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Home My WebLink About0063 OLDHAM ROAD - Health 63 Oldham Road, Osterville A= 120 - 109 1/ L�i�LtaiC BORTOL01"I'I CONSTRUCTION, INC.' 765 WAKEBY ROAD,MARSTONS MILLS,MA 02648 f a 508-771-9399 508428-8926 FAX: 508-428-9399 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A LL CERTIFICATION Property Address: 3 Q/d/Igo, s4-r'VI'/le M4 d o?&sS;— Date of Inspection: -.,77-gee . Inspector's Name: Owner's Name and Address:T -? a . ( _® A� rYl�l aza s.� CERTIFICATION STAT M NT• I certify that I have personally inspected the sewage disposal system at this address and that the informa tion reported below is true,accurate and complete as of the time of inspection. The inspection was per- formed based on my training and experience in the proper function auci maintenance of on-site sewage disposal ems. The System: Passes ' Conditionally Passes Needs Further E luation By th ocal Aproviug Authority Fails Inspector's Signature: Date: The System Inspector shall submit opy of this inspection report to the Approving authority within thir- ty(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. llYSPECTION MMARY• A)SYSTE�ASSES: N✓ I have not found any information which indicates that the system violates any of the failure criteria as defined in 31,0 CMR 15.303. Any failure criteria not evaluated are indicated below. B)SYSTEM CONDITIONALLY PASSES; One or more system components need to be replaced or repaired. The systein,upon comple- tion of the replacement or repair, passes inspection: Indicate yes, nor,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,cracked,structurally unsound,shows substantial infiltration or exfiltration,or tank failure is imminent. The system will pass inspection if the existing sep- tic tank is replaced with a conforming septic tank as approved by The Board of Health. Sewage backkup 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): - 1 - � c� SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Broken pipes)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'Pie Board of Health): Broken pipe(s)are replaced Obstruction is removed 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 THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 Feet of a surface water Cesspool or privy is within 50 Feet of a bordering vegetated wetland or a salt marsh. 2)SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER,IF APPROPRIATE)DETERMINES THAT THE SYSTEM IS FUNCTION- ING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: rption system and is within l00 Feet to a surface The system has a septic tank and soil abso water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and is with a Zone I of a public water supply well. The system has a septic tank and soil absorption system and is within 50 Feet of a private water supply well. The system has a septic tank and soil absorption system and is less than 100 Feet but 50 Feet or more from a private water supply well, unless a.well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from the facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. D)SYSTEM FAILS: 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. Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of eIluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. Static liquid level in the distribution box above outlet invert due to an overloaded or clog- ged SAS or cesspool. Liquid depth in cesspool is less than G"below invert or available volume is less than 1/2 day flow. Required pumping more than 4 times in the last year NO!due to clogged or obstructed pipe(s). Number of times pumped -2- SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) 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 I OO 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 coliforin bacteria,volatile organic compounds,ammonia nitrogen and nitrate nitrogen. E)LARGE SYSTEM FAILS: The following criteria apply to a large system in addition to the criteria above: The design flow of a system is 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: 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 I1 of a public water supplywell. The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Check if the following have been done: ✓ Pumping information was requested of the owner,occupant,and Board of Health. ✓None of the system components have been pumped