Loading...
HomeMy WebLinkAbout0835 MAIN STREET (OST.) - Health g-3S Yyc�%" �+�� 0�- . i ` TOWN OF BARNSTABLE LOCATION � `'� y w'AM 91 SEWAGE # VILLAGE �C ASSESSOR'S MAP & LOT INSTALLER'S NAME Si PHONE NO. SEPTIC TANK CAPACITY -jrOO t r LEACHING FACILITY:(type)-- �c ° (size) i ODD NO. OF BEDROOMS PRIVATE': WELL OR PUBLIC WATER y ,� BUILDER OR OWNER r� l rl9/U� �Ur _ DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No �r✓I f4-i N �i � O� +I Gommonwealth of Massach usetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 835 Main Street Properg Address TD Bank Owner information is required for every page. Oarne/s Name Osterville MA 02655 November 20 2018 City/Town Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. A. Inspector Information Patrick T. Sullivan lmportant: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. Name of Inspec{or Ready Rooter Excvating Company Name PO Box 89 02644 Company Address Forestdale City/Town 508-509-0802 State st12843 Zip Code Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); I have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: 1. X Passes 2. n Conditionally Passes 3. ! Needs Further Evaluation by the LocalApproving Authority 4. ! raits November 27 2018 The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. lf the system 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 form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: 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. tsin$ d@. rev 7l26t2O1A TiUe 5 Ofhcial Inspeclion Fom: Subsurfa@ Sewage Disposl System'Page'l of 18 Commonwealth of Massach usetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 835 Main Street Property Address TD Bank Owner information is required for eveq7 page. Owne/s Name Osterville November 20.2018 City/Town State Zip Code Date of Inspection G. lnspection Summary lnspection Summary: Complete 1, 2, 3, or 5 and all of 4 and ti. 1) System Passes: X 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: 2l System Conditionally Passes: n 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. Check the box for "yes", "no" or "not determined" (Y, f.f , Dfdf tor the following statements. lf "not determined," please explain. ,,' The septic tank is metal and over 20 years old* or septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or or tank failure is imminent. System will pass ying septic tank as approved by the Board ofinspection if the existing tank is replaced with Health. * A metial septic tank will pass inspection i!is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is than 20 years old is available !v !ru n ruo1 below): t5inso-doc . ev. 7 fZ;12O1 8 Tille 5 Official Inspection Form: Subsurfae Sewage Disposal System'Page2 of18 Commonwealth of Massach usetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 835 Main Street Property Address TD Bank Owner information is required for eveny page. Owner's Name Osterville November 20 2018 City/Town Zip Code Date of Insoection G. Inspection Summary (cont.) 2l System Gonditionally Passes (cont.): n pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. E Observation of sewage backup or break out or static water level in the distribution box due to broken or obstructed pipe(s) or due to a , settled or uneven distribution box. System will pass inspection if (with approval of Board ): ! broken pipe(s) are replaced tr obstruction is removed n distribution box is or replaced n no (Explain below): n UO (Explain below): E ttO (Explain below): Ev TY TY n n n N N N ! fne system required pumping more than 4 times a year $ue to broken or obstructed pipe(s). The system will pass inspection if (with approval of the Boa/ of Health): ZX Ev 3) Further Evaluation is Required bV t,tle Board of Health: n Conditions exist which require frytner evaluation by the Board of Health in order to determine if the a. 310 cMR 15. ct Public health, safety and the environment: n ! ! tr broken pipe(s) are replaced obstruction is removed !n !ru ND (Explain below): ND (Explain below): t5in$dG.rev 712612018 Title 5 Official Inspeclion Fom: Subsurfa@ Sewage Disposl Systffi' Page 3 of 18 Gommonwealth of Massach usetts Title 5 Official lnspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 835 Main Street Property Address TD Bank Owner information is required for every page Owne/s Name Osterville MA 02655 November 20 2018 City/Town Zip Code Date of Inspection G. Inspection Summary (cont.) ! Cesspoolor privy is within 50 feet of a surface water n Cesspoolor privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. 