HomeMy WebLinkAbout0791 MAIN STREET (OST.) - Health F81 MAIN STREET, OSTERVILLE
A= 117 088
1
- = TOWN OF BARNSTABLE
LOCATION lY'", I 5T SEWAGE #
VILLAGE I1�T'C B I �� ASSESSOR'S MAP &LOT < 0
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY 4S 00 filar
LEACHING FACILITY: (type) .(size) *IX 21 X-1
NO.OF BEDROOMS
BUILDER OR OWNER S U k l t V0. VJ
TERMffDATE: 101, I.1 z COMPLIANCE DATE:
Separation Distance Between the: �2
Maximum Adjusted Groundwater Table to the Feet
Private Water Supply Well and Leaching Facility (If any,wells exist
on site or within 200 feet of leaching facility) _� Feet
Edge of Wedand and Leaching Facility(If any wetlands exist'
within 300 feet of le4qhing facility) Feet
Furnished
BIZ ' 8 1 -
Fri
A4 1L'
As -a, as- u� 7
AI- fit'
COMMONWEALTH OF MASSACHUSETTS .
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS NOV 25 1998
TOWN OF BARNSTABLE
DEPARTMENT OF ENVIRONMENTAL PROTECTION �j HFALiHDEPL
ONE WINTER STREET, BOSTON MA 02108 (617) 292-5500
W U-LIAM F.WELD TRUDY CORE
Governor Secretary
,
ARGEO PAUL CELLUCCI DAVID B. STRUHS
Co*
Lt. Governor ***+ s ioner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
vkk PART A
q� CERTIFICATION _
{ ,
Property Address: _7 S l ���� S t O S'\tvL�� Address of Owner:' C-1��� , 1,, L SUS\\\)�tiVV
Date of Inspection: �C\ (If different)
Name of Inspector:
I am a DEP approved system inspector pursuant to Section 15.340`of Title 5 (310 CNQ2 15.000).;, 3y �\c�►ah�0 �VL
Company Name:
Mailing Address: i'i c�r >< a,��,�� �Y�P �t �;vZ\c�lc�•• t�1to5
Telephone Number:
x
CERTIFICATION STATE." E`T
1 certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and
was performed based on my training and experience in the proper func
tion and maintenance
e time of inspection. The inspection _ P
complete as of the pP -
of on-site sewage disposal systems. The system: "
Passes
_ Conditionally Passes
_ Needs Further Evaluation By the Local Approving Authority
Fails
Inspector's Signature. Date:
The System Inspector shall submit a copy of this inspection report to the Approving Authority within thiriv (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. rt ,
J
INSPECTION SUNSURY: Check A, B, C,,or 'D: .. "
A] SYSTEM PASSES:
I have not found anv information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Anv
failure criteria not evaluated are indicated below.
COMMENTS
B] SYSTEM 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 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, 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 exfihration, 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 04/25/97) Page 1 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued) .
Property Address:
Owner:
Date of Inspection:
B] SYSTEM CONDITIONALLY PASSES (continued) '
_ Sewage backup or breakout or high static water level observed in the distribution box is due�(o broken or obstructed pipe(s) or
due to a broken. settled or uneven distribution box. The system will pass inspection if(wt{h approval of the Board of Health).
Describe observations: / ^
broken pipe(s) are replaced
obstruction is removed /
distribution box is levelled or replaced j
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 i
obstruction is removed
i
j
C] FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
Conditions exist which require further evaluation by the Board of Health i/order to determine if the system is failing to protect the
public health, safety and the environment.
1) SYSTEM «ILL PASS UN-LESS BOARD OF HEALTH DETERS ` ES THAT THE SYSTEM IS 'NOT FL1CT10�TNG IN A
NIA.NT-ER NNTr-CH NNZLL PROTECT THE PUBLIC HEALTH A_N'D SAFETY A_N-D THE EN-V-IRONIIEN?:
_ Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering_v etated wetland or a salt marsh.
2) SYSTESI 'tiTLL FAIL LNLESS THE BOARD OF HE TH (AN'D PLBLIC «'ATER SLPPLIER, IF APPROPRIATE)
DETER.NUNES THAT THE SYSTEM IS FUNCTION 'G IN A S1AN-NER THAT PROTECTS THE PUBLIC HEALTH A.N-D
SAFETY AIND THE EN-VIROLMNfEN'T:
The system has a septic tank and soil abs tion system (SAS) and the SAS is within 100 feet to a surface water supply or
tributary to a surface water supply.
The system has a septic tank and soil sorption system and the SAS is within a Zone I 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 s absorption system and the SAS is less than 100 feet but 50 feet or more from a private
water supply well, unless a well ater analysis for coliform bacteria and volatile organic compounds indicates that the well is
free from pollution from that fa lity and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm.
Method used to determine dist nce (approximation not valid).
