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HomeMy WebLinkAbout0042 GINGER LANE - Health 42 GINGER LAN TE , ®STERVILLE.- A = 165 015 TOWN OF BARNSTABL$ LOCATION i�' L`� A SEWAGE # 66 m VILLAGE d s l ASSESSOR'S'MAP & LOT INSTALLER'S NAME&'PHONE NO. ��-�3 '�`" '� �`� Y � SEPTIC TANK CAPACITY LEACHING FACILITY: —(Size) �- NO.OF BEDROOMS J BUILDER OR OWNER QV i L PERMTTDATE:_S-/T"6-6 COMPLIANCE DATE: S'V/9_&_Z Separation Distance Between the: Maxiimum Adjusted Groundwater Table d Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of 1 chiing facility).. Feet Edge of Wetland and Leac] acility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by PL jV*tv.L �9 ��0 No. � Fee $50 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer. Yes PUBLIC:,HEALTH DIVISION i4'TOW OF BARNSTABLE, MASSACHUSE. ,gi C"Sd't .°r c, ' �'i �ij r r 'i s t 3 'S �• '� y h a, r4 .' �� rs s . 3�'' . YiCation fore g o al p�teritF ot�g4 trUctiort errn�it d.Apphcation for a Pemuf to Construct(�';)Repair 01 )Upgrade( . )Abandon(�L)�❑Complete System. Indtvidual Components C.F. ,..,,':.. w:,.. .°Et },•.:._' s vc - Y-r - s ... .. a..S' z y x Location Addies's or Lot No Owner s Name;Address and Tel.No "3 3 27 Ginger Lane , 'Qrville Robert'Dubois ste t Assessors Map/Parcel R at �` , • a s� .:r2 0< R dgewayypRd.>:,� WestonFMA r c s Installer's Name;Address;and Tel No , x r Designer s Name Address and Tel No S. Wm, E. MRobnso,n Sept'°ic S`ervice , P 0 Box `1089,, Centerville -rt 3 ,Type of Building: Kfs , Dwelling :No.of Bedrooms i'- Lot Sizea d sq:ft a Garbage Grinder( ) `Other Type'of Building %' No'.of Persons k Showers( ,;•)=Cafe_tens(` ) }. Other Fixtures' rt Design Flow - gallons per day Calculated daily flow r :gallons. Plan Date Number`of sheets Revision Date; Title ":Size of Septic Tank Typeof S A S u Description of Soil. 'San r Nature of Repai s:orAlterations(Answer.when`apphcable) Title=5°«se Ut iC , system Consist , of -a--tarik, D=box, and; 2#'coricret,e "leach,�cYiamberso}wit,h `°stone ": �` •; a, around:., . , Date last inspected f :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 En_vuonmental bode and not to place theSysteiii'm operation until a Certifi- cate of Compliance liar been.iss ed by s B d of,H L R 3 = Sign y p Date Application Approved by• A ` Date the folA lication,DisaP roved for lowin reaso a 4 ° E Permit No. ,'� M Date Issued` OA f •" :THE COMMONWEALTH OF.MASSACHUSETTS•: < � Dubois BARNSTABLE,`MASSACHUSETTS �,t '�ertif irate of. ontYiarice � FF THIS IS TO CERTIFY,thatlthe On=site Sewage Di al System'Constructed( :'r)Repaired(X )Upgraded"(- r) Lane Ginger ' Abanddoned.(, )by Wm. E. Ro•binBon' Septic Service 42 Gift at g � . sery e . `: "'... hasJ3heen,constructed in',accordance • �. with the provisions of Title 5 and the for Disposal System Construction PermitN0 t/liHated r •Installer Wm,_ E.: 'Rob in on S r':'_ Designer ` .. -. .1.. .. .,... The issuance of this 1 not be construed as a guarantee that`the,s ` e" 11 func'o signe A, ti Date '.Inspector <ti NO. rz _" # # 4 K� —FeeJO a ,< +lEo ;'11�E4LTbI QI='MASSACHUSETTS ; - w Dubois PUBLIC HEALTKDIVISI N -.BARNSTABLEs MASSACHUSETTS ipgteM .Co ottu'dion erm�tt Permission is hereby: ted xo.Con"ss t Re air X")`Lj ade )Abandon s System located at G'inger&Lane, „�sterv.l e � x 'and as described'in the above Application for Disposal'System'Construction'Penni,t The-app hcant"recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions' s M Provided Constructi must a completed within three years of the date of pe ,,.,"Date: 6 'An Provedby .s.....-..� .--.-..w .....-. - ..n_ ........ +.._..«. .rdu... ,..,md.^.. ...r..e.s....,_./a•.-7��•r� ...-._ � .. �.'.,/...w....+a't't..R..e.�`,.s...., w .�.. �+w-.,... a _� .. a_.. .. 1/6199 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(WYMOUT DESIGNED PLANS) William E. Ro)7 ins on,S�eby certify that the application for disposal works construction permit signed by me dated ✓r /�— �� , concerning the property located at 4.2 Ginger Lane , Osterville meets all of the following criteria: • The failed system is connected to a residential dwelling only. There are no commercial or business uses associated with the dwelling. The soil is classified as CLASS I and the percolation rate is less than or equal to:5 minutes per inch. There are no wetlands within 100 feet of the proposed septic system There are no private:wells within 150 feet of the proposed septic system There is no increase in flow and/or change in use proposed • There are no variances requested or needed. • The bottom of the proposed leaching facility will nqt be located less than five feet above the ma.