HomeMy WebLinkAbout0362 SEAPUIT ROAD - Health 362 SEAPUIT ROAD, OSTERVILLE
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TOWN OF BARNSTABLE
�,/ C� ���J/ h SEWAGE #
LOCATION .%�o� DA tJ�J �/��/ 4 /LD .
VII.LAGE� !// O&SS, ASSESSOR'S MAP LOT
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY
e
LEACHING FACILITY: (type.)) --0;'Y (size)
NO.OF BEDROOMS
BUILDER OR OWNER � J
PERMITDATE: 1`GGS 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 fe lea ing f ility) _ Feet
y Furnished b
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TOWN OF BARNSTABLE
LOCATION I D SEWAGE # �
VILLAGE 5Ee % !! i'a ASS SSOR'S MAP & LOT
INSTALLER'S NAME&PHONE NO. .- dfi' aEi
SEPTIC TANK CAPACITY
—LEACHING FACILITY: (type) (size)
:.f NO.OF BEDROOMS f
BUILDER OR OWNER -iF/&
PERMTTDATE: COMPLIANCE DATE: S
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 fen of leaching facility) Feet
Furnished by �� hl��e�x U,� 4W 3-.30
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Commonwealth of Massachusetts
Executive Office of Environmental Affairs "
t
®epartmant of
Environmental Protection .
V Trull Coxe
WOam F.Weld :. s.er«uy r
Argao Paul Glluccl David B.Struhs
. SUBSURFACE 52"%1'aE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION o-
Property Addrda: .3 6 2 et S e a p U z t. Road O s t e r V i l l e Address of Owner.
Date of In�peotjons 3/3[7/ 7 (It different)'
Name of Inspector. 'Joseph P. Macomber Jr.
Company Nance,Address and Telephone Number.
J:P.Macomber & Son, M. Box 66 Centerville,Mass. 02632
568-775-3338 ..
I
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage a:sroaal system at this address and that the information reported below is true,acpurata j
•and complete as of the time of inspection. The Lr-ipection was performed based on my training and ex&riencs in the proper function and
maintenance,of on-sits sewage disposal systems. h r,';tee:
Passes
i Conditionally Passes " q
`-J Needs Further Evaluation t?;e Local Approving Authority I
Fail
Inspector's signat
Date: i
i
The System Inspector submit a copy of this t gpection report to the Approving Authority within thirty(30)days of completing this
inspection. If the system is a shared system or lu+.a a :i,,n flow of 10,000 gpd or greater,the inspector and the system owner shall submit the
report to the appropriate regional office of the D 5 ! :ia,.: or Environmental Protection.
The original should be sent to the system owner z: c.. '.e, sent to the buyer,if applicable and the approving authority. i
INSPECTION SUMMARY:
Check A.B,C,or D. -
A] SYSTEM PASSES:
have not found any informationthat the system violates any of the failure criteria as defined in 310 CMR 15.303. i
Any failure criteria not evaluated are u Lcc,Gc,i be10w., E{
B] SYSTEM CONDITIONALLY PASSES: i
AM, One or more system components need to I re.�?aoed or repaired. The system,upon,completion of the replacement or repair,passes r
Indicate yes,no,or cot determined(Y,N,or ND). '3^sc ice basis of determination in all instances. If"not determined",ezplain pity not)
` z,—dVif�QJ The septic tank is metal,cracked, fit Lcturally unsound,shows substantial infiltration or exMtmtion,or tank failure is
imminept. The"system will Tas:s ins�:ion if the existing septic tanlf is replaced with a po:}forming septic tank as approved.
by the$oard of Health.
(revised 11/03/95) 1
I
One VAnter Street a Boston,MA 4 nc' ra!!!s 02108 a FAX(617)556-1049 • Telephone(617)292-SM
�, Printed-i Rayded Paper" ,
' I
I
• SUBSURFACE SEWAGE,DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
PropertyAddrem 362 Off Seapuit' Road Osterville,Mass.
Owner. "Lou & Linda' McKnight `
Date of Inspeotiou: 3/3 0/9 Ej
BI SYSTEM CONDITIONALLY PASSES(contiuted) z
Akf, Sewage backup or breakout or h static water level.observed in the distribution box Is due to broken or obstructed pipes)
or due to a broken,settl*d or uneven distribution box. The system will pass inspection it(with approval of the Board of ;
Health):
broken pipes)are replaced
`.. . obstructiou is removed
} distribution boo is levelled or replaced .;`
,A The system required pumping more than four timed a year due to broken or obstructed pipe(s). The system will pans
inspection if(with approval of the Board of Health):
broken pipes)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:
�Q Cesspool or privy is within 60 foot of a surface water
Cesspool or privy,is within 50 feet of a bordering vegetated wetland or a salt marsh.
S) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER.IF APPROPRIATE)
DE E MINESTER THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND
SAFETY AND THE ENVIRONMENT:
vj1Q The system has a septic tank and soil absorption system and is within 100 feet to a surface water supply or tributary to a
surface water supply. 4
�} The system has a septic tank and soil absorption system and is within a Zone I of a public water supply well.
The system has a septic tank and soil absorption system and is within 60 feet of a private water supply well. .
The system has a septic tank and soil absorption'system and is Is"than 100 feet but 60 feet or more from a private water
supply well,unless.a well water analysis for coliform bacteria and volatile organic compounds indicates tbat the well is free„
from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or Ins than 6 ppm.
3) OTHER
(revised 11/03/95) 2
' N
• SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (Continued)
PropertyAddrroaa: 362 Off Seapuit Road Osterville ,Mass .
Owner. Lou & Linda McKnigY t
Date of Lupeotion:3/3 0/9 6 e
D) SYSTEM FAILS: •
100 I haw determined that the system violates one or more of the following failurs 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 oorred the
• failuiw:;
P ded
Backe of sewage Into facility or system component due to an overloa or dogged SAS or Cesspool.
Discharge or ponding of effluent to the surface of the tround or surface waters due to an overloaded or clogged SAS or
I� cesspool.
AltVQi Static liquid level in the distribution box above outlet invert due to an overloaded or dogged SAS or cesspool.
Liquid depth in cesspool is less than 6"below invert or available volume is leas than 1/2 day flow.
Ragui�pumping than 4 times in the last year NOT due to clogged or obstructed sisa(s).
Number of times pumped
y� Any portion of the Soil Ahcorption System, cesspool or privy is below the high groundwater elevation.
Any portion of•a cmp'00l or privy is within 100 foot 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 60 foet of a private water supply well.
Ada Any portion of a cesspool or privy is lee than 100 feet but greater than 60 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:
The following criteria apply to large systems in addition to the criteria abovo:
Alb The system sernu a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to publi:
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 mappod Zon°II of a public
water supply well)
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..
(revised 11/p3/95) 3
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
ProportyAddre.c 362 OFF Seapuit Road Osterville,Mass .
Owner. Lou & Linda McKnight
`,•,'f: Date of Inspeotlon: 3/3 0/9 6
Chock if`the following have been done:
„ePumping information was requested of the owner,occupant,and 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.
AAAs 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.
ZThe system does not receive non-sanitary or industrial waste flow'
The site was inspected for signs of breakout.
ZAll system components, uding the Soil Absorption System, have been located on the site.
/tJ .�The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of bafllea or
toes,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 .
appsoiimated by non-intrusive methods.
f`The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of Sub
Surface Disposal System.
(revised 11/03/95) 4
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 362 Off Seapuit Road Osterville ,Mass .
Owner. Lou & Linda McKnight
Date of Iaspeotion: 3/3 0/96
FLOW CONDITIONS
RESIDENTIAI: •
Design flow. 'J�U gallons .^ •
Number of bedrooms:
Number of current residents:
Garbage grinder(yes or no):_&W
Laundry connected to system(yes or no):X
Seasonal use.(yea or no):�}a
L'�OC� Z 5
Water meter readings,if available: f 1�.Last date of oocupancy:lk `1 I�� ( t✓' �'C�;:L'�'--�
COMMERCIALnNDUSTRIAL:
Type of establishment: A)
Design flow:-22 lions/day
Grease trap present: (yes or no)LLf—I
Industrial Waste Holding Tank present: (yes or no)Aa
Non-sanitary waste discharged to the Title 5 system: (yes or no)i A
readings
Water meter , if available:
.Last date of occupancy:
OTHER (Describe)
Last date of occupancy: N
GENERAL INFORMATION
PUMPING RECORDS and source of information: ,
'A.,
System pumped as part of ins ior.: (yes or no)AP 5y j%" /�/
If yes,volume pumped: on$
Reason for pumping: �t.}
TYPE OF SYSTEM
A I(I Septic tank/distribution box/soil absorption system
Single cesspool
Overflow cesspool
A 41. Privy
AM 2bared system(yes or no) (if ye
attach previous inspection records, if any)
Other(explain) � iCl�" ylry
APPROXIMATE AGE of all components, date installed(if known) and source of information: Z '
Sewage odors detected when arriving at the site: (yes or no)
(revised 11/03/915) 6
b
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
p,op, y,dd,..„ 362 Off Seapuit Road Osterville ,Mass .