3) OTHER
(revised 04/25/97) Page 2 of 10
r
Y
SUBSUR
FACE SEWAGE DISPOSAL SYSTEM INSPECTI N FOR.M
PART A
CERTIFICATION (continued)
Property Address:
Owner:
Date of Inspection:
D] SYSTEM FAILS:
You must indicate either "Yes" or "No" as to each of the following:
I have determined that the system violates one or more of the following failure riteria as defined in 310 CMR 15.303. The basis for
this determination is identified below. The Board of Health should be contac d to determine what will.be necessary to correct the
failure.
Yes No
Backup of sewage into facility or system component due to an verloaded or clogged,SAS or cesspool.
Discharge or ponding of effluent to the surface of the groun or surface waters due to an overloaded or clogged SAS or
cesspool_
Static liquid level in the distribution box above outlet inv ri due to an'overloaded or clogged SAS or cesspool.
Liquid depth in cesspool is less than 6" below invert o available volume is less than;1/2 day flow.
Required pumping more than 4 times in the last yea NOT due to clogged or obstructed pipe(s).
Number of times pumped
Any portion of the Soil Absorption System: cess ool or privy is beloµ,the.high groundwater elevation:
Any portion of a cesspool'or privy is within l 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 oubiie we11. `
Any portion of a cesspool or privy is it n 50 fee: of a private water supply well.
Any portion of a cesspool or privy is I s than 100 feet but greater than'50 feet from a.private water supply well with no
acceptable water quality analy' is. If t e well has been,analyzed to be acceptable• attach copy of well water analysis for
collform bacteria, volatile orvantc co pounds. ammonia nitrogen and nitrate nitrogen.
E] LARGE SYSTEM FA.ILS: -
You must indicate either "Yes" or "No" as to each f the following- "
The following criteria apply to large syst ms i,n addition to the criteria above:
The system serves a facility with a des' n flow of 10.000 gpd or greater-(Large System) and the system is a significant threat to public
health and safety and the environment ecause one or more of the following conditions exist:
Yes No s .
the system is within 4 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 stem shall bring the system and facility'inio full compliance with.the groundwater treatment program
requirements of 314 CMR 5.00 an 6.00. Please consult the local regional office of the Department for further information.
(revised W,'25%97) Page 3 or to
Y
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: t' Mva�rV
Owner: ';;'kk�JCLI\.1
Date of Inspection:
Check if the following have been done: You must indicate 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 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.
.�9-0(x�
A.s_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.
— 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 constructiim, 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 ori:
— The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of Sub
Surface Disposal System.
— Existing information. Ex. Plan at B.O.H.
— Determined in the field (if any of the failure criteria related to Part C is at issue. approximation of distance is unacceptable)
[15.302(3)(b)]
(revised 44125i97) Page 4 of 10
' I
SUBSURFACE SEWAGE DISPOSAL.SYSTEM LNSPECTION~FOR.M
PART C
SYSTEM INFORMATION
Property Address: t;40tkN
Owner:
Date of Inspection:11I1t'k� "
FLOW CONDITIONS
RESIDENTIAL
Design flow: g.p.d./bedroom for S.A.S. r
Number of bedrooms: �.
Number of current residents:_ r
Garbage grinder (yes or no):_ x p
Laundry connected to system (yes or no):_
m�
Seasonal use (yes or no):_ ,
Water meter readings. if available (last two ('_') year usage (gpd):,
Sump Pump (yes or no):
Last date of occupancy:
CON, nIERC1AL/IN-Dt`STRIAL: ;
Type of establishment:
Design flowNly$O eallons/day
Grease trap present: (yes or no)—kjS
Industrial Waste Holding Tank present: (yes or no)_t-�-Q ,
Non-sanitan• waste discharged to the Title 5 system: (yes or no)A A x
Water meter readings. if available:
Last date of occupancy:
OTHER: (Describe)
Last date of occupancy:
GENERAL L\T'ORAL-kTIO "
PUNT PLNG RECORDS and source of information:
System pumped as part of inspection: (yes or no)
If yes, volume pumped: gallons'
Reason for pumping:
TYPE OF SYSTEM r..
L Septic tank/distribution box/soil.absorption system
�q ,
Single cesspool
% r N
Overflow cesspool .:
Privy
Shared system (yes or (if yes. at notach previous inspection records, if an).
I/A Technology etc. Copy of up to date contract? '
Other
APPROXIMATE AGE of all components, date installed'(if known) and source`of information:
Sewage odors detected when arriving at the site: (yeas or.no)_
(reriuid W.'25,97) Page 5 of 10
6 ` s
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORINI
PART C
SYSTEM INFORMATION (continued)
Property Address:
Owner:
Date of Inspection:
BUILDING SEWER:
(Locate on site plan)
[ �t
Depth below grade: a
Material of construction: cast iron )�,4TPVC _other (explain)
Distance from private water supply well or suction line o�
Diameter' � 6u
Comments: (condition of joints. venting. evidence of leakage, etc.)
S t r- S, o
SEPTIC TANK:- >
(locate on site plan
Depth below grade:ArC-"eLoc, —
Material of construction: _concrete _metal _Fiberglass _Polyethylene —other(explain)
If tank is metal. list age _ Is age confirmed by Certificate of Compliance _(Yes/No)
Dimensions: )-5)O cl�
Sludge depth: L�4 �ll
Distance from top of sludge to bottom of outlet tee or baffle:_
Scum thickness: 3 U S t
Distance from top of scum to top of outlet tee or baffle: `
Distance from bottom 0° scum to bottom of outlet tee r baffle:_ °
How dimensions µere determined:
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.) tj S, n
G
GREASE TRAP—
(locate on site plan)
Depth below grade:
1 Pol_Polyethylene _other(explain)
Material of construction: concrete _meta —Fiberglass _ 5
M �S,
Dimensions: %0 3r-)eA.4P 1
Scum thickness:
Distance from top of scum to top of outlet tee or baffle: S�t ,t
Distance from bottom of scum to bottom of outlet tee or baffle: a'S
Date of last pumping: , s
Comments: Q
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet i en. structural integrity.
evidence of leakage, etc.) C
(revuid 04I25197) Page 6 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM_
PART C
SYSTEM INFORMATION (continued)
Property Address: I(Ok tAymJ l ,
Owner: JC�\\whil'v
Date of Inspection: ;l `
keWo ,
TIGHT OR HOLDING TANK: (Tank must be pumped prior to, or at time, of,inspection) ,
(locate on site plan)
Depth below grade: x r
Material of construction: _concrete _metal _Fiberglass Polyethylene _othet(explain)
Dimensions: '.
Capacity: gallons
Design flow: gallons/day .
Alarm level: Alarm in working order Yes No
Date of previous pumping:
Comments:
(condition of inlet tee. condition of alarm and float switches. etc.) " h
►ISTRIBUTION BOX: .15 � °
(locate on site plan)
Depth of liquid level above outlet invert: .LA 0 -TS r
Comments: -
(note if level and distribution is equal. evidence of solids carryover evidence of leakage into or out of box..etc:)
-® �O
NG t C".Avt u
PUNIP CHAMBER:_
(locate on site plan)
Pumps in working order: (Yes or No)
a r
Alarms in working order (Yes or No)
Comments: �.
(note condition of pump chamber, condition of pumps and appurtenances, etc.)
4
(rev6cd 041255197) P2ge 7 of 10
SU
BSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: r,'Ot ljk\�1
O«mcr: SUlkvio,,,_
Date of Inspection:
SOIL ABSORPTION SYSTEM (SAS):
(locate on site plan, if possible; excavation"not required, but may be approximated by non-intrusive methods)
WS
If not determined to be present, explain:
Type:
leaching pits, number:_
leaching chambers, number:_
leaching galleries, number:
leaching trenches. number.length:
leaching fields, number, dimensions:
overflow cesspool.
I,
P number:
Alternative system:
Name of Technology:
omments:
�te condition of soil, signs of hydraulic failure, level of ponding, condition of vegetatio etc.)
0%
W J N _
V
:SSPOOLS: _
=a(e on site plan)
-nber and configuration:
xh-top of liquid to inlet invert.
uh of solids layer:
nth of scum layer:
tensions of cesspool:
_rials of construction:
ration of groundwater:
inflow (cesspool must be pumped as par[ of inspection)
ments:
condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
Y:
on site plan)
9
als of construction:
Of solids: Dimensions:
ents:
ondition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
uizs197)
P2ge 8 of 10
r r
SUBSURFACE SEWAGE DISPOSAL. SYSTEM CtiSPECTION 'FORM
" PART C
SYSTEM INT'ORNLiLTION (continued)
Property Address:��, %4l vi
Owner: cj-A%VjPI
Date
t of Inspection: ,
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100' (Locate where puhlic water supply comes into house)
}
•N
m
a
Rz = r3e �Z rL i
Li
(fCYUcd 03:'_S,4') Pjgc 9 of to
SUBSURFACE SEWAGE DISI'OS,VL SYSTEI1. LtiSPECTION FORM
PART C
SYSTEM L\FORNIATION (continued)
Property Address: jt"tlRkKJ
O%�-ter: p Vj l
Date of Inspection:
Denth to Groundw'ate.' Feel
Please indicate all the methods used to determine High Groundµater Elevation:
Obtained from Design Plans on record
Observation of Site (Abuttirg proper}'. obsenatiun hole. basement sump etc.)
Determine it from local conditions
C'nc:k u ith Ic:aI Board of ival;it
Chc_k FENIA
Check pump:'1C
Chcck Ic,,�al ctca%ators. ,ns:ai:cs
Usc ISGS Da:a
" dust e eomF;e:rd)
DexrIr.hr , vncr ems:: uo:,:5 hcu �u:: cs:abi�shcd the Bic (,
h Grtur '.,a:c v E.eauan h tio
of �r �•• i ka '
(rc,i,ed 04._5 97) Page 10 of 10