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Home My WebLink About0863 MAIN STREET (OST.) - Health MAIN STREET, OSTERVILLE A- - 4 i ' y" •`BORTOLOTTI CONSTRUCTION, INC. 45 INDUSTRYAOAD';°MARSTONS`MILLS, MA 02648 t;: ... . 508-771-9399 508-428-8926 FAX: 508-428-9399 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM . PART A CERTIFICATION Property Address: Date Of Inspection Inspector's Name.. .Owner's Name and Address: yx-- V. CERTIFICATION STATEMENT: I Certify that I have personally Inspected the Sewage Disposal System at this address and that the inform - tion reported below is true,.accurate and complete as of the time of Inspection. The Inspection was perform- ed based on my Training and Experience in the Proper Function and Maintenance of On-Site Sewage Dis- posal Systems.The system: Passes Conditional) asses Needs Fu ,Ev` i n'By the Local Approving Authority Failur Inspector's Signature. ! Date t�! y� The System,inspector. hall submit a copy of this Inspection Report to the Approving Authority with 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: A) SYSTE PASSES: I have not found any Information which indicates that the System violates any of the fail ure criteria as defined in 310 CMR.15.303..Any Failure Criteria not evaluated are indi- cated below.: B) 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,nor,or not determined(Y,YN,OR ND). Describe.bases of determination in all instances. If"not determined",explain why not. t The Septic Tank.is Metal,Cracked,Structurally Unsound,shows Substantial Infiltration or exfil- !ration,or,Tank Failure is imminent. The System.will Pass Inspection if Existing Septic Tank - is Replaced with a conforming Septic Tank as Approved by the Board.Of Health. .Sewage Backup or Breakout or High;Static WatertLevel observed in the Distribution Box is clue 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): -1 - 'SUBSURFACE' SEWAGE DISPOSAL°SYSTF.M'IN5PECTION FORM �.: PART A , A CERTIFICATION (continued) Broken pipe(s)replaced Obstruction is removed Distribution Box is leveled 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. C) FURTHER EVALUATION I5 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,Safety and the Environment. 1)SYSTEM WILL PASS UNLESS BOARD OF HELATH 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 FUNCTION- ING"ING IN A MANNER THAT PROTECTS 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:Tributary to a Surface Water Supply. The System has,a Septic Tank and Soil Absorption System and is with a Zone 1 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. G 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 from pollution from the facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm..... .._. D)SYSTEM FAILS: '1 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 overload 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. Static liquid level in the distribution.box above outlet invert due to:an overloaded or clog ged,SAS or cesspool. - Ligwd'&lith in cesspool is leg§than V below invert or available.volume is less than 1/2 day flow. j Required pumping more than 4 times m.the last yearFNOT due to clogged or obstructed pipe(s). Number of times pumped I - 2 - rSUBSURFACE. SEWAGE,DISPOSAL SYSIIJM_1N51'ECTION FORM CERTIFICATION(continued) Any portion,of the Soil Absorption System,cesspool or privy is below the high groundwaler 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 1 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) LARGE SYSTEM FAILS:. e The following criteria apply to a large system in addition to the criteria above: . The design flow of a"system is 10,060 ggd 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: 4 ,._ 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 wat: er supply `The system is l.ocated'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 315 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART.B. CHECKLIST Check if the fo lowing have been done: Pumping information was requested of the owner,occupant,and Board of Health. _ one of the system components have been pumped for atleast 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. �As-built plans have been obtained and examined. Note if they are not available with N/Ai he facility or dwelling was inspected for signs of sewage back-up. The system does not receive non-sanitary or industrial waste flow. _ZThe site was inspected for signs of breakout. All system components,excluding the Soil Absorption System,have been located on site. _The septic tank'manholes were uncovered,'opened,and the interior'of the septic tank was in spectedrfor condition of bathes`or tees,material of construction,dimensions,depth of liquid, - _t zs aA>s v� .v k.