HomeMy WebLinkAbout0027 OLDHAM ROAD - Health 27 OLDHAM RO, OSTERVILLE
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COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTEC g
ONE WINTER STREET, BOSTON,MA 02108 617-292-5500
WILLIAM F.WELDBarbara hP4 "/�t/.� "
d! TRUDY CORE
Governor �Secretary
ARGEO PAUL CELLUCCI r0 0,�rys5 49-0 VID B,TRUHS.
Lt.Governor SUBSURFACE SEWAGE DISPOSAL SYST6CINSPECTION FO Commissioner
PART A -
,
CERTIFICATION
Property Address: 27 Oldham d.. ,Osterville ,MA Address of Owner: 27 Old.ha d�, -sterville
Date of Inspection: f•2 Q V (If different) MA
Name of Inspector: Wm E Robinson Sr
I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000)
Company Name: WM E Robinson Septic Serv; -e
Mailing Address: PO Box 1089 , C _ntPr ri 1 1 ,- MA 02632
Telephone Number] 5 0 8 7 7 5—R 7 7
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 sew ge disposal systems. The system:
Passes
_ Conditionally Passes
Needs Further Evaluation By the Local Approving Authority
Fails
Inspector's Signature: e�, G Date:
The System Inspector shall submit a copy of this inspection report to the Approving Authority 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.
INSPECTION SUMMARY: Check /A,J B, C, or D:
A] SYSTE PASSES: `
I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303.
Any failure criteria not evaluated are indicated below.
COMMENTS:
B] YSTEM 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.
Indic to 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) in 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 conforming septic tank
as approved by the Board of Health.
( vised 04/25/97) Page 1 of 10
DEP on the World Wide Web: http:Uwww.magnet.state.ma.usldep
CJ Printed on Recycled Paper
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SUBSURFACE SEWAGE'DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 27 Oldham Rd., Osterville
Owner: Barbara Pah
Date of Inspection: , 4
B] STEM CONDITIONALLY PASSES (continued)
R
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). Describe observations:
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
C] FU THER 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.
SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER
WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
_ Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT
HE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE
NVIRONMENT:
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 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).
OTHER
(zevieed 04/25/97) Page 2 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 27 Mftam Rd.. ,osterville
Owner: Barbar$ a
Date of Inspection: /2,XT- r
D] YSTEM FAILS:
You ust indicate ei;!,er "Yes" or "No" as to each of the following:
I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis
for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct
the failure.
x
Yes o
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 a cesspool 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] LAR E SYSTEM FAILS:
You m st 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 own r or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program
require is of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.
(revised 04/25/97) Page 3 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 27 Old.ham Rd.. ,Osterville
Owner: Barbara Pahl
Date of Inspection:
Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following:
Yes/ No
_ Pumping information was provided by the owner, occupant, or Board of Health.
_ None of the system components have been pumped for at least two weeks and the system has been receiving normal
flow rates during that period. Large volumes of water have not been introduced into the system recently or
as part of this inspection.
V _ 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 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:
_ The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of
Sub-Surface Disposal System.
Existing information. Ex. Plan at B.O.H.
_ Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is
unacceptable) [15.302(3)(b))
1
(revieed 04/25/97) Page 4 of 10
.SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 27 Oldham Rd.. , Osterville
Owner: Barbara Pah
Date of Inspection: l OZF�j
FLOW.CONDITIONS
RESIDENTIAL:
Design flow: —33 p.d./bedroom for S.A.S.
Number of bedrooms:
Number of current residents: 8
Garbage grinder (yes or no):AYR
Laundry connected to system'-(yes or no): 3
Seasonal use (yes or no):Xi-'�
Water meter readings, if available (last two (2) year usage (gpd): 1 9�)9 1 ��' 000 gal
Sump Pump (yes or no):L 1997 135, 090 gal
Last date of occupancy: �✓
COMMERCIAUINDUSTRIAL:
Type of establishment:
Design flow: gallons/day
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, a d source of information:'
System p ped as part of inspection: (yes or no)
If yes, volume pumped: gallons
Reason for pumping:
TYPE OF
WSTEM
✓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. Copy of up to date contract?
Other
APPROXIMATE AGE of all components, date installed (if known) and source of information:
Sewage odors detected when arriving at the site: (yes or no) 14,d
(revised 04/25/97) Page 5 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Addre 27 Oldham Rd.. ,Osterville
Owner: Barbara Pahl
Date of Inspection:��
BUILD( G SEWER:
(Locate o site plan)
Depth bel w grade:
Material construction: _cast iron _40 PVC_other (explain)
Distance rom private water supply well or suction line
Diamete
Comm s: (c ndition of joints, venting, evidence of leakage, etc.)
SEPTIC TANK:_
(locate on site plan)
.Depth below grader
Material of construction: t/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: IV f
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: a
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.) /AC .t/ �-+%^ . OAG
Sz.9. �-q
—T
GREASE TRAP:
(locate o site plan)
Depth be w grade:
Material f construction: _concrete _metal _Fiberglass Polyethylene —other(explain)
Dimensi ns:
Scum t ickness
Distan a from top of scum to top of outlet tee or baffle:
Distance rom bottom of scum to bottom of outlet tee or baffle:
Date of I st pumping:
Commen s:
(recom ndation 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 04/25/97) Page 6 of 10 .