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: ,.,,I fne system has a septic tank and soil absorption s;rbtem (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a sqrface water supply. I fne system has a septic tank and SAS/nd 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 is, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: 4l System Failure Criteria Applicable to All Systems: You must indicate "Yes" or "No" to each of the following for all inspections: Yes n tr No x x Backup of sewage into facili$ 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 tsins9 doc. rcv 712612018 Title 5 Official Inspedim Fom: Subsurfa@ Sewage Disposal System ' Page 4 of 18 Gommonwealth of Massachusetts Title 5 Official lnspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 835 Main Street Property Address TD Bank Owner information is required for every page. Owne/s Name Osterville November 20.2018 Cig/Town Zip Code Date of Inspection C. Inspection Summary (cont.) 4l System Failure Criteria Applicable to All Systems: (cont.) 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 lz day flow Required pumping more than 4 times in the last year IVOI 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 water supply 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 wellwith no acceptable water quality analysis. flhis system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent 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 and chain of custody must be attached to this forml The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. 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. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either or "no" to each of the following, in addition to the questions in Section C.4. Yes No the system is 400 feet of a surface drinking water supply within 200 feet of a tributary to a surface drinking water supply is located in a nitrogen sensitive area (lnterim Wellhead Protection A) or a mapped Zone ll of a public water supply well Yes No uxnxnxnxnxnx !X !x nx NX !n ntr nn the s the s Area tsinso d@' rcv 7l2t3l2o'18 Title 5 Ofiicial Inspedion Fom: Subsurface Sewage Disposl System. Page 5 of 18 Gommonwealth of Massach usetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 835 Main Street Property Address TD Bank Owner information is required for every page Owner's Name Osterville MA 02655 November 20 2018 City/Town Zip Code Date of Inspection C. Inspection Summary (cont.) lf you have answered "yes" to any question in Section C.5 the system is considered a significant threat, or answered "yes" to any question in Section C.4 above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section C.4 shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate "yes" or "no" for each of the following tor all inspections: 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 normalflows 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? (lf 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 allsystem 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: 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(5)] Yes No xn NX x! !x X!xn x! xtrxn !X XN x! tsinsp doc. rcv 712:.6120'18 Title 5 Official Inspection Fom: Subsurfa@ Swage Disposl System . Page 6 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface sewage Disposal system Fomr - Not for Voluntary Assessments 835 Main Street Property Address TD Bank Owner infomation is required for every page. Owneis Name Osterville MA 02655 November 20 2018 City/Town Zip Code Date of Inspection D. System Information 1. Residential Flow Gonditions: Number of bedrooms (design): DESIGN flow based on 310 GMR Description: Number of bedrooms (actual): 15.203 (for example: 110 gpd x # of bedrooms): Number of current residents: Does residence have a garbage grinde? Does residence have a water treatment unit? lf yes, discharges to: ls laundry on a separate sewage system? (lnclude laundry system inspection information in this report.) Laundry system inspected? Seasonal use? Water meter readings, if availabb (last 2 years usage (gpd)): Detail: XNo XNo ! ! Yes Yes fl ves X No !YesE No !YesX No 2O16= Sump pump? Last date of occupancy: fl Yes X No Cunent tsine.dc. rev 7l26ln1A Tite 5 Oftcial lnsp€dim Fom: Subsrfae SeHge Disposl System . PqeT ot 1A Gommonwealth of Massach usetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 835 Main Street Property Address TD Bank Owner information is required for every page. Owne/s Name Osterville MA 02655 November 20 2018 City/Town Zip Code Date of Inspection D. System Information (cont.) Commercialllndustrial Flow Gonditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? Water treatment unit oresent? lf yes, discharges to: lndustrial waste holding tank present? Non-sanitary waste discharged to