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HomeMy WebLinkAbout0103 MAIN STREET (OST.) - Health 03 Main Street �- ste rville P P= 185 022 F -- , - " y 4 d p r e y o - TOWN OF BARNSTABLE LOQATION 1 o3 ✓yI41) Sr SEWAGE # A , ILLAG I ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY a ClUD (�6 to,7-5 / ova 'LEACHING FACILITY: (type) a" (size) NO.OF BEDROOMS 3 BUILDER OR OWNER GrA1 G 4-v1L PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility 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 of leachin facility) _..� / Feet Furnished by �n SPGU ion 1 C a B r c � 3 y a /7 3 I a a� a3 y DOI a9l S f -7&, _w S COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION RECEIVED MAY 1 9 2004 TOWN OF BARNSTABLE TITLE 5 HEALTH DEPT, OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 103 Main Street t Q 5 Osterville, MA 02655 [VAAP Owner's Name: Craig Janney PARCEL, ; Qz Z Owner's Address: 6506 E. Exeter Road Scottsdale, AZ 85251 LOB' Date of Inspection: April 22, 2004 Name of Inspector: (Please Print) James M. Ford Company Name: James M. Ford Mailing Address: P.O. Box 49 Osterville,MA 02655-0049 Telephone Number: (508) 862-9400 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 the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority F Inspector's Signature: Date: April 27, 2004 The system inspector shall sub t a copy of this inspection report to the Approving Authority(Board of Health or DEP) within 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 DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page I Page 2 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 103 Main Street Osterville, MA Owner: Craig Janney Date of Inspection: April 22, 2004 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: ✓ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any 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. Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined",please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 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 ND explain: 2 Page 3 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 103 Main Street Osterville,'AM Owner: Craig Janney Date of Inspection: April 22, 2004 C. 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 public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: Cesspools 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 any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has aseptic 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 SAS and the SAS is within a Zone 1 of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance "This system passes if the well water analysis, performed at a DEP certified laboratory, 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,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: 3 Page 4 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 103 Main Street Osterville, MA Owner: Craig Janney Date of Inspection: April 22, 2004 D. System Failure Criteria applicable to all systems: You must indicate either`yes"or"no"to each of the following for all inspections: Yes No ✓ Backup of sewage into facility or system component due to 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 ✓ 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 '/z 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 SAS, cesspool or privy is below high ground water elevation. ✓ Any portion of 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. [This system passes if the well water analysis, performed at a DEP certified laboratory,for cotiform 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,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] No (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large System: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd• You must indicate either`yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) 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 11 of a public water supply well If you have answered`yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 4 Page 5 of 1 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 103 Main Street Osterville, AM Owner: Craig Janney Date of Inspection: April 22, 2004 Check if the following have been done: You must indicate"yes"or"no"as to each of the following: Yes No ✓ Pumping information was provided by the owner,occupant, or Board of Health ✓ Were any of the system components pumped out in the previous two weeks? ✓ Has the system received normal flows in the previous two week period? ✓ Have large volumes of water been introduced to the system recently or as part of this inspection ? ✓ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ✓ Was the facility or dwelling inspected for signs of sewage back up ? ✓ Was the site inspected for signs of break out? ✓ Were all system components,excluding the SAS, located on site? ✓ Were the septic tank manholes uncovered, opened,and the interior of the tank inspected for the condition of the baffles or tees, material of construction,dimensions,depth of liquid,depth of sludge and depth of scum ? ✓ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes No ✓ Existing information. For example, a plan at the Board of Health. ✓ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)]. 