I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 27 01J.ham Rd.. , Osterville
Owner: Barbara Pahl
Date of Inspection:f;L—0AT ti
TIGHT HOLDING TANK: (Tank must be pumped prior to, or at time, of inspection)
(locate on s to plan)
Depth belo grade:
Material of nstruction: _concrete _metal _Fiberglass _Polyethylene —other(explain)
Dimensions:
Capacity: gallons
Design flow: gallons/day
Alarm level: Alarm in working order_Yes, No
Date of pre sous pumping:
Comments:
(condition f inlet tee, condition of alarm and float switches, etc.)"
DISTRIBUTION BOX:
(locate on site plan)
Depth of liquid level above outlet invert: :. +
Comments:
(note if level and distribution is equal, eyid t of solids carryover, evidence of leakage into or out of box, etc.)
PUMP CHA)1a
(locate on siPumps in wder: (Yes or No)Alarms in wder (Yes or No)
Comments:
(note conditmp chamber, condition of pumps and appurtenances, etc.)
., (revised 04/25/97) Page 7 of 20
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 27 01d.ham Rd.. ,0sterville,
Owner: Barbara Pahl
Date of Inspection:Ja2—
SOIL ABSORPTION SYSTEM (SAS):
(locate on site plan, if possible;_excavation not required, but may be approximated by non-intrusive methods)
If not determined to be present, explain:
Type: l
leaching pits, number:_
leaching chambers, number:_
leaching galleries, number:
leaching trenches, number,length:
leaching fields, number, dimensions:
overflow cesspool, number:
Alternative system:
Name of Technology:
Comments:
(note condition of soil, signs of hydraulic failure, leveed of ponding, c9Dditio not vegetation, etc.)�a� O �bf Y'�-�GbSt L f LI SJ� aLL A)_ f '�.. „
CESS)ofpsoli
: _(locaite plan)
Numconfiguration:
Dept liquid to inlet invert:
Deptli s layer:
Deptu layer:
Dime o cesspool:
Mate co struction:
Indicf g oundwater:
lo (cesspool must be pumped as part of inspection)
Comments:
(note condition f soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
PRIVY:_
(locate on site Ian)
Materials of co truction: Dimensions:
Depth of solids-
Is'
(note condition f soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
(revised 04/25/97) Page a of 10
`SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 27 Oldham Rd . , Osterville
Owner: Barbara Pahl
Date of Inspection: / �
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100' (Locate where public water supply comes into house)
i 1
SIi a
S � i„- I k?
e
(revised 04/25/97) Page 9 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 27 .Oldham Rd.. , Osterville
Owner: Barbara Pahl
Date of Inspection:
Depth to Groundwater Feet
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from Design Plans on record
✓ Observation of Site (Abutting property, observation hole, basement sump etc.)
Determine it from local conditions
kCheck with local Board of health
Check FEMA Maps
Check pumping records
Check local excavators, installers
Use USGS Data
Describe in your own words how you established the High Groundwater Elevation. (Must be completed)
✓�s i/��1�: �I. a ! 5 5 7 43 0 1G r
r. .
(revised 04/2S/97) Page 10 of 10
,. No........... ........... F�$. .......... ..
THE COMMONWEALTH OF MASSACHUSETTS
tg
BOAR® OF HEALTH
OCR/ LJ.........OF.... - '............
Appltration f nr I it, as al Mirk.5 Tow3 rarttnn ramit
Application is hereK17,(:Z.0
for ae Per mit to Co truct ( or Repair ( ) an Individual Sewage Disposal
System at: �•l:. h f
..... ... ��. ........ --------------------............. .........................................................
/ at
-Addres or Lot
i Own � . , Address
aller Address
Q Type of Building Size Lot...
� �!i;� .Sq. feet
U Dwelling—No. of Bedrooms................. .__.............___....Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
Q' Other fixtures ------------------------------- - -
d -�---------------------------------•----•---------
W Design Flow........._. ......................gallons per person � ay. Total daffy flow..`.... _._______.______._gal s.
WSeptic Tank—Liquid capacity/ allons Length �...... Width...... . _ Diameter________________ Depth�__.�__.
x Disposal Trench—No. .................... Width_-._____•-______._ Total Length......__._`._._.__. Total leaching area--___---•------•---•sq. ft.
1 Seepage Pit No.__/------------- p ' g 7 q.____.. Diameter��-�_�?__. De th below mlet__�.��_.. Total leaching area._. s ft.
Z Other Distribution box ( Dosin -tank
a Percolation Test Results Performed by.. � ,��� �� £ � �jCDate.. / ...��-l_.__.
,a Test Pit No. 1.. _ minutes per inch Depth of Test Pit__Z_�Y,P Depth to ground water-__ l_�-___-
Gi, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
........................................==.........................................