Owner. Lou & Linda McKnight
Date of Inspeotlon: 3/3 0/9 6
SEPTIC TANK-_&eX(,
(locate on site plan)
Depth below gradu:-62L�
Material of constructionA'fiooncrete_metal_FRP_other(eiplain)
Dimension.
Sludge depth:_ �
Distance from top of sludge to bottom of outlet tee or bafTIe; {;'L
Scum thickness: ti f�
Distance from top of scum to top of outlet tee or baffler
Distance from bottom of scum to bottom of outlet tee or baffle: 1L N
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.)'
GREASE TRAP:&`0,V Lk—
(locate on site plan)
Depth below grade:XM�
Material of oonstruction;tLt4 concrete_metal_FRP_other(explain)
1r}
Dimensions: �A
Scum thiclmess:
Distance from top of scum to top of outlet tee or bafIIe: L
Distance from bottom of scum to bottom of outlet tee or baffle: A
Comments:
(recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,
eviden ,of leakage,etc.)
Top", '.f,
(revised 11/03/95) 6
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 362 Off Seapuit Road Osterville ,Mass .
Owner. Lou & Linda McKnight
Date of Inspection: 3/3 0/.9 6
TIGHT OR HOLDING TANK,A';VC- e
(locate on site plan) •
Depth below grade:6
Material of construction:/] oncrete_metal_FRP_other(explain)' `
1
A�
Dimensions:—
Capacity:_ NA gallons
Alarm
�ons/day +
flow:
Alarm level:
Comments:
(condition of inlet tee,condition of alarm and float switches, etc.)
DISTRIBUTION BOX:/? lit"lam
(locate on site plan)
Depth of liquid level above outlet invert: VA
Comments:
(note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, eta.)
xf,, Cf:1ti1G1F.n175
PUMP CHAMBER:. o-ol .
(locate on site plan)
Pumps in working order:(yes or no)_42
Comments:
(note condition of pump chamber; condition of pumps and appurtenances,etc.)
(revised 11/03/95) 7
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• 1
v SUBSURFACE SEWAOr nisrosAL 9YSTF-hi INSPECTION FORM
SYST_'.`. " .........3.N (oontinuod)
PropertyAddressa 362 Off Seapuit Road Osterville ,Mass ..
Owner: Lou & Linda -McKnight
CD
Data of Inspootiont 3/3 0/9 6-
BOLL ABSORPTION SYSTEM (SASr
(locate on site plan, if poesihle;acavatioa not requ*but may be arprozimatod by non-intruslve methods): :
If not&Urminod to be pit,oxplala.
Type:
leaching pits,number.
les—king chambers,number4l
leaching trenches, number,leagth — ,
leaching fields,number, dime oac.
va
arilow cesspool, aumbar.
Comments:(not.s condition of soil, signs of hydraulic failure, 1 c' ^.a'^ condition of vegetation,etc.)
CESSPOOLS: -
(locats on site plan)
Number and oontiguration• `
Depth-top of liquid to inlet invert: WIZA
Depth of so"layer. ,1
Depth of scum layer.
Dimensions of oesspooL to
Materials of construction: J }
Indicntion of groundwater:
inflow(cesspool must be pumped as part
T•nam� anr3 t,0 mPdiitm Sand ;
Comments:(note condition of soil, signs of hydraulic Wvro, 1,v^l condition of vegetation,W.)
Loamy Sand to Medium sand; no signs of hydraulic failure or ponding.,
Aii vege� lemon is norma , . o repairs are needed at. t is time . , '
PRIVYt
(Iocate on site plan)
Materials of construction: �'Pi/� _ --- Dimensions
Depth of eolicL: /L�a
Comments:(note eoadiitoa of soil,signs of hydraulic failu:0. a of vegetation,etc.)
(revised 11/03/.95). 8
f
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (oontinued)
Property Add,,: 362 Off Seapuit Road' Osterville ,Mass .