5 Page 6 of 1 I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 103 Main Street Osterville, AM Owner: Craig Janney Date of Inspection: April 22, 2004 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Number of current residents: 0 Does residence have a garbage grinder(yes or no): Yes Is laundry on a separate sewage system (yes or no): No [if yes separate inspection required] Laundry system inspected(yes or no): No Seasonal use(yes or no): No Water meter readings, if available(last 2 years usage(gpd)): Unavailable Sump Pump(yes or no): No Last date of occupancy: Unknown COMMERCIAL/lINDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sqft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no) Non-sanitary waste discharged to the Title 5 system (yes or no): Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Unavailable Was system pumped as part of the inspection(yes or no): No If yes, volume pumped: _gallons-- How was quantity pumped determined? Reason for pumping: TYPE OF 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) Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight Tank Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: Date unknown Were sewage odors detected when arriving at the site(yes or no): No 6 Page 7 of l l OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 103 Main Street Osterville, MMA Owner: Craig Janney Date of Inspection: April 22, 2004 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction: _cast iron _40 PVC other(explain): Distance from private water supply well or suction line: Comments(on condition of joints, venting,evidence of leakage, etc.): SEPTIC TANK: ✓ (locate on site plan) Depth below grade: 2" Material of construction: ✓ concrete _metal _fiberglass _polyethylene _other(explain) If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of certificate) Dimensions: 2000 gal. Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle: 40" Scum thickness: 1" Distance from top of scum to top of outlet tee or baffle: 6" Distance from bottom of scum to bottom of outlet tee or baffle: 15" How were dimensions determined: Measuring stick Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage,etc.): Tees were present. The liquid level was even with the outlet invert. There did not appear to be any signs of leakage. Steel covers were to grade. GREASE TRAP: None (locate on site plan) Depth below grade: Material of construction: _concrete _metal fiberglass _polyethylene _other (explain): Dimensions: 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 baffle: Date of last pumping: Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): 7 Page 8 of I 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 103 Main Street Osterville, MA Owner: Craig Janney Date of Inspection: April 22, 2004 TIGHT or HOLDING TANK: None (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: _concrete metal _fiberglass _polyethylene _other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: ✓ (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Even Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover,any evidence of leakage into or out of box,etc.): The D-box was level. No solids were present. PUMP CHAMBER: None (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no) Comments(note condition of pump chamber, condition of pumps and appurtenances,etc.): 8 Page 9 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 103 Main Street Osterville, MA Owner: Craig Janney Date of Inspection: April 22, 2004 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type ✓ leaching pits,number: 2- 6'x 6'- 1000 gal. leaching chambers, number: leaching galleries; number: leaching trenches,number, length: leaching fields,number, dimensions: overflow cesspool;.number: Innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding,damp soil, condition of vegetation,etc.): One pit (#1) was dry and clean. The scum line was approximately 6"up from the bottom. The cover was T below grade. The other pit(#2)was dry. The scum line was approximately Y up from the bottom. The cover was 2'below grade. The bottom of each pit to grade was 8. There did not appear to be any signs of failure in either pit. CESSPOOLS: None (cesspool must be pumped as part of inspection)(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(yes or no): Comments (note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.): PRIVY: None (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.): 9 Page 10 of 1 I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 103 Main Street Osterville, AM Owner: Craig Janney Date of Inspection: April 22, 2004 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. r C C 6 c � 3 y a � a a 5 33 31 y 'a. 10 r Page 1 1 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 103 Main Street Osterville, MA Owner: Craig