for atleast two weeks and the system has been receiving normal flow rates during that period. Large volutnes 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 site. The septic tank manholes were uncovered,opened,and the interior of the septic tank was in- spected 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 or approximated by non-intrusive methods. -3- SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART 11 CIIECKLIST(continued) The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of Subsurface Disposal System SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION FLOW CONDITIONS - ' ' , J Design Flow: G� gallons Number of Bedrooms: Number of Current Residents: (/ Garbage Grinder: LDS _ Laundry Connected To System: VLOS.. Seasonal Use: Water Meter Readings, if available: - Last Date of Occupancy _�� /� C'OMMER ALODUSTRIAL• /Y6 Type of Establislunent: _ Design Flow: gallons/day Grease Trap Prescnt: (yes or no)_ Industrial Waste Holding Tank Present: _ Non-Sanitary Waste Discharged To The Title V System: Water Meter Readings, If Available: Last Date of Occupancy: OTHER: Describe) _ Last Date of Occupancy: GENET , INFORMATION PUMPING RECORDS and source of informa''tiyyu:—� '�� ..`:`. _ System Pumped as part of inspection: /YQ if yes,voTuirie pumped gallons y P Reason for pumping: TYPE SYSTEM: Septic,TanVDistribution Box/SoiI Absorption System Single Cesspool Overflow Cesspool Privy Shared System(If yes,attach previous inspection records,if any) Other(explain): APP OXIMAT AGE of all components,date i stalled(if known)ano source of information: O'er Sewage odors detected when arriving at the site: _ -4- SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C GENERAL INFORMATION (continued) SEPTIC TANK: Depth below grade:— Material of Construction:. ✓concrete metal FRP. Other (explain) Dimisions: 9: �.YCo' Y,5` Sludge Depth:- 3 Scum Thickness: Q Distance from top of sludge to bottom of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: ` wcle4 Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid / level in relation o outlet invert, structural integrity,evidence of leakage,etc.), �5 Q, /000 Q jail �s d GREASE TRAP: Depth Below Grade: Material of Construction: concrete nietal ' FRP Other (explain) — — — — Dimensions: Scum'thickness: Distance from top of scum to top of outlet tcc.or baffle: . Comments: (reconunendation 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.) TIGHT OR HOLDING TANK: AA Depth Below Grade: Material of Construction: concretc metal FRP Other(explain) Dimensions: Capacity: gallons Design Flow: gallons/day Alarm Level: Continents: (condition of inlet tee,condilion.of alarm and float switches;,ctc.)- - > DISTRIBUTION BOX: t/ Depth of liquid level above outlet invert: &-Aod Comments: (note if level and distribution is equal,ee` dcnce of solids carryover,evidence of leakage into or out of box,.etc.). PUMP CHAMBER: Q Pump is in working order: Comments: (note condition of pump chamber,condition of pumps and appurtenances,etc.) M -5- SUBSURFACE SEWAGE DISPOSAL SYSTEM .INSPECTION FORM PART C SYSTEM INFORMATION (cuMinued) SOIL ABSORPTION SYSTEM(SAS): (Locate on site plan, if possible;excavation not required,but may be approxinnated by non-intrusive methods) If not determined to be present,explain: _ .type: Leaching pits, number:1_Leaching chambers, number:__.Leaching galleries;nurnber: . Leaching trenches, number, length: Leaching fields, number, dimensions: - Overflow cesspool, number: Comments: (note condition of soil, signs of hydraulic failure level of nding, condition of vegetation, etc.) (�,-� - Ca�LL_ ''"Gy� !7-►_l�llll __..30a CESSPOOLS: Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer:_ _Dimensions of Cesspool: Materials of construction: Indication of groundwater: Inflow(cesspool must be pumped as part of inspection)— Comments: (note condition of soilk, signs of hydrai.ilic failure, level of ponding,condition of vegetation, etc.) PRIVY: /Y 4 Materials of construction: Dimensions: Depth of Solids: Comments: (note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.) — -------- -G - SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PA RT C - SYSTEM INFO11MATION (conlinuc(l) SKETCH OF SEWAGE DISPOSAL SYSTEM: Include ties to atleast two permanent references, landmarks or benchnmrks. Locate all wells within 100 Feet. r �3 S o DEPTH TO GROUNDWATER: , Depth to groundwater: i 7 Feet Method of Determination or Appr iniatiow. �)11�� i"�� 5 �� .