�murn adjusted groundwater table elevation: [Adjust the groundwater table using the Frimptor method when applicable) • If the S.A.S.will be located with 250 feet of any vegetated wetlands,the bottom of the proposed leaching facility will not be located less than fourteen(14)feet above the maximum adjusted groundwater table elevation, Please complete the following: A) Top of Ground Surface Elevation(using GIS information) Y (,, (n B) G.W.Elevation +the MAX High G.W. Adjustmen j! DIFFERENCE.BETWEEN A and B 2 ; SIGNED : L U ✓ o "DATE: el [Sketch proposed plan of system on back[. y:health folder:cen l ,r COM\10\'«'EALTH OF MASSACHL;SETTS . _ r EXECUTIVE OFFICE OF EINVIRONMENTAL AFFAIRS F DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE R'I\TER STREET. BOSTON TLC,0210c t61' 292-550k TRL DY COXZ Secre:a--. ARGEO PAi;L CELLUCCI DAIM B STR'-*HS Governor Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM , PART A CERTIFICATION Property Address: 42 ringer Lane Name of owner Ro ,ert Dubois/ Nancy Bild.zok O S t P ;V* l�e Address of Owner: S Date of Inspection: _/jf V-v Name of Inspector:(Please Print)Wm. E . Robinson Sr. I am a DEP approved systerrl inspector rsuant to Section 15.340 of Title 5(310 CMR 15.000) CopanyName: Wm. E . Robinsoneptic Service ni Mailing Address: PO Box 1069, Centerville , MA Telephone Number: 8 0 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: 44 sses Conditionally Passes Needs Further Evaluation By the Local Approving Authority _ Fails Inspector's Signature: f!+( ✓—� Date: The System Inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)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 ttre system owner and copies sent to the buyer, if applicable, and the approving authority. NOTES AND COMMENTS Y, J �^14M1 T. t a ?p0 revysed 9/2/9E Page IofII 4 • ,led o^Rea-drd Panc, v SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) 'rop"Address:42 Ginger Lane , Osterville .)weer: Dubois Date of Inspection: INSPECTION SUMMARY: Check�B, C, of D: A. SYS PASSES: I have not found any information which indicates that'any of the failure conditions described in 310 CMR 15.303 exist. Any failure criteria not evaluated are indicated below. COMMENTS: B. YSTEM CONDITIONALLY PASSES: One'or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair,as approved by the Board of Health, will pass. Indicate y s, 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, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance (attached) indicating that the tank was installed within twenty (20)years prior to the date of the inspection; or the septic tank, whether or not metal, is 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 complying septic tank as approved by the Board of Health. Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health). broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed revise.^•', 9/2/98 Page 2ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Prop"Address:42 Ginger Lane , Osterville Owner: Dub 0 s Date of Inspection. 8 C. THER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: onditions exist which require further evaluation by the Board of Healthin order to determine if the system is failing to protect the p blic health, safety and the environment. 1) S1 STEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 15.303 1111(b)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 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 ANY)DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and the SAS is within a Zone 1 of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS 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. Method used to determine distance (approximation not valid). 3) OTHER revise: Page 3of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 42 Ginger Lang , Osterville Owner: Dubois Date of Inspection: D. SY TEM FAILS: ,o' You must'ndicate either "Yes" or "No" to each of the following: I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this d termination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes N Backup of sewage into facility or system component due to an overloaded orclogged 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. 