€. epth o slutlge;depth of§cum. s�<.u f he size and location of the Soil Absorption System on the site tias'be`en determined based on existing information or approximated by non-intrusive methods.F - 3 - �•SUBSURFACE SEWAGE tDISPOSAL,SYSTEMy INSPECTION FORM PART B CHECKLIST(continued) / The facility owner(and occupants,if different from owner)were provided with information on. the proper maintenance of Subsurface Disposal System. u SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION FLOW CONDITIONS - RESIDENTIAL: Design Flow: gallons Number of Bedrooms: Number of Current Residents: Garbage Grinder: 'Laundry Connected To System: Seasonal Use: Water Meter Readings,if available: Last Date of Occupancy: COMMERCIALANDUS Type of Establishment: kel Desigq•Flow: gallons/da Grease.Trap resent: (yes r no) 9 Industrial,Waste Holding Tank Present// Non-Sanitary Waste.Discharged To The Title.V System•/X47— Water Meter Readings,If Available: Last Date of Occupancy: OTHER: (Describe) Last Date of Occupancy: GENERAL INFORMATION ATI N PUMPING RECORDS any source of information: System Pumped as part of inspection: ff yes,vbfurne.pumpeV gallons Reason for Pumping: �Xic SYSTEM: Tank/Distribution Box/Soil Absorption System Single Cesspool Overflow Cesspool Privy Shared System(If yes,attach previous inspection records,If any) Other(explain): AVRROXIMATE AGE of all components,,date installed.(if-known)and source of information: f. Sewage,odors detected when arriying.at.the site: -4- SUBSURFACE SEWAGE' DISPOSAL`SYSTEM INSPECTION FORM PART C GENERAL INFORMATION (continued) SEPTIC'TANK: �, Depth below grade: Material of Construction: ✓concrete - metal FRP Othei• (explain) Dimensions: ludge Depth:--42zzKg Scum Thickness:, Distance from top of sludge to bottom of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffler Comments: (recommendation for pumping,conditioin of inlet`and outlet tees or baffles,depth of'liquid 1 vel in relation to outl invert,structural integrity,eyide a of leakage etco%,(� Q a. zooai oz- GREASE'TRAP Depth Below Grade: Material of Construction: concrete metal FRP . Other (explain): Dimensions: Scum Thickness: Distance from top of scum to top of outlet tee or baffle: Com►ilents:.(recommendation for`pumping,"condition of inlet and outlet.tees or baffles;deptkof liquid level ' in_rela.tion,to.outlet:inyert,structural:integrity,;evidence'of leakage;etc.)=. ,4: _ a.y.�.}. r.•,.,--;l,p ► 5 TIGHT OR HOLDING TANK:— _ ncr t me F Other Depth Below Grade: Material of Construction: co e e tat RP � O p (explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm Level: Comments: (condition of inlet tee,condition of alarm and float switches,etc.) DISTRIBUTION BOX: Depth of liquid level above outlet invert: Comments: (no Y level and distribution is a al,evidence of solids car yover,evidence of leakage into or (oout9f b x,etc. �� 7" GL� 22212 PUMP CHAMBER: Pump is in working rder. Comments: (note condition of pump chamber,condition of pumps and_appurtenances;etc.) '- A " SUBSURFACE SEWAGE'DISPOSAL'SYSTEM INSPECTIONFORM w 'PART.0 SYSTEM INFORMATION(continued) SOIL ABSORPTION SYSTEM(SAS): (Locate on site plan,if possible;excavation not required,but may be approximately by non-intrusive methods) if not determined to be present,explain: Type: Leaching pits,number: l Leaching chambers,number: Leaching galleries,number: Leacahing trenches,number,length: Leaching fields,number,dimensions: Overflow cesspool,number: mments:(note conidtion ofsojl,,signs of hydraulic failur level of pon 'ig condition of vogetation,etc.)_ CESSPOOLS: 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) f Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation, etc.) PRIVY Materials of construction: Dimensions: Depth of Solids: Comments: (note condition of soil,signs of hyddraulic failure,level of ponding,condition of vegetation, etc.) - 6 SUBSURFACE SEWAGE.,DISPOSAL�SYSTIJM INSPECTION—FORM w t: PART'..0 ,.. SYSTEM. INFORMATION•(continued) SKETCH OF SEWAGE!DISPOSAL-SYSTEM o, Include ties to atleast two permanent references,landmarks`or ben'c'1.ks. Locate all wells within 100 Feet..,, ; r y , r, _ a. a.. ... #FS ��i. r ' s ' � ,�� c% <x�t} �.""�I^ ^wvs '�s d �t ,. :s .n ��,Jhl i 3 sri,�¢�y 9 y� - 4 +�f• � ,��` _ - - s u 4 r a 5 _ DEPTH TO GROUNDWATER: " y Depth to groundwater: eet f✓ "k ,' Method of Determination or Approxim tion: ,.)'1 !"'I^O�l --4( �� t"-k 7 4 4 r 764