••-------------------------------------------_-----
O Description of Soil �' 4� rZ_ ��'�`��.---•-....-----c'-�' �---.��-�~�-
t
U
W ---- -•-------------------------------------------------------------------------••--------------------------------------------.-----.---.-----------------------------....----------•-•-••••-••---•...
UNature of Repairs or Alterations—Answer when applicable__________________________________________________________________________________•-_-_-------.
... .---- ----
Agreement
L The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of i i LE y g g p y
5 of the State Sanitary Code— The undersigned further agrees not to place-the s stem in
operation until a Certificate of Compliance has been issued by the board of heal
3�
Sig d.--
.._ ._.. . _ .
Date
Application Approved By= f .. .... ----/- --7- --7-f-=....
Date
Application Disapproved for the following re ons:.......... .............................. ...^.__._
11 j . . . ................................Date..............—
Permit No................... '1 ,.....• ........ / _ i Issued.... ---••----••.............._4---•--------------.
��-�� .......
� Date t
f
No........... - y s FEs...._
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH _
---°" ............OF.../.---�>,/9 T GIF----------------
Appliratinn for Uhyoaa1 Works Tomuurtinn Vamit
Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal
System at: _
r cation-Address
----------- -•--------- f< =...... j1-----...........?..:....J'v-------------
Ow er ♦ Address
�Imstaller f Address
Type of Building - Size Lot___ly_�__e_�__�v__Sq. feet
U Dwelling—No. of Bedrooms__-------•••_17......................Expansion Attic ( ) Garbage Grinder ( )
Other—Type of:Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( )
04 Other fixtures _
W Design Flow_ __ ----- ___gallons per person per day. Total daily flow----._._..................gallons.
WSeptic Tank`—I tqutd;:capacity/� allons Length:__ __ Width. __ __ Diameter______ ________ Depth _ . .
x Disposal Trench No_ ____________________ Width.................... Total Length.................... Total leaching area____ �:----sq. ft.
Seepage Pit.No ______________ Diameter/��.- _. Depth'below mlet_ ..... _ _. Total leaching area__,.LX5 sq. ft.
Other Distribution box Dostn tank
'-' Percolation Test Results Performed by �./d' _fV1 i9f l 't> �S C Date__'.......................�_...
,--a Test Pit No. L." _ minutes peter.,inch Depth of Test Pit _�6�__ Depth to ground water.._.`.____.
w Test Pit No. 2................minutes,per inch Depth of Test Pit...._............... Depth to ground water........................
p4 ..------•-• --•••-••--_•-
,'
Descriptionoil-- ----------••• ------ ' ......
U ----- ;
W ----------------------------------------------------------------------------------------------------------------------------------------------------------------...........................
U Nature of Repairs or AIterations—Answer when applicable------------------------------------------------_________________...............................
-------------------------------------- ------ ........................................................................................................................................................
Agreement:
The tmdersigne&agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
1'1'•°•
the provisions of['1.:.T i i' 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the oard of health.
RIN
Signe _`" .--- - � -_------_--_-------------
Date
Application Approved By_.,.--le;yl
• -- - -- •r Date
�-
�'"
Application Disapproved for the following reasons:...........................V-------•••----•-----------•--------------•--•••----•---••-•••----•••--•••-_---
«.:,,, ,
Date
rp
PermitNo........................... = ----------------------- Issued_.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS H
BOARD ,rOF HEALTH
......:OF... E r! �04_4...................
Trrfifiratr ,af, Tuntlrltanrr
HI IS T TI, Y, That the Ina vidual Sewage Disposal System constructed { or Repaired ( )
by ----f�-r--�.- .----. .. ----- ------'-------------------------------------------------------•-----------•--------......----- ------- ------......-•-----.....-----....--
> Installer
has been installed in accordance with the provisions of' I 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No.- . - ............. dated__-___ x.
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
iDATE...:..:.....................•-----•-------------........-••---•---..._....._._.. Inspector................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF .HEALTH'
f 'rt,�... OF.:-�.�--�.2 _�:Y-- . c -�'� ----......._.. ,r
Mopo7n1ndividual
or"age!.&ISTposal
t inn rrntit
Permission is hereby granted =---`•••--------•------••---•-----•----•----•••--•-••-•••----••-•.......... ............
to Constru t or R/epair ( ) S stem
at No.40•= fir-•----•--� . J�-- -_
Street t^
as shown on the application for Disposal Works Construction Per it No A
Dated___.��-_7� ,T_____________
DATE` . � .__:"'___._�`_} 1 ��--•----------------------•---• of e t
--• -----•••-__--------•_
FORM 12'55 HOBBS & WARREN, INC., PUBLISHERS _
LOCATION ' SEVAGE PERC31T 930.
VILLAGE
IDSTA L L E R'S NAME S ADDaES-5-
�7, M
MULDER OR OWNER
DATE PERMIT I S S W f D
DAT E COMPLIANCE ISSUED.
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