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. E. RGE SYSTEM FAILS: You st indicate either "Yes" or "No" to each of the following: The following criteria apply to large systems in addition to the criteria above: The system serves 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: Yes No 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 wrier or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional offic of the Department for further information. revised 9j2/98 Page 4of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM. PART B • :w CHECKLIST Pr Address: 42 Ginger Lane, Ostervi opertY lle Owner: Dubois Date of Inspection: Check if the followinghave been done: You mustyindicate 'either,"Yes" or "No" as to each of the following Yes/ No Pumping information was provided by the owner, occupant, or Board of Health. _✓ _ None of the system components have been pumped for at least two weeks and•the system has been.reeeiving 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. a ✓ _ The system does not receive non-sanitary or industrial waste flow. ' The 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.. The size and location of the Soil Absorption System on the site has been determined based on: 1 Existing information. For example, Plan at B.O.H. Determined in the field(if any of the failure criteria related to Part.0 is at issue,approximation of distance is unacceptable) [1.5.302(3)(b)) - _ The facility owner (and occupants,if different from owner)were provided with information on the pro permaintenaar��f Subsurface Disposal Systems. revisen 9/2/98 Page curlt SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION kopeny g Address: 42 Ginger Lane , Osterville owner: Dubo is Date of Inspection: 6� FLOW CONDITIONS RESIDENTIAL: Design flow:4/. 0 g.p.d./bedroom. Number of bedrooms(design): 3 Number of bedrooms(actual): Total DESIGN flow Number of current residents: C� Garbage grinder(yes or no): `C7o Laundry Iseparate system) (yes or no);/Y.0 : If yes, separate inspection required Laundry system inspected (yes or no) Seasonal use lyes or no):4-- 0 Water meter readings, if available (last two year's usage (gpd): 19�9 2' , 000 gal . Sump Pump(yes or no):A—0 1998 20, 000 gal. , Last date of occupancy: J1'j A COM RCIAL/INDUSTRIAL: Type of stablishment: Design fl w: gpd ( Based on 15.203) Basis of esign flow Grease tr p present: (yes or no)_ Industrial Waste Holding Tank present: (yes or no)_ Non-sani ry waste discharged to the Title 5 system: (yes or no)_ Water m ter readings, if available: Last dat of occupancy: OTHE : (Describe) Last a of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: System pumped as part of inspection: (yes or no) 4,O If yes, volume pumped: gallons Reason for pumping: TYPE 0 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) I/A Technology etc. Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other APPROXIMATE AGE of all components, date installed(if known)and source of information: A,a:t.t 5 Sewage odors detected when arriving at the site: (yes or no)�i I revised 9/2/0E Page 6of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Icontinued) - 'rop"Address:42 Ginger Lane, Osterville . owner: Dubois Date of Inspection:S`e?—c,.� BUILDING SEWER: ' (Local on site plan) Depth b low grade:_ _ Material of construction:_cast iron 40 PVC_other(explain) Distan a from private water supply well or suction line Diame er Com ents: (condition of joints, venting, evidence of leakage,-etc.) SEPTIC TANK: (locate on site plan) Depth below grade: Material of construction:t.concrete_metal_Fiberglass _Polyethylene—other(explain) If tank is metal,list age_ Is.age confirmed by Certificate of Compliance_(Yes/No) Dimensions: Sludge depth: Distance from top of sludge to bottom of outlet tee or baffler 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 baffler How dimensions were determined: i t✓�✓ r ` -omments: E (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.) L, 1- GREASE TRAP: (locate on site plan) Dermendation w grade:_ Maf construction:_concrete_metal_Fiberglass _Polyethylene'_other(explain) Dims: Sc Hess: Disrom top of scum to top of outlet tee or baffle: . Disrom bottom of scum to bottom of outlet tee or baffle: A Datst pumping: b Co : (rendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, avif leakage,etc.( A. _ revised 9/2/98 Page 7of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM . PART C SYSTEM INFORMATION(continued) J,rop"Address: 42 Ginger Lane , Osterville Owner: ,,77'� Date of InsDpec6' •1 S Tl T OR HOLDING TANK: (Tank must be pumped prior to, or at time of, inspection) (IONS on site plan) Depth low grade:_ Material f construction:_concrete_metal Fiberglass_Polyethylene_other(explain) Dimensio s: Capacity: gallons Design flo gallons/day Alarm pre ent Alarm lev I: Alarm in working order: Yes_ No_ Date of revious pumping: Comme ts: (condi n of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX: V (locate on site plan) Depth of liquid level above outlet invert: Comments: Inote if level and distribution is equal.-evidence of solids carryover, evidence of leakage into or out of box, etc.) - PUMP HAMBER:_ (locate n site plan) Pumps i working order: (Yes or No) Alarms n working order(Yes or No) Comm ts: (note ondition of pump chamber, condition of pumps and appurtenances, etc.) revises 9/2/98 Page 8of11 I� SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continu6d) r _ 'ropertyAddress: 42 Ginger Lane , Osterville Owner: Dubois Date of Inspection: /?T s SOIL ABSORPTION SYSTEMI_- / e (SAS): / (locate on site plan, if possible;excavation not required,location may be approximated by non-intrusive methods) If not located, explain: ;+ Type: leaching pits; number:_ leaching chambers,number. leaching galleries, number:_ leaching trenches,number, length: leaching fields, number, dimensions: Y, . overflow cesspool, number:_ Altemative system: Name of Technology: Comments: (note condition o soil, signs of hydraulic failure, level of ponding, damp soil, of vegetation, etc.) CESSPOOLS:_ (locate on site plan) Number and configuration: y Depth-top of liquid to inlet invert: Oepth of solids layer: lepth of scum layer:- �;//, - - • ii Dimensions of cesspool Materials of construction: , Indication of groundwater. inflow (cesspool must be pumped as part of inspection', ' Com ents: (note ondition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRI _ hoc eon site plan) _ t; M erials of construction:De p�h of solids: Dimensions: Co ments: no a condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.) reti �seo 5/2/7E Pacc 9 of I I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(corrdrwed) Nop"Address: 4.2 Ginger Lane , Osterville lwrmr: Dubois Jate of Inspection:S a-B—L SKETCH OF SEWAGE DISPOSAL SYSTEM: ✓J include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house)q CG no _ 3®© revised 9;2/9R Page 10of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) roP"Add►ess: 42 Ginger Lane , Osterville owner: D ub O i Date of Inspection: NRCS - Report name Soil Type Typical depth to groundwater USGS Date website visited Observation Wells checked Groundwater depth: Shallow. Moderate Deep SITE EXAM Slope Surface water Check Cellar Shallow wells Estimated Depth to Groundwater V J Feet Please indicate all the methods used to determine High Groundwater Elevation: • Obtained from Design Plans on record " Observed Site(Abutting property, observation on hole, basement sump etc.) _• ' Determined from local conditions Checked with local Board of health Checked FEMA Maps Checked pumping records Checked local excavators, installers Used USGS Data Describe how you established the High Groundwater Elevation. (M=st be completed) Y revised 9/2/96 Page 11 of 11 TOVyTt OF BARNSTAB}LE j LOCATION 412- : to SEWAGE # 0-0 VILLAGE D l ASSESSOR'S MAP & LOT ' INSTALLER'S NAME&`PHONE N0. � IA-d d -7 SEPTIC TANK CAPACITY fs� T I r LEACHING FACILITY: (type)vZ- s""c1 oZ C (size) �- fNO. OF BEDROOMS 3 BUILDER OR OWNER PERMIT DATE: /�" 6-6 COMPLIANCE DATE: f Separation Distance Between the: �' Maximum Adjusted Groundwater Tableand Bottom of Leaching Facility Feet . Private Water Supply Well and Leaching Facility (If any wells exist ' on site or within 200 feet of leKching facility) Feet Edge of Wetland and Leachi acility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by te� '7 _. . ._ PO r-