�• � - 7 TOWN OF BARNSTABLE e� LOCATION(�0 3 G 1d hQ 4-21� IeOq-d SEWAGE # VILLAGE_ S ASSE OR'S MAP &LOT A0 9 a _ '0 KZ; NAME&PHONE N t''r`• SEPTIC TANK CAPACITY AOn 00` 6n k LEACHING'FACILITY: (type) � (size) NO.OF BEDROOM S � /f J BUILDER O �f rt 12&&I' 21 P" PERMITDATE: COMPLIANCE DATE: ' Separation Distance Between the: Maximum Adjusted Groundwater Table and 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 leaching facility) Feet Furnished by 7 m Sob" o 3y� S pit No ................ � B THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEA T �I Q.._W...N...------.OF....... �Q�.>F'/ ...5... Q-� /dam...................... Appliration for Dwpaii al Workii Tomitrnrtiun ramit Application is hereby made for a Permit to Construct or Repair ( ) an Individual Sewage Disposal System at: 3 c-04-111 Ile- Locatio •Addy — ��— � �+ t No.�X� e�!(!'t..... ----......... ....� ,5��..................... Y v was / Owner Addre� . a � ........ 1-•�-=--------•._........._ ,l ld.rl�. ✓O� i �1, ....... f' -- .. Ins aller Address /� �� Type of Building Size Lot_________L._ __S_o..Sq. feet U Dwelling—No. of Bedrooms.____________________________________Expansion Attic ( ) Garbage Grinder ( ) PL4 Other—Type of Building ....1U-e_&_e........... No, of persons____________________________ Showers ( ) — Cafeteria ( ) 114 Other fixtures •-•-• --------•--•-•••----•--••-----...-•-----------•---•--•------------..•---------•---------------------------•=--------••---------- W Design Flow..........3---3.__0....................gallons per person per day. Total daily flow...........�1._.�z___0.____.__________.gallons. WSeptic Tank—Liquid capacity/A a Pgallons Length................ Width................ Diameter__.__________-__ Depth................ x Disposal Trench—No,..,_________________ Widt _ otal ngth _______.__.___._._ Total leaching area....................sq. ft. 3 Seepage Pit No..... Q-0 0 �"eter.d___________ _ pt 1 ow et____._..._...._._._. Total leaching area..................sq. ft. z Other Distribution box ( Dosing tank - D A �G�12, p-.2v - 711. Percolation Test Results Performed by... _B �______________:-:::__,4....,.4at_:�Lf_.:____ Date.... ............... Test Pit No. 1____, ......minutes per inch Depth of Test Pit____________________ Depth to ground water........................ Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ - .... Ig Description of Soil --- 1 .. --••-•.............�- -=--- �' - -------_---_.. x x -•-•---•-•--------------------------------•-•--•--------------------•--••-•-.-...----••-----------------•-----•-----------------...•-•--------------••••--•--•-----•--•--------••-•---•---...__.....---- U Nature of Repairs or Alterations—Answer when applicable_______________________________________________________________________________________________ -•-•--=----••-•--------•--•--••-------•-------•----•-----------•---•----•--••----------•-------------------------------------••---------------------•-•__..-----------------------....__•-•---...__----- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of iITL 1Z 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 board of health. Sid ----- _____________________•---•--_-••-•-------------------------- -------------------------------- Date Application Approved By......... `"`'.. /6 '` L�lil . . +� - 7�- Date Application Disapproved for the following reasons: -•-•-••--•---------•----•-•-•-------•--------------------•______._---•-•-----..._.._...._ t ._.l' L �1 I.. Date Permit No.......... l' { Date----- --•-----------•....... THE FOLLOWING IS/ARE THE BEST IMAGES FROM POOR QUALITY ORIGINALS) IM A DATA (7) No.. ....T 4...... FnB...J. ...�""�.. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH c 1, r`... .;!..........OF.......:.............................../ /! Appliration for lliipustal Works Tomitrnrtiun ramit Application is hereby made for a Permit to Construct (s`)or Repair ( ) an Individual Sewage Disposal System at: , Ile— Ad Location:Address. /1 or Lot No. W \/ _ /i .......... •-•-•--•--•-.....•-••---•--••--•.......................... - �.. Owner Address;'/-- Installer M1 t j r Address d Type of Building Size Lot_.__...ff_______ _______Sq. feet U Dwellin No.•:of Bedrooms .......................... s Expansion Attic Garbage Grinder�+ g— P ( ) g ( ) PL4 :Other—Type of Building ....L...:................. No. ,;of persons............................ Showers ( ) — Cafeteria ( ) Other`fixtures ------- -----------------------•----===-----------•-------------------------------------•-----•-----._.._..-----..........--•------.......-•--•--- W Design Flow...........................................gallons per person per day. Total daily flow.............................................gallons. WSeptic Tank,=Liquid capacity...........;gallons Length................ Width................ Diameter_____-_--___-._- Depth................ x Disposal Trench iNo. .................... Width_ -.::........`Total Length��................ Total leaching area....................sq. ft. Seepage Pit No--------------------- Diameter._'..".r _..'. Depth-below•inlet.................... Total leaching area..................sq. ft. _.z /Other Distribution box ( ) Dosing tank '-' Percolation Test Results Performed''by.__ .. 7a ...... Date...- -2iW_.7.t --------__ . Test Pit No. 1.... X._minutes per in6 _ of Test Pit.................... Depth to groundwater ....._............_ Gx, Test Pit No. 2................minutes.per inch Depth of Test Pit.................... Depth to ground water........................ f •-•-••... . ._..... ------------------•---.-•--- O Description of Soil.............. . _.. ,�_ - - W ....................................................."t --------•------------------•-••------•-•-•---•-------••----•------•-----•......--------•-------•-•-•---------------..._........-------------- U Nature of.=Repairs or Alterations—Answer when applicable............................................................................................... ...............................•---••--•- - `'...................................................... z_----------------------- ....................................................... Agreement: ; The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of T IT 1E ;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 board of health. j =• Sigd...........................................••-.._........._......--••--•---••-•••-•--• ..........................-.... /� Date Application Approved BY - �• -0---4 Date: j'Application Disapprov#d for the following reasons:.......... ------------------------------------- -----------------------------------------•--•----.....----•-•-•-•---•-•.-•=-----•---------------•----•---••---••--•-•---•----•----•----•-•-•--•••------•...._..-- .. Date { PermitNo.-t....................................................... Issued....................................................... Data THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .................. ...................................................... Trrtifirtt#r of TI-Impliatta ,�-- THIS IS TO CERTIFY,,.That the IndiVidual Sewage Disposal System constructede�) or Repaired ( ) :..I CAL.-n�'_�. bY----------------••--••-•--- ............ ----•---..... 00... ......-•••--•• ••--•-•--- .---....-•-• ........................... ' .�. � i• Installer --� _.............................. __._.. has been installed in accordance with the provisions of TYR?4 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No. T _____17",.............. dated-----� .. •___x+}'r-_-_-_.__.---- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FU CTION SATISFACTORY. DATE................ --•--•.. .......... Inspector -----••-----------•-.. =.................................................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH '' :_ No._.......... FEE.,:,, ..0........... Disposal Works .Tons#r ion rrnti# Permission`is hereby .granted...................-_. -!�''� 'f r to Construct (-:')_or:Repair ( ) an Individual Sewage Disposal System atNo----..._..--•------------•----•-----•--••-•--...•• - ,:.e—i.ti ''Street as shown on the application for Dispos I'Works Construction Pe it .No..................... Dated..... ........... �• oar o .�.. DATE------` •-----I-P.C..----.....-•-••.......................... FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS U I i• .r.l T7ATA �AAAe F'LOw a 110 4 3 G.P.V. , SP`>.-ZL PIT - t ocx:no GAi.., S'uzw,,tiLL AeE.A l5o s.it. 19�p� SF 9 2.S = 3`1S G.PD. � BOTTOM AZT_ � � � ST=. ' ��. � �ISfs 34 I � s�. x 1 .o - 50 Cam.R D. *---- ToTA L � 25 o� •co,&t L`( - P j , PRO) 0 TbT FLD W - 33D 6.1?D. 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