Owner. Lou & Linda McKnight
Date of Inrpeotion:3 3 0 9 6
o
SKETCH OF SEWAGE DISPOSAL SYSTEM: •
include tier to at kart two permanent references landmarks or benchmarlcr
locate all wreIIs within 100'
Cent.exv.-lle_ Osterv_ille Marston Mills
Water Company
428-6691
6
I _
2,17
I
I �
�. 9,Xl
r
• e
DEPTH TO GROUNDWATER
Depth to vvundwater. 2 1 + feet
method of determination or approximation: All c e s s No wat e r: No water encountered
when installed.
(revised 11/03/95) 8
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IR 'TOWN OF Barnstable BOARD OF HEALTH l
51111S1111FACF SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART D •- CERTIFICATION
�••.•r.r.-r••.^.:.-r.,v.••.rrr..r..--n•rt:.Tr..r.—.r.rrrr.•.r•-v--.----nrrrr.-crw*.rrr r.�-^*++'+-s-rr.'rs - rs*nn-+rtm-nn:v-.rr.rr•m.:-rrr-•r.•�r••••.
—TYPE OR PRINT CLEARLY—
PROPERTY INSPECTED
STREET ADDRESS 362 Off Seapuit Road Osterville ,Mass .
ASSESSORS HAP , BLOCK AND:'PARCEL #
OWNER' s NAME Lou & Linda McKnight
PalPT D - CERTIFICATION
NAME OF iNSPECTOR Joseph P. Macomber Jr..
COhfPANY NAME J.P.Macomber & Son Inc .
COMPANY ADDRESS Box 66 Centerville ,Mass 02632
Street Town or City scat• LIP
COMPANY TELEPHONE ( 508 ) 775 - 3338 FAX ( 508 1 790 - 1 578
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposcii system at
this address and that the information reported is true , accurate , and
complete as of the time of .inspection . The inspection was performed and any
recommendations regarding upgrade , maintenance , and repair are consistent
with my training and experience in the proper function and maintenance of on-
site sewage disposal systems ,
Check one :
XXXXXXXXSysteiii PASSED
The inspection which I have conducted has not found any information
which indicates that the system fails to adequately protect public
health or the environment as defined in 310 CMR 15 , 303 . Any failure
criteria not evaluated are as stated in the FAILURE CRITERIA section of
this form .
System FAILED*
The inspection which I have conducted has found that the system fails to
Protect the public health and the environment in accordance with Title
5 , 310 CMR 15 , 303 , and as specifically noted on PART C - FAILURE
CRITERIA of this inspection form ,
Inspector Signature /. , �. tG G� Date _ 4/8/96
One copy of this ert.ification must be provided to the OWNER, the BUYER
( where applicable ) and the I30ARD OF IIEAL11I
* If the inspection FAILED, the owner or "oporator shall upgrade ' the ayetem
within one year of the date of the inspection , unless allowed or _' Quire_d
W
THE COMMONWEALTH OF MASSACHUSETTS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
BE IT KNOWN THAT
Joseph P. Macomber, Jr.
Has satisfied the Department's. qualifications as required.and is hereby
authorized to use the title
CERTIFIED TITLE 5 SYSTEM INSPECTOR
as provided in 310 CMR 15.340 and Section 13 of Chapter 2_1A of the
General Laws. Issued by The Department of Environmental Protection.
June 8, 1995
Acting Director,of the ' •ion of Water Pollution Control
Department of •
Environmental Protection
• f
a William F.Weld Trudy Coxe
Argo Paul Celluccl David B.Struhs
tL Gowmoe ComnJulorrr
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
Ba
J PART A
CERTIFICATION
PropertyAddross: 362A Seapuit Road Osterville,MA AddressofOwner- 243 Parker Road
Date of Inspeotl;on: 3/3 0 9 6 (If different) O s t e r v i 11 e Mass .
Name oflnr.pector. Joseph P. Macomber, Jr. 02655
Company Name,Address and Telephone Number.
J.P.Macomber & Son Inc . Box 66 Centerville ,Mass . 02632
CERTIFICATION STATEMENT 5087775-3338
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
u _ Needs Further Evaluation By the Local Approving Authority
Fails
Inspector's signature: d Date: _`
70
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,B, C,or D:
A] SYSTEM PASSES:
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.
B] SYSTEM CONDITIONALLY PASSES:
VO One or more system components need to be replaced or repaired. The system,upon completion of the replacement or repair,passes
inspection.
Indicate yes no,or not determined(Y,N,or ND). Describe basis of determination in all instances. If"not determined",explain.why not)
4-0iib The septic tank is metal, cracked, structurally unsound,shows substantial infiltration or exf:ltration,.or tank failure is
imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved
j by the Board of Health.
(reylsed 11/03/95) 1
One Winