Loading...
HomeMy WebLinkAbout0920 MAIN STREET (OST.) - Health (4) p .o r 92Q�'�I Main Street.(Ost )-,5, e 4 �Ost rville N �p (2 , A 117 058001 i . ° o ` o t ° , u , e , e ry` d v a " v ° , ° No. o [ 039 Fee �✓ THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 4pliration for Misposal *pstem Construction permit Application for a Permit to Construct( ) Repair X) Upgrade( ) Abandon( ) ❑Complete System Individual Components Location Address or Lot No. S (05�" Owner's Name Address and Tel.No. LD �. r` 0S i e t/'r' V fLL 4QF �otvt70 c Assessor's Map/Parcel ® �U UN tT� FlR (�i�-DI Cr ,i4-N �''t,.t T Installer's Name,Address,and Tel.No. T 09-4177_997'7 Designer's Name,Address,and Tel.No. d T)rpe of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) :T:_AjS (�(*L. G5?� �� --�.C) © �� Us t j* Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of h. /I SigM4 A VJLj Date Application Approved by Date —2 Application Disapproved by Date for the following reasons Permit No. 0 3 9 Date Issued a -. ,r e- j .is � ^•,f-.. ..yC -•. y,,��• ,,. '„f°r•.a....'S�,. .r�tin.;•�.y:. ..:m... ,y.Y. ,. No. Fee 75- THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS , Zipplicatio' n for -Mispboat"Opstem Construction Permit • r� t Application for a Permit to Construct( °) Repair>0 Upgrade( ) Abandon( ) ❑Complete System X Individual Components r' Location Address or Lot No:. � - �� -? Owner's Name,Address,and Tel.No. Assessor's Map/Parcel ( ® ._a1O LD UU t l S.,T A.dPt_:4X M A/ 'r Installer.'s Name,Address,and Tel.No. ;FOX-t/77 -BE T Designer's Name,Address,and Tel.No. nv r N 44 Type of Building: r Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date a Title Size of Septic Tank Type of S.A.S. Description of Soil-' Nature of Repairs or Alterations(Answer when applicable) =VKi., we_`). 14•.-" D . POG Uf t�-�(,5491. Date last inspected: Agreement: The undersigned agrees to ensure the construction and maigtenance of the afore described on-site sewage disposal system in, accordance with the provisions of Title 5 of the Environmental Code 1 not to place the system.in operation until a Certificate of Compliance has been issued by this Board of H alth. Sigrae n '"�" _ Date Application Approved by ( , Date t- 2 Application Disapproved by Date for the following reasons Permit No. -G 1 rl Q G► Date Issued .---_ - - •__ w_W- -.- .-_-. _ ..:.- - _.--_ - - - .- .: _ - -- - --- ----------------- n THE COMMONWEALTH OF MASSACHUSETTS Q L,� ✓'��"k BARNSTABLE,MASSACHUSETTS - -- Certificate of CotnpliancP ' THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(/X) Upgraded Abandoned( )by �� lrtJl, x�'a . 'LIS , `v at � � tij�.(�� 7` - _. _ has been constructed-in accordance_ -n` Si with the provisions of Title 5 and the for Disposal System Construction Permit No. u J Ll dated Installer d 0(kWjtj- E� !Q.� J Designer AIA J! #bedrooms Approved design flow e /� gpd The issuance of this permit+shall not be construed as a guarantee that the system will fiinct of n as designed Date ( f y c of E `y Inspector No. (2 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -BARNSTABLE,MASSACHUSETTS Misposal Opstem CarrstrUction J)Prmit Permission is hereby granted to Construct( ) Repair Upgrade( )- Abandon( ) System located at / 1 �j'7�ti --�"'`` /2 S' V//_L1.W" and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this permit. . ( /Date fir. f '� _ I Approved by ( s / �f t, �i�Ca��� COMMONWEALTH OF MASSACHUSETTS NOV 0 8 2004 EXECUTIVE OFFICE OF ENVIRONMENTAL1 `FhFAI.Rj!'T �E DEPARTMENT OF ENVIRONMENTAL PROTECTION MAPI ➢.l PARCEL, LOT a TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 920B Main Street Osterville,MA 02655 1 F Owner's Name: Terrence&Mariorie Huzzard j Owner's Address: . ti3i Date of Inspection: October 19, 2004 , Z, P` > El Name of Inspector: (Please Print)James M. Ford X Company Name: James M. Ford. Mailing Address: P.O.Box 49 a 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 F er Evaluation by the Local Approving Authority Fails Inspector's Signature: 7!�� Date: October 21. 2004 ' The system inspector shall sub 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 1 Page 2 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 920B Main Street . Osterville MA Owner: Terrence&Mariorie Huggard Date of Inspection: October 19. 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: 920B Main Street Osterville,MA Owner: Terrence&Mariorie Huggard Date of Inspection: October 19, 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: 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 any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a Y P 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. Tlie 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: 920B Main Street Osterville,AM Owner: Terrence&Mariorie Huggard Date of Inspection: October 19, 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 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.] 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 II 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 11 OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 920B Main Street Osterville.kM Owner: Terrence&Mariorie Huzzard Date of Inspection: October 19, 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 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE"DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 920B Main Street Osterville,MA Owner: Terrence&Mariorie Hug arg_d Date of Inspection: October 19, 2004 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): n/a Number of bedrooms(actual): 2 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 220 Number of current residents: 0 Does residence have a garbage grinder(yes or no): n/a Is laundry on a separate sewage system(yes or no): n/a [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 COMMERCIALANDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,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: AQe unknown-orikinal system Were sewage odors detected when arriving at the site(yes or no): No 6 Page 7 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 920E Main Street Osterville,MA Owner: Terrence&Mariorie Huggard Date of Inspection: October 19, 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) (Cesspool acting as a septic tank) Depth below grade: Steel cover to grade Material of construction: concrete metal _fiberglass _polyethylene ✓ other(explain) Cesspool block If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of certificate) Dimensions: S'W x 3.S'T x S'bottom to grade Sludge depth: -- Distance from top of sludge to bottom of outlet tee or baffle: -- Scum thickness: 1" Distance from top of scum to top of outlet tee or baffle:. -- Distance from bottom of scum to bottom of outlet tee or baffle: -- 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.): The cesspool had]'of liquid on the bottom. An outlet tee was present. 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 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 920B Main Street Osterville,MA Owner: Terrence&Mariorie HuQQard Date of Inspection: October 19, 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: Qallons 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: None (if present must be opened)(locate on site plan) 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.): 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.): t 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: 920B Main Street Ostervilk AM Owner: Terrence&Mariorie Hug armed Date of Inspection: October 19 2004 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,numbe r: leaching chambers,number: leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: ✓ overflow cesspool,number: 1 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.):, The overflow cesspool was 6'W x 9'T x 1 D S'bottom to grade and was dry. The scum line was approximately Y up from the bottom The cover was 12"below grade There did not appear to be any signs offailure. 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 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 920B Main Street Osterville, MA Owner: Terrence&Mariorie Huggard Date of Inspection: October 19, 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. A a 6 yo y(. a- 10 ' • M Page 11 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property.Address: 920B Main Street Osterville,MA Owner: Terrence&Mariorie Huzzard Date of Inspection:. October 19, 2004 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 50+/- feet Please indicate(check)all methods used to determine the high ground water 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 Barnstable topographic maps andwater contours maps the maps were showing approximately 50'+1-to groundwater 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 andlor this report. 11 ' - . COMMONWEALTH OF MASSACHUSETTS �t{0.�' EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS *� DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET, BOSTON MA 02108 (617)292-5;f500 vr® JUN 2 � 8 t 1040r 200� a, �.,%- 7; COXE . � . � See�e�tary� ARGEO PAUL CELLUCCI q? DAVID B.s - S Governor Co mmissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A - CERTIFICATION Property Address: 920B Main Street, Osterville, MA Name of Owner: Paul Davis Address of Owner: 235 Oturch Road Date of Inspection: May 23, 2000 Winnetka, IL 60093 Name of Inspector: (Please Print) James M. Ford I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000) Company Name: James M. Ford Mailing Address: P.O. Box 49, Osterville, MA 02655-0049 Map: Telephone Number: (508)862-9400 Parcel. 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: ✓ Passes Conditionally Passes Needs Further Eval n By the Local Approving Authority ails Inspector's .Signature: Date: May 25, 2000 The System Inspector shall submi 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 the system owner and copies sent to the buyer, if applicable,and the approving authority. NOTES AND COMMENTS revised 9/2/98 Page Iof11 Printed on Recycled Paper r -4K SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM t`t PART A CERTIFICATION (continued) Property:Address: 920B Main Street, OsterWle, MA Owner: ye,t: Paul Davis Date of Inspection:, May 23, 2000 INSPECTION SUMMARY: Check A, B, C, or D: A. SYSTEW PASSES: ✓ I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist. Any failure criteria not evaluated are indicated below. COMMENTS: B. 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 exfiltration,or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken,settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health) broken pipe(s)are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed i revised 9/2/98 Page 2of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 920B Main Street, Osterville, MA Owner: Paul Davis Date of Inspection: May 23, 2000 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 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: 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 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 to a surface water supply or tributary to a surface water supply. The system has aseptic tank and soil absorption system and the SAS is within a Zone 1 of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a } private water supply well,unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less .. than 5 ppm.'Method used to determine distance (approidmation not valid). 3) OTHER revised 9/2/98 Page 3of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 920B Main Street, Osterville,MA Owner: Paul Davis Date of Inspection: May 23, 2000 D. SYSTEM FAILS: You must indicate either"Yes"or "No" as 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 1h day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped_. Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone 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: You must indicate either"Yes"or"No"as to each of the following: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone II of a public water supply well The 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 4of11 9 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 920B Main Street, Osterville, MA Owner: Paul Davis , Date of Inspection: May 23, 2000 Check if the following have been done: You must indicate either"Yes"or"No" as to each of the following: Yes No E ✓ _ 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. n/a 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 manholes were uncovered,opened,and the interior of the septic tank was inspected for conditions 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. For 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) [15.302(3)(b)l• ✓ _ The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of SubSurface Disposal Systems... revised 9/2/98 Page 5of11 p V SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 920B Main Street, Ostemlle, MA Owner: Paul Davis Date of Inspection: May 23, 2000 FLOW CONDITIONS RESIDENTIAL: Design flow: n/a g.p.d./bedroom. Number of bedrooms(design): n/a Number of bedrooms(actual): 2 Total DESIGN flow n/a Number of current residents: 2 Garbage grinder(yes or no): No Laundry(separate 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 two year's usage(gpd): 1999-13,000 jeals.:1998-13.000 gals. Sump Pump(yes or no): No Last date of occupancy: 0grently occupied. COMMERCIAL/INDUSTRIAL: Type of establishment: Design flow: gad(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: Pumped in 1995-per owner. System pumped as part of inspection(yes or no): No 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 APPROXIMATE AGE of all components,date installed(if known)and source of information: Unknown Sewage odors detected when arriving at the site: (yes or no) No revised 9/2/98 Page 6of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 920B Main Street, Osterville, MA Owner: Paul Davis Date of Inspection: May 23, 2000 BUILDING SEWER: _ (Locate on site plan) . Depth below grade: Material of construction: _cast iron 40 PVC _other(explain) Distance from private water supply well or suction line Diameter Comments: (condition of joints,venting,evidence of leakage,etc.) SEPTIC TANK: None (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: 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: Distance from bottom of scum to bottom of outlet tee or baffle: How dimensions were determined:: Comments: a (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.) GREASE TRAP: None 4 (locate on site plan) Depth below grade: Material of constriction: 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.) revised 9/2/98 Page 7of11 . r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 920B Main Street, Osterville, MA Owner: Paul Davis Date of Inspection: May 23, 2000 TIGHT OR HOLDING TANK: None (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: Alarm level: Alarm in working order:Yes_ No Date of previous pumping: Comments: (condition of inlet tee,condition of alarm and float switches, etc.) DISTRIBUTION BOX: None (locate on site plan) Depth of liquid level above outlet invert: Comments: (note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.) 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.) revised 9/2/98 Page 8of11 zf SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 920B Main Street, Osterville,MA .x Owner: Paul Davis ; Date of Inspection: May 23, 2000 SOIL ABSORPTION SYSTEM (SAS): ✓ (locate on site plan, if possible; excavation not required; location may be approximated by non-intrusive methods) If not located,explain: Type: . leaching pits, number: leaching chambers,number: leaching galleries,number: leaching trenches, number, length: leaching fields,number,dimensions: overflow cesspool, number: 1 Alternative system: Name of Technology: Comments: (note condition of soil, signs of hydraulic failure, level of ponding,damp soil,condition of.vegetation,etc.) 77ie overow cesspool was 6'Wx 9'Tx 10'6"bottom to grade. The cesspool was dry. The scum line was 3'w from the bottom. There were no signs of failure. CESSPOOLS: ✓ (locate on site plan) Number and configuration: I with overflow Depth-top of liquid to inlet invert: -- Depth of solids layer: 2" Depth of scum layer: 1" Dimensions of cesspool:5'W x 3'6"Tx 5'bottom to Qrade Materials of construction: Block , Indication of groundwater: None inflow(cesspool must be pumped as part of inspection). Comments: (note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.) The cesspool had I'of water on the bottom. The bottom to grade was 5'. 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.) revised 9/2/98 � Page 9of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 920B Main Street, Osterville, MA Owner: Paul Davis Date of Inspection: May 23, 2000 Map: Parcel: 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) rrronT q Al- f3� . 31 (• Aa- yo yu 13a" � i O revised 9/2/98 Page 10of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 920B Main Street, Osterville, MA Owner: Paul Davis Date of Inspection: May 23, 2000 NRCS Report name Soil Type Typical depth to groundwater USGS Date website visited Observation Wells checked Groundwater depth: Shallow Moderate Deep I� SITE EXAM Slope Surface water Check Cellar i Shallow wells Estimated Depth to Groundwater _Feet " Please indicate all the methods used to determine High Groundwater Elevation: I 4 Obtained from Design Plans on record Observed Site(Abutting property,observation hole,basement sump etc.) Determined from local conditions ✓ Checked with local Board of Health L Checked FEMA Maps Checked pumping records. Check local excavators,installers ✓ Used USGS Data Describe how you established the High Groundwater Elevation. &ust be completed) The bottom of the overflow cesspool to grade was 10'6". Using the Barnstable topographic map and water contours map, the maps were showing approximately 50' +/-to groundwater at this site. Using the Cape Cod Commission Technical Bulletin, the high groundwater adjustment for this site(MI W 29, Zone C, 4100)was 3.1'. 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. , revised 9/2/98 Page 11of1I