 50 feet of a private water supply well. _ 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. EJ LARGE SYSTEM FAILS: The following criteria apply to large systems in addition to the criteria above: 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 II 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 5.00 and 6.00. Please consult the local regional office of the Department for further information. • 9 (revised 8/15/95) 3 a SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST �c (.-Oss C-"4) Pj4C C Property Address: Owner: CIS• l�llJi) .S;r»w�o:�s_ Date of Inspection: /y� �5�6 Check if the following have been done: -ZIP—umping information was requested of the owner, occupant, and Board of Health. JZ"N 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. AA As built plans have been obtained and examined. Note if they are not available with N/A. Z'The facility or dwelling was inspected for signs of sewage back-up. ZThe system does not receive non-sanitary or industrial waste flow , Zhe site was inspected for signs of breakout.. All 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. Zhe size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods. Zee facility o Nnc: (and occupants, if different from owner) were provided with information on the proper maintenance of Sub- Surface Disposal System. a (revised 8/15/95) 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION . Property Address: /O h/`GSI(i✓f� //ACC- (1S/P�..�� Owner: /'7s• //,.i S:m�w.r� Date of Inspection: /7 FLOW CONDITIONS RESIDENTIAL: Design flow: �Ooms, s Numberof be Number.of current residents: Garbage grinder (yes or no): /_$ Laundry connected to system (yes or no): �AT-5 - Seasonal use (yes or no):JfS ` Water meter readings, if available: �b y Last date of occupancy: COMMERCIAUINDUSTRIAL: Type of establishment: Design flow: >allons/day Grease trap present: (yes or no)_ Industrial Waste Holding Tank present: (yes or no)_ Non-sanitary waste discharged to the Title S system: (yes or no)_ Water meter readings, if available: Last date of occupancy: OTHER: ;Describe) Last date of occupancy; GENERAL INFORMATION PUMPING RECORDS and source of information: System pumped as part of inspection: (yes or no) If yes, volume pumped. Rallons Reason for pumping. TYPE OF SYSTEM _Septic tank/distribaHeR-Liex/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) and source of information: a y��2s C76 Sewage odors detected when arriving at the site: (yes or no) NO (revised 8/15/95) 5 `Ft SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INF?RMATION (continued) Property Address: /D CCw w.�j ,��e — Cis i1'"; e Owner: Date of Inspection: SEPTIC TANK: (locate on site plan) 71 Depth below grade: O Material of construction: _concrete �etal _FRP —other(explain) Dimensions: /0 X 5/19i%2 x 5 FT 7�n� Sludge depth: A/i 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: y �� Distance from bottom of scum to bottom of outlet tee or baffle: 1.2 ' 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.) 7�n t f T 7 6o o o Coa ai%i o r GREASE TRAP:_ (locate on site plan) Depth belo"• 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 bottom t� bottom of outlet tee or battle 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 8/!5/95) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: crov ) Owner: /y�. /�ril <S'/r1i�7Ui7J Date of Inspection: 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/dad 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: Comments: (note if le e' and d:str:b::r e : ' d ^c,, or sn1id ca« e�, evidence of leakage 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, condition of pumps and appurtenances, etc.) (revised' 8/15/95) 7 t SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) JD C. Property Address: , Owner: J J,S. J 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: 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. NU Si C.)_S '9-i,411 rjje/717 CESSPOOLS: _ (locate on site plan) Number and configuration: 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 (cesspool must be pumped as part of inspection) condition of vegetation, etc.) ( h hydraulic failure level of onding, g , Comments: (note condition of soil, signs o yd P PRIVY: _ (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, etc.) (revised 8/15/95) 8 II SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM . PART C SYSTEM INFORMATION (continued) Property Address: /O Ci'05sw,9� //icc - �• Owner: 1125. All IJ Sii/7iTIUiJ Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' `)2zCZewc9 ' DEPTH TO GROUNDWATER Depth to groundwater: feet /1 %-. ro method of determination or approximation: - CAP(' w0 CoM,19IS5jo i, "- ��7/L-� `tUn��d� (revised 8/15/95) 9 No..2&�.......... ......... THE COMMONWEALTH OF MASSACHUSETTS BOARD 9F HE _ T a 4,......... ...... .......4...t ..................OF. .......... ....... ...................... Appliration for 14sposal Works Tonstrurtijan Prrutit Application is hereby made for a Permit to Constr&t or Reit ( ),,an Individual Sewage Disposal syst a 11/2 ... ... .......... .......... . .. . ......... ... ...... .... . .... Locatiodress or Loy No Owner Address ...... .. ......... ................................................................................................. ------------------------------------------------ Installer Address Type of B Size Lo,.-g..r &.. q. feet U Building of Bedrooms..........41------------------_--------Expansion Attic ( ) ---- Dwelling Garbage Grinder ( P4 Other—Type of Building ............................ No. of persons..__................._...... Showers Cafeteria ( P_, Other fixtures ...................................................................................................................... Design Flow. ..... ............gallons per person per day. Total daily flow.......... ��ZF ............................gallons. Septic Tank E'Liquid capacityJZS_Agallons Length________________ Width................ Diameter.....__...._..._ Depth................ Disposal Trench—No...................... Width......_.._._.___.._. Total Length.................... Total leaching area....................sq. ft. Seepage Pit No._______17..... Diameter____________________ Depth below inlet.................... Total leaching area..................sq. f t. Z Other Distribution box (),�) Dosing tank ( ) Percolation Test Results Performed by..................... .................................................... Date........................................ Test Pit No. 1................