HomeMy WebLinkAbout0257 OST.-W.BARN. RD - Health 257 Ost W/Barn. RED- -- -
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TOWN OF BARNSTABLE
LOC TION � ? O 3y71w A01PA- 1') SEWAGE #
VILLAGE C�5/ ASSESSOR'S MAP & LOT
R�9 ER NAME&PHONE NO.�edkco j�
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) (size)
NO.OF BEDROOMS "~
BUILDER OR WNER /All
PERMITDATE: COi CE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
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COMMONWEALTH OF MASSACHUSETTS
Z W EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
n F
+ d DEPARTMENT OF ENVIRONMENTAL PROTECTION
RECEIVED
�qM s�0v
/� v 350 MAIN STREET . APR 2 7 2003
/r WEST YARMOUTH,MA
508-775-2800 TOWN OF BARNSTABLE
HEALTH DEPT.
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
P v 5 PART A
CERTIFICATION
Property Address: 257 OSTERVILLE WEST BARNSTABLE ROAD
OSTERVILLE,MA 02655 i
Owner's Name: PINKAVA,JOHN
Owner's Address: 275 WOODSIDE DRIVE
WEST BARNSTABLE,MA 02668
Date of Inspection APRIL 14,2003
Name of Inspector:(please print) -JAMES D.SEARS
Company Name: A&B Canco .
Mailing Address: 350 Main Street-
West Yarmouth,MA 02673
Telephone Number: 508-775-2800
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 G
Conditionally Passes
FNeeds Further Evaluation by the Local Approving Authority -
' ils
Inspector's Signature: Date:' 7 -/
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. 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 tot he 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 1
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Page 2 of 11 `
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 257 0STERVILLE WEST BARNSTABLE ROAD .
OSTERVILLE,MA 02655
Owner: PINKAVA,JOHN
Date of Inspection: APRIL 14,2003
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: '
• r -
R ,
B. System Conditionally Passes: N/A
_ 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)iri�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 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: ^;
` t
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)"
r
broken pipe(s)are replaced
obstruction is removed
ND explain:
Title 5 Inspection Form 6/15/2000 2
Page 3 of l l
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(CONTINUED)
Property Address: 257 OSTERVILLE WEST BARNSTABLE ROAD
OSTERVILLE,MA 02655
Owner: PINKAVA,JOHN
Date of Inspection: APRIL 14,2003--
C. Further Evaluation is Required by the Board of Health: N/A
Conditions exist which require further evaluation by the Board of Health in order to detennine 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 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
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 public water supply.
The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a
private water supply well**. Method used to detennine 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:
i
Title 5 Inspection Form 6/15/2000 3
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Page 4 of 11 ' _� '•° ,F n� a° t a
OFFICIAL INSPECTION FORM`—NOT FOR VOLUNTARY ASSESSMENTS_,
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(CONTINUED)
Property Address: 257 OSTERViLLE WEST BARNSTABLE ROAD 4 .
OSTERVILLE,MA 02655
Owner: PINKAVA,JOHN'
TS
Date of Inspection: APRIL 14,2003
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each`of the following for all inspections:
Yes No
✓ . Backup of sewage into facility or system corponent due to overloaded or clogged SAS or cesspool'='
✓ Discharge or ponding of effluent to thersurface of the ground or surface waters'.due to an overloaded
or clogged SAS or cesspool
N/A Static liquid level in the distribution box above outlet invert-due to adoverloaded or clogged SAS or
cesspool ,' k
✓ Liquid depth in pit is less than 6"below invert or available volume is less than'/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 SAS,cesspool or privy is below high ground water elevation
✓ Any portion of cesspool orprivy is within 100 feet of,a surface water supply or tributary,to a ?
surface water supply a,
✓ 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 or less than 5 ppm,provided that no other
failure criteria are triggered. A copy of the analysis must be attached to this form.)
q
NO (Yes/No)The system fails.1have determined,thafone 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 Systems: N/A .
To be considered a large system the system must service a facility with a'design flow of 10,000 gpd to., t .p
15,000 gpd.
'You must indicate either"yes"'or"no to each of the.following
(The following criteria apply to laige;sy§teris 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
r the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area_IWPA)or a 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
z. •'Q-yes"in Section D above the large system is failed. The owner or operator of any large system_ considered a significant a
.1 threat under Section E or failed`under Section D shall upgrade the system,in accordance with 3106CMR 15:304. The_, ,-%
i
n system owner'should contact the appropriate regional office of the Department., ; h>
Title 5 Inspection Form 6/15/2000 4 x
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Page 5 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
. CHECKLIST'
Property Address: 257 OSTERVILLE WEST BARNSTABLE ROAD
OSTERVILLE,MA 02655
Owner: PINKAVA,JOHN
Date of Inspection: APRIL 14,2003
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 nonnal flows in the previous two week period') \
J Have lar e volumes of water been introduced to the system recently or as art of.this inspection?
g .. . Y Y p P
N/A 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)has been determined based on:
Yes No ;
N/A 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)[3.10 CMR 15.302(3)(b)] `
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Title 5 Inspection Form 6/15/2000 5
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Page 6 of 1 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 257 OSTERVILLE WEST BARNSTABLE ROAD
OSTERVILLE,MA 02655
Owner: PINKAVA,JOHN
Date of Inspection: APRIL 14,2003. "
FLOW CONDITIONS
RESIDENTIAL
Number of Bedrooms(design): 3 Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd z#of bedrooms: 330
Number of current residents: 0
Does residence have a garbage grinder(yes or no): 'NO
Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required]
Laundry system inspected(yes or no): YES
Seasonal use(yes or no): NO y
Water meter readings,if available(last 2 years usage(gpd)): N/A
Sump pump(yes or no) NO
Last date of occupancy: OVER 12 MONTHS
COMMERCIAL/INDUSTRIAL '
Type of establishment:
Design flow(based on 310 CM 15.203):
Basis of design flow(seats/persons/sqft,etc.):
Grease trap present(yes or no):
Industrial waste holding tank present(yes or no):
Non-sanitary waste discharged to the Title 5 system(yes or no): ;
Water meter readings,if available:
Last date of occupancy/use:
OTHER(describe): '
GENERAL INFORMATION t
Pumping Records `
Source of information: N/A -
Was system pumped as part of the inspection(yes or no): NO
If yes,volume pumped: gallons—How was quantity pumped detennined?