Janney Date of Inspection: April 22, 2004 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 30 +/- feet Please indicate (check) all methods used to determine the high groundwater elevation: Obtained from system design plans on record- If checked, date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) ✓ Checked with local Board of Health-explain: topographic and water contours maps Checked with local excavators, installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: Using the Barnstable topographic map and the Cape Cod Commission water contours map,the maps were showing approximately 30'+/-to ground water at this site. This report has been prepared and the system inspected and passed as of the date of inspection. This report is not a warranty or guarantee that the system will function properly in the future. There have been no warranties or guarantees, either expressed, written or implied, relating to the system, the inspection and/or this report. 11 I - TOWN OF BARNSTABLE I LOCATION 03 ��� SEWAGE # VI LLAGE O STory �- ASSESSOR'S MAP & LOT �S INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY a t711D _ LEACHING FACILITY: (type) O� �'' to, S (size) NO.OF BEDROOMS 3 BUMDER OR OWNER PERMITDATE: COMPLIANCE.DATE: Separation Distance Between the:.- Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist Feet on site or within 200 feet of leaching facility) Edge of Wetland and Leaching Facility(If any wetlands exist Feet within 300 feet of leachin facility) Furnished byn I U O I (%01 �`'o`'J - c� CON r I U\Y11 UI .B,a1'IIStl11)1C Deparinlelil of Ilcellh,Safely,and rrlvironnlcnlal Services 1,11blic 11ca1111 Division Dale 00 $ 367 Main Street,Ilymmis MA 02601 UAWWAMP- „CIU AIA93 JJ 'Jto 1639. � ITlle Scheduled OL I iilie `jF cc I d ' . )Soil Suitabilit ;i Assessment for Se►vage Disposal . Performed Ily: S. 70!L:C-- Wilncsscd Ily:_- `rXOkA16 ` _ L(7GA`IgION & GI,NE1tAL INVOftMA`I`ION Localion Address I� jY1� /h) «�' Owner's Nnme i/" 1/0 ©3F4XVl L Address _ Assessor's t,inp/I'nrcel: '��(r.0 A 9--oC? Engineer's Nnmc STEPHEN J. DOYLE & SSOC. / 42 Canterbury Lane NEW CONSTRUCTION v Itr-VA11 'telephone 9 East Falmouth, MA 0 536 - 534 Land Usc r5, 4.-L Slopes ,o) p-'z y -JA�I� npcs(a I Surface SRmcs � n Distances Isom: Open Water Ilody }3e�0 Il Possible et Aren Zov% n Drinking Waler Wcll f1, Drainnge Wny > 5-0 II I'lopelly Line tO It Qlher u S IMITC11: (Street nnme,dimensions of lot,cxnc(locations()('test holes&perc tests,locnlc wclimlds in proximity to holes) l G:�i'DG u1 FlZ ids,Lei _ r- r I'arenl innlerinl(geologic) Qr Depth to Iledrock 0/A Depth to Groundwaler: Standing Water in I lolc: '13�A Weeping Flom I'll fnce " WA lislimalcd Seasonal Iligh(iroundwnlcl _�'A�gsr�,t.. < tl„ �. Dr'I'I;RMINATION IVOI -I ASONA.I. IIIGII:`�Yi1`I'I�R.'I'A13L1, hiclhod Osed: Depth Observed slnoding in obs.hoic: in. Depth to soil mollies: Depth to weeping from side of obs.hole:. hl. Groundwnler Adjoslmcol tl. _ liulex Well/! _ _ IinndlnR I7n1e: _ _ Index Well level __ _ Atli. factor Adj.Choundwoler Level I'CItC()I.,A PION 'I CST `_ "''i)ill! 5^Iv`O��Ihllc li -^ Observnlino I tole ll 1 Z •I'ime at 9". Depth of I'm ..SG Sy' Time nl 6" Slml Pre-soak Timc (®r lo'J� kU to Thnc ff'V) End Lo-z Bale Min./Inch G Z <Z Site Suitability Assessment: Site Pnsscd Site Pniled: Addilioudl'I'esling Necdcd(YIN) Originnl: Public Ilcnitll Divislon C)hservnliou Ilole Dnln 'I'o Ile Completed oil clack j Copy: Appllennl 1)1;ET013SERVATION U** U1410c, 11ol it Ucplh trout Soil iforizoll WITC-4111rc Soil Color Soil 011ier Sill lince(ill.) (USIM) Nfolilifig (Sillicillic,Slolics,llooldetcs. im—Ycj) to'(R. -.S/Z ko'j 0, 5-/6 DEEP OBSERVATION HOLE LOCII Hole 11 OCIIIII I'loill Soil I folizoll SoilTexillic Soil Color Soil Mier Sill hice fill.) OISDA) (NIIIIISCII) Stolics,llooldcles. v A -T� Izu SAW) .--Z.,q DFUTOBSNAOIATION 11OLIP, LOG .11ole I/ DCpdl from Sill[I lot Imill SoilTC.-ollre Soil Color Soil Ulhcr Surface(ill.) (USDA) (NIIIIISCII) 1.4nlllhr g (Sillicillic,Sloot:s.IIIIIII(IcIcs. DEOPT. OUSLItVATION HOLI�l LOG Depth flool Soil Horizon Soil Soil Color Soil Odicr Surface(ill.) (IISPA) (Silliclurc,Slolics,lloollICIC.S. ............. IqIL(IAullSll!IIIIKL Me N13,11i Above 500 year flood boundary No Yes V/ Will1ill 500 yetir boull(Ijily No V Yes %Vlllllfl 100 year flood butiodrory No I/ Yes Lhiffli ()LNaIILuIjJLDLcr_uLtIng ill Does -at least four feet 01"11,111111-Mly Oc6ill-rillf; pervious material exist ill all ni-cas obscl-ved 1111olighoul file -11-c;l proposed F01- IIIC soil absorption SYSIC1117 x I r not, what is file depill or malu"111Y occurring ill9 Pul-violls IIIII(cl i,'117 I certify Illal on ((lale) 111 have passed file Soil evevaluatoreximilindoll'ipproved by file Depril-111licill of Ellivil-ollilICIIII'll llroIcclioll "'I'd Illill the -IbOvc 111,11)'SiS will lici-rol-illecl by Ille coll.sisicill will) the required Indoing, cxl)cl-(isc and cxl)cf'icllcc described in 3 10 CIVIR 15.017. Signature Dale 6.5-- 1 P,-0 0 TROY WILLIAMS 110 SEPTIC INSPECTIONS Certified by MA Department