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.................. ----------------------------------------------------------------- U ........................................................................................................................................................................................................ W ........................................................................................................................................................................................................ Z U Nature of Repairs or Alterations—Answer when applicable._......___._._."............................................................................... .................................................................................................................................................................. ..................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the: State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has ssued�by the boar S* e ..........glie---- ----1 - - -------------- ;o,mpl,,a,n,ce I"as.b ssued I '/ _3...... Si .....gne -1... .�:� Date Application Approved By...... .4 . -, -4111--------------- ate Application Disapproved for the following reasons:................................................................... ....................................... ........................................................................................................................................................................................................ Date PermitNo......................................................... Issued........................................................ Date —--------------—----------------------------------------------- --- No. .......... FEE.... ..:........ ........ THE COMMONWEALTH OF MASSACHUSETTS BOARD QF H EALT .� --------------- ..... ..OF...... 'A..,; -- ........ , ppliration for 1hop od Works" (inset-trurtion rprutut Application`is hereby:made-'for a Permit to Constr ct ( N) or Re it '( ) an Individual Sewage Disposal S' 't Locatio - dress or Loy/No. Owner Address ....... a...................................•-_ -----t- ' _._...._................................... 4............. '� __. Installer Address Q Type of Buildi Size Lot... _ q. feet Dwellin No. of Bedrooms............ .. Expansion:Attic Garbe Grinder aOther—Type of Building ............................ No. ofpersons............................ Showers ( ) — Cafeteria ( ) QOther fixtures ------------------------•-------------------------------•--•-------•-----•----------------------------••-•---------------------••---•----------•----- WW Design Flow ......01M.S._!............gallons per person per day. Total daily flow.......... " .................gallons. WSeptic Tank-C Liquid capacityp.COgalIons , Length................ Width................ Diameter................ Depth-_-__-..____-__- xDisposal Trench—No..................... Width...:................. Total Length.................... Total leaching area....................sq..ft.' Seepage Pit No Diameter___________________ Depth below inlet.................... Total leaching area..................sq. ft. Other Distribution:box Dosing tank Percolation Test Results Performed by.......................................................................... Date............................. ------ Test Pit No. 1................minutes per inch Depth of Test Pit...................... Depth to ground water.,----------..:._::---- w Test-Pit No. 2................minutes per inch Depth of Test Pit.................... Depth-to ground water........................ P-I' = - - ----.......................................------- - -=------ Ow Description of Soil........ .., .................. ----------------------- = U Nature of Repairs or Alterations.—Answer when applicable..................::................,------_------------....................................... ---------------------11------------ ------------•------•------ --•----••---------------•-----------_---- ---------------------------•-----•••------------_.. Agreement The undersigned.agrees to install the aforedescribed Individual Sewage Disposal System in.accordance with the provisions of Article YI of the State Sanitary Code—The undersigned further agrees not to..place the system.in operation until a Certificate of Compliance has bperotssuedby ,th�e`board Signe t '... .. - . ate Application Approved By... ...... IS"ate Application Disapproved for the following reasons:................................................................................................................. . .................•----.........-•-•------.....---•-----------------.....------------•-=-•---•------------...-•-------------------------------------------•------------------------------------------•-•-- Date PermitNo.....................................................•-- Issued........................................................ Date THE COMMONWEALTH OF MASSACHUSET:TS 4* BOARD HEALTH ...................OF......... :.................0. L-::.:................................ Trrtif iratr of 00 atpiinUrr THIS 3 0 CERTIfFY, T�, he Indivi a ewa e Disposal System constructed ( ) or Repaired ( ) by---.----.. -...... �1- ..................../7 Inst ._.--•-- ............................................. at ' ..__...f - -- ----�� •--•-•-••--•-- ---- has been installed in accordance with the pr isions of Article XI of The State Sanitary Code s de cribed in the application for Disposal Works Construction Permit No.._ �...................... dated____ 2 _. ............ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. F DATE................................................................................ Inspector.................................................................................... ; THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ......... Z__�.. ;6 .� No....`` .,! '. t - FEE..�---•-•- !/ -_ `'Bisvos t inlay s 01.1 strudw' t Firnfit Permissions eby-granted..._ ---------•----•---•---•.. ............................................... to Construct (l/) or air ( ) an Individual S a Disposal Syst - at No.::�-�...if. ----.. .1� //�_ .. ....._ ............................................ iy"' St : street as shown on the application for Disposal orks Construction Pe t No.... _. Dated...2...%Z� .>........... Board of Health DATE......................................•-•--....................--------......... FORM 1255 HOBBS 8; WARREN, INC., PUBLISHERS' r 1v 7, � '064-SbN �� , .� ,, w"" �`�• . t� �. a o �..., e � f d�J� _� ' } r _ �..-� 1 Z 1 f �: � � ,. � # x t s � • � I-Y 1 rf