the Title 5 system? Water meter readings, if available: Last date of occupancy/use: Other (describe below): 225 Gallons per day (gpd) 2567 sq ft @75 qal per thousand ft nvesX No nvesX No !vesX No fl Yes X No 2017-2018= 110 GPD Current 3 Pumping Records: Source of information: Was system pumped as part of the inspection? lf yes, volume pumped: How was quantity pumped determined? Reason for pumping: Readv Rooter Records: Pumped 2016 !YesX No tsinspd@.rev 7a6m1a Title 5 Oficial Inspedion Fom: Subsurfae Sewage Disposal System. Page I of 18 Com monwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 835 Main Street Property Address TD Bank Owner information is required for every page. Owner's Name Osterville MA 02655 November 20 2018 City/Town Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: X Septic tank, distribution box, soil absorption system n 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) and a copy of latest inspection of the l/A system by system operator under contract Tight tank. Attach a copy of the DEP approval. Other (describe): Approximate age of all components, date installed (if known) and source of information. System installed over 35 years ago. Approx age of components. n tr n ! ! Were sewage odors detected when arriving at the site? Building Sewer (locate on site plan): Depth below grade: Material of construction: EvesX No feet n cast iron X +o pvc fl other (explain): Distance from private water supply well or suction line: Comments (on condition of joints, venting, evidence of leakage, etc.): tsine d@. rev 7ltl6l2o'18 Title 5 Official Inspection Fm: Subsurfa@ Swage Oisposl System. Page I of 18 Commonwealth of Massach usetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 835 Main Street Property Address TD Bank Owner information is required for every page. Owner's Name Osterville November 20 2018 City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank (locate on site plan): Depth below grade: Material of construction : X concrete f] metal feet fl fiberglass ! polyethylene n other (explain) lf tank is metal, list age:years ls age confirmed by a Certificate of Compliance? (attach a copy of certificate) n Yes E No Dimensions: Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle Scum thickness Distance from top of scum to top of outlet tee or baffle 10.5'x 5.5'x 5' 1500 qallons Distance from bottom of scum to bottom of outlet tee or baffle 13" How were dimensions determined?Dip tube and tape measure Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): lnlet and outlet concrete baffles in place. Liquid level at outlet invert. Risers bring covers within 6" of qrade. Recommend maintenance pumping every two years. 1 10" tsin$ doc. rev 7lil6m18 Tifle 5 Official Inspection Fom: Subsurfae Semge Disposl System. Page 10 cf 18 Commonwealth of Massach usetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 835 Main Street Property Address TD Bank Owner information is required for every page. Owne/s Name Osterville November 20.2018 City/Town State Zip Code Date of lnspection 7 D. System Information (cont.) Grease Trap (locate on site plan): Depth below grade: Material of construction: feet fl polyethylene! concrete n metal n other (explain): Dimensions: Scum thickness Distance from top of scum to of outlet tee or baffle Distance from bottom of 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.): 8. Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction : ! concrete n metal n fiberglass ! polyethylene n other (explain): Design Flow: tsinsp,dm. rev 7 li26l2o18 gallons per day Title 5 Omcial lnspeciion Fom: Subsurfa@ Sewage Disposal System ' Page 1'l of 18 Gommonwealth of Massachusetts Title 5 Official Inspection Form Subaurface Sewage Disposal System Form - Not for Voluntary Assessments 835 Main Street Property Address TD Bank Orvner information is required for every page. Olvne/s Name Osterville 02655 November 20.2018 Ci$/Town State Zip Gode Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank (cont.) Alarm present: Alarm level: Date of last pumping: Comments (condition of alarm and !Yes nruo Alarm in working order:! Yes nno Date switches, etc.): * Attach copy of current pumping contract (required). ls copy attached? Distribution Box (if present must be opened) (locate on site plan): ! Yes [] tto Depth of liquid level above outlet invert 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.): tsiN.dm.rev 7f6m1g f itte 5 Oficial lrepedim Fom: Subsurf@ Sewag€ Oisposal Systffi . Page 12 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Fom - Not for Voluntary Assessments 835 Main Street Property Address TD Eank Owner information is required for every page. Owne/s Name Osterville November 20 2018 City/Town State Zip Code Date of Inspedion D. System Information (cont.) 10. Pump Chamber (locate on site plan): Pumps in working order: Alarms in working order: Comments (note condition of pump ! Yes fl No. fl Yes fl No. , condition of pumps and appurtenances, etc.): '11 * lf pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): lf SAS not located, explain why: Type: X ! ! tr n ! n leaching pits leaching chambers leaching galleries leaching trenches leaching fields overflow cesspool innovative/alternative system Type/name of technology: number: number: number: number, length: number, dimensions: number: 'l-H-20 6'x 6'M stone tsine ds. rev 7lbmlA Tifl€ 5 Ofrctal krspedim Form: Subsurfffi Disposl Syslem 'Pag€ 13 d.18 Gommonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 835 Main Street Property Address TD Bank Owner information is required for evelry page. Owne/s Name Osterville 02655 November 20.2018 City/Town Zip Code Date of Insoection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Liquid level 40" below invert at time of inspection. High water staining 32" below invert. No sign of past hydraulic failure. Metal ring and cover brinqs cover to qrade. 12. Cesspools (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 Comments (note condition of soil Eves nuo of hydraulic failure, level of ponding, condition of vegetation, etc.): tsinso doc. rcv 7126DO18 Title 5 Otticial Inspeclion Fom: Subsurfa@ Semge Disposl System - Page 14 of 18 Gommonwealth of Massachusetts Title 5 Official lnspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 835 Main Street Property Address TD Bank Owner infomation is required for every page. Owneis Name Osterville City/Town November 20.2018 Zip Code Date of Inspection D. System lnformation (cont.) 13. Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of etc.): i signs of hydraulic fiailure, level of ponding, condition of vegetation, tsinsD doc. rev TliBlNlA Titte 5 Otrcial lnspectim Fm: Subsriae Sffige Di Systm . Page 15 of 18 Commonwealth of Massachusetts Title 5 Official lnspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 835 Main Street Property Address TD Bank Owner information is required for every page Owne/s Name Osterville November 20.2018 City/Town State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view 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. Check one of the boxes below: X hand-sketch in the area below n drawing attached separately T<r(r-r-z\- .-r---t'o(=cJ- fi7'a( .3.n. G.r'.\.\i)A A B tsine ds. rev 7nWn1A Title 5 Official Insp€ction Fom: Subsurfa€ Sewage DisPosal System'Page 16 of 18 Gommonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 835 Main Street Property Address TD Bank Owner information is required for every pa9e Owner's Name Osterville 02655 November 20 2018 City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ! Check Slope n Surface water n Check cellar ! Shallow wells Estimated depth to high ground water: >2 Please indicate all methods used to determine the high ground water elevation: ! Obtained from system design plans on record n tr lf checked, date of design plan reviewed: Observed site (abuttin g property/observation Checked with local Board of Health - explain: Date hole within 150 feet of SAS) n x Checked with localexcavators, installers - (attach documentation) Accessed USGS database - explain: maos. massors. tate. ma. us/oliver. pho You must describe how you established the high ground water elevation: Accessed local ground water contours and topo mapping. Adjusted ground water in area of system 12.5' below qrade. Base of leach pit 9' below qrade. Before filing this lnspection Report, please see Report Completeness Checklist on next page. tsinsD d@. rev 7l',2612018 Title 5 Offcial lmp€tion Fom: Subsurfa@ S#age Disposl System. Page lT of 18 Gommonwealth of Massachusetts Title 5 Official lnspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 835 Main Street Property Address TD Bank Owner information is required for everry page. Owne/s Name Osterville Gity/Town 02655 November 20 2018 TipCode Date of Inspection E. Report Gompleteness Checklist Gomplete all applicable sections of this form inclusive of: X n. Inspector lnformation: Complete allfields in this section. X A. Certification: Signed & Dated and 1, 2,3, or 4 checked X C. Inspection Summary: 1,2, 3, or 5 completed as appropriate 4 (Failure Criteria) and 6 (Checklist) completed X O. System lnformation: For 8: TighUHolding Tank - Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included tSiN ds. rev 7't&t2o16 Tife 5 Otrcial Insp€dim Fom: Subsrfae Sryage Disposl Systffi . Page 18 of 18