of Environmental Protectionv `�(508) 385-1300 19 Hummel Drive South Dennis; MA 02660o� FDA ' m COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMEN AL�k-FFAIRS` y DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET, BOSTON MA 02108 (617)292-5500 000c S G' JRUDY COXE Secretary ARGEO PAUL CELLUCCI � DAVID B. STRUHS Governor Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A 1 ' CERTIFICATION Property Address: 103 Mc,*-, Stre..e f . Name of Owner Gre-9 5 e-/1c, 0 S+e.r V" I(e Address of Owner: P.0. )3 o)c 838 Date of Inspection: 6 Ia0/OQ U S fe r V (( Name of Inspector:(Please Print) M Troy Vlfilliams I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000) 6 S C xnpany Name: Troy Wiliams Snntle Inanactlons Maine Address: 19 Hummel'Drive. So. Dennis MA 02660 Telephone Number: (508) 385-1300 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: 2 Passes Conditionally Passes Needs Further Evaluation By the Local Approving Authority . _ Fails Inspectors Signature: Is Date: 16 /070 IGO 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 thte system owner and copies sent to the buyer,if applicable,and the approving authority. NOTES AND COMMENTS Although system meets the minimum requirements set forth by the Massachusetts Department of Environmental Protection,certification is not to be construed as a guarantee of future working condition of system,piping or components. This inspection represents the conditions of the system on the Date of Inspection noted above. F revised 9/2/98 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 103 Main Street,Osterville,MA Owner: Greg Fossella Date of Inspection: June 20, 2000 r - INSPECTION SUMMARY: Check A, B, C, or D: A. SYSTEM PASSES: VI 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. SYSTEM CONDITIONALLY PASSES: /V/19 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 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 8-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 S y revised 9/2/98 Page 2of11 ` f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) 103 Main Street,Osterville,MA- Property Address: Greg Fossella owner: Date of Inspection: June 20,2000 , C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:,N/11 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 HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 15.303(1)(b)THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: 1 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 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 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 n revised 9/2/98 Pvgc3of,I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) 103 Main Street,Osterville;MA Greg Fossella Property Address: June 20, 2000 Owner: Date of inspection: D. SYSTEM FAILS: AJIA You must indicate 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 determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No 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. 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 acesspool 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. LARGE SYSTEM FAILS: A1119 - You must 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 greeter(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 owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional office of the Department for further information. revised 9/2/98 Page 4ofII t� SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST 103 Main Street,Osterville,MA Property Address. Gre Fossella Owner: g , Date of kspection: June 20, 2000 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•forat least two weeks and-the system has been-receiving imrmal 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. _ 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 manholeil woo 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. IFor.example, 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) / 115.302(3)(b)) The facility owner(and occupants,if different from owner) were provided with information on tha propermaintanan"of SubSurface Disposal Systems. revised 9/2/98 Page 5ofII f :a SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION - Property Address: 103 Main Street; Osterville,MA owner: Date of Inspection: Greg Fossella June 20, 2000 FLOW CONDITIONS RESIDENTIAL: Design flow: /1D g.p.d./bedroom. `��S��sw1 Number of bedrooms(design): $4- 12 umber of bedrooms(actual): 3 Total DESIGN flow 550 nw �Iwh Number of current residents: i Garbage grinder(yes or no):__yE.S Laundry(separate system) (yes or no):No; If yes, separate inspection required Laundry system inspected (yes or no) Seasonal use(yes or no):_No Water meter readings,if available(last two year's usage(gpd): 30,000 S a��o�s g$ _ �y.dd6 Sump.Pump(yes or no): NU Last date of occupancy: 13; COMMERCIALIINDUSTRIAL: N/.q Type of establishment: Design flow: a_pd ( Based on 15.203) Basis of design flow Grease trap present: (yes or no)_ Industrial Waste Holding Tank present:(yes or no) Non-sanitary waste discharged to the Title 5 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: dyes or no)­&O If yes, volume pumped: gallons Reason for pumping: TYPE OF 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 n APPROXIMATE AGE of all components, date installed Hf known) and source of information: 2 A/8 3 Sewage odors detected when arriving at the site: (yes or no) ��0 revised '9/2/98 Page 6ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM 1INFORMATION(continued) Property Address: 103 Main Street; Osterville,MA Owner: Date of hupecfm: Greg Fossella June 20, 2000 BUILDING SEWER: (Locate on site plan) Depth below grade: 18'4 Material of construction: cast iron_,/40 PVC_other(explain) Distance from private water supply well or suction line Diameter Ll Comments:(condition of joints, venting, evidence of leakage,etc.) SEPTIC TANK: (locate on site plan) Depth below grade:�� 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: 7 'x p?000 4c.11oN Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle:_ Scum thickness: /1/0/v!= Distance from top of scum to top of outlet tee or baffle: A16 S c- w+ Distance from bottom of scum to bottom of outlet tee or baffle:&- s How dimensions were determined: arc 6 c /r,&... Comments: - (recommendation for pumping, condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert, structur&Hntegrity, evidence of leakage,etc.) Ptic /c, I Cc. c c o �r.i c + �w ( c�l�. �r. 4 w•a 1 J J can K 4 s rc h /�. i s, ,.t "f- ,. ,..4 GREASE TRAP: / (locate on site plan) Depth below grade:_ Material of construction:_concrete_metal_Fiberglass _Polyethylene_other(explain) Dimensions: 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 baffle: Date of last pumping: 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.) A revised 9/2/98 Page 7of SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C Hj SYSTEM INFORMATION(continued) r Property address: 103 Main Street,Osterville,MA - Ownw: Da of Inspection: Greg Fossella ce - , June 20, 2000 TIGHT OR HOLDING TANK:1tllt-1 (Tank must be pumped prior to, or at time of, inspection) (locate on site plan) Depth below grade:_ Material of construction:—concrete—metal_Fiberglass—Polyethylene other(explain) Dimensions: Capacity gallons Design flow: gallons/day Alarm present ya Alarm level: Alarm in working order:Yes_>No " z Date of previous pumping: �: Comments: . . : .. ; (condition of inlet tee, condition of alarm and float switches,etc.) . . . t • DISTRIBUTION BOX: t' (locate on site plan) " 4' Depth of liquid level above outlet invert: d Comments: f g • (no a if le1vel and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) - —1 oic J c:i 'Jr e"r 1r W��- Vt. a1-�c w4 •h.e- 4 tt / S�:4 �, •�-/�, „i...�.� / -�a -t L ,o 4 $- 2 PUMP CHAMBER: ^//,a (locate on site plan) Pumps in working order:(Yes or No) .�„ Alarms in working order(Yes or No) Comments: m (note condition of pump chamber,condition of pumps and appurtenances,,etc' revised 9/2/98 Page 8ofII n .. - :fib' - SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 103 Main Street,Osterville,MA Owner: Greg Fossella Date of Inspection: g , June 20,2000 SOIL ABSORPTION SYSTEM(SAS): (locate on site plan, if possible; excavation not required, location maybe approximated by'non-intrusive methods) If not located,explain: Type: leaching pits, number: /x L L e- )` 7 '}�' w� }� 3 'f leeching chambers,number: leaching galleries,number._ leaching trenches,number, length: _ leaching fields, number, dimensions: overflow cesspool,number: Alternative system: Name of Technology: Comments: (not condition of soil, signs of hydraulic failure, level of ponding, damp soil, conditi n of vegetation, etc.) c� c f u.J �, �s �.�:J� L� �.. cam.•. CA u-'tu -� + &j o j �✓ r/r W, w o.- t✓ ✓� .�I h �1 N .-.•r c U ti t c.. •�c.. /yam e V Jr_h •-� 0 7-' r'U . Ii.!L L A r e-S t rt ems-j-- CESSPOOLS:A[/rq (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) Comments: j (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY:_V/9 (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 9/2/98 Page 9of I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued( Property address:Owner: 103 Main Street,Osterville,MA Date of Inspection: Greg Fossella June 20,2000 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) 6 U SLP�' 4c E 3t 46 revised 9/2/98 Page lootII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION"FORM PART C SYSTEM INFORMATION(corrtirr#ad) Property Address: 103 Main Street,Osterville,MA Owner: Greg Fossella Dane of Inspection: June 20, 2000 NRCS Report name N/4? Soil Type_ Typical depth to groundwater USGS Date website visited Observation Wells checked Groundwater depth: Shallow Moderate Deep SITE EXAM Slope V/ " Surface water ✓ Check Cellar Shallow wells Estimated Depth to Groundwater IB,/Feet Please indicate all the methods used to determine High Groundwater Elevation: �1 Obtained from Design Plans on record Observed Site iAbutting property, observation 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. (Must be completed) 1 ,L 5 S vi G (,..)t ✓1 o L-i J.,y y revised 9/2/98 Page a of II