Reason for pumping: '
TYPE OF SYSTEM ,
J Soil absorption system
./ 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 copy of the DEP approval
Other(describe):
Approximate age of all components,date installed(if known)and source of information:
UNKNOWN
Were sewage odors detected when arriving at the site(yes or no): NO
Title 5,Inspection Form 6/15/2000 6
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OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 257 OSTERVILLE WEST BARNSTABLE ROAD
OSTERVILLE,MA 02655
Owner: PINKAVA,JOHN
Date of Inspection: APRIL 14,2003
BUILDING SEWER(locate on site plan): ✓
Depth below grade: 8"
Materials of construction: Cast iron p! 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 onsite plan): N/A
Depth below grade:
Material of construction: concrete metal fiberglass polyethylene
_ other(explain)
If tank is metal list age: Is age continued by_a Certificate of Compliance(yes or no): (attach a copy of
certificate)
Dimensions: `
Sludge depth: -
Distance from top of sludge to the 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 were dimensions detennined:
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as
related to outlet invert,evidence of leakage,etc.):
GREASE TRAP(located on site plan)' N/A
Depth below grade: J
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.):
Title 5 Inspection Form 6/15/2000 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: 257 OSTERVILLE WEST BARNSTABLE ROAD
OSTERVILLE,MA 02655
Owner: PINKAVA,JOHN
Date of Inspection: APRIL 14,2003
TIGHT or HOLDING TANK: N/A (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:
Material of construction: concrete metal fiberglass polyethylene other(explain)
Dimensions:
Capacity: gallons
Design Flow: gallons/day
Alarm present(yes or no)
Alarm level: Alarn in working order(yes or no):
Date of last pumping
Comments(condition of alanri and float switches,etc.):
DISTRIBUTION BOX: N/A (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: N/A (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.):
. • ... • , •- �" . . 'y III
Title 5 Inspection Form 6/15/2000 8 a
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Page 9 of 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 257 OSTERVILLE WEST BARNSTABLE ROAD
OSTERVILLE,MA 02655
Owner: PINKAVA,JOHN
Date of Inspection: APRIL 14,2003
SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required)
If SAS not located explain why:
Type
./ leaching pits,number: 1
leaching chambers,number: '
leaching galleries,number
leaching trenches,number,length
leaching fields,number,dimensions:
overflow cesspool,number:
innovative/alternative system Type/name of technology:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of,
vegetation,etc.)
LEACHING IS ONE H-20 1,000 GALLON PRE CAST PIT WITH STONE.PIT AND COVER 3' BELOW GRADE
IN STONE DRIVEWAY.PIT DRY,NO SIGN OF OVERLOADING OR SOLID CARRYOVER. STAIN LINE AT
20".WALLS CLEAN.
MAIN CESSPOOLS: ✓ (cesspool must be pumped as part of inspection)(locate on site plan)'
Number and configuration: 1
Depth—top of liquid to inlet invert: DRY
Depth of solids layer: DRY
Depth of scum layer: DRY
Dimensions of cesspool: 6'
Materials of construction: BLOCK
Indication of groundwater inflow(yes or no): NO
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation etc.):
MAIN POOL 6' BLOCK. DRY WITH COVER AT 10".INLET TEE PVC,OUTLET TEE PVC.
•
PRIVY: N/A (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.)
Title 5 Inspection Form 6/15/2000 9 "
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Page 9 of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 257 0STERVILLE WEST BARNSTABLE ROAD '
OSTERVILLE,MA 02655_w_
Owner: PINKAVA,JOHN
Date of Inspection: APRIL 14,2003 . . r
SKETCH OF SEWAGE DISPOSAL SYSTEM'
Provide a sketch of the sewage disposal system including ties to at least two pennanent reference landmarks or.
benchmarks. Locate all wells within 100 feet. Locate•where public water supply enters the building.
.,
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Title 5 Inspection Forrn 6/15/2000 10 _
Page 1 1 of 1 1 a
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM"
PART C
SYSTEM INFORMATION(continued) _
4
Property Address: 257 OSTERVILLE WEST BARNSTABLE ROAD
OSTERVILLE,MA 02655
Owner: PINKAVA,JOHN
Date of Inspection: APRIL 14,2003
SITE EXAM '
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to no groundwater 14 `r` -feet
Please indicate;check)all methods used to detennine the high ground water elevation:
Obtained from system design plans on record-If checked,date of design plan reviewed:
%f Observation site(abutting property/observation hole within 150 feet of SAS) w
Checked with local Board of Health-explain: `
Checked with local excavators,,installers-(attach documentation -
Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
HAND DUG TEST HOLE 14"NO-WATER,TEST HOLE 5' BELOW BOTTOM OF PIT_
Title'5 Inspection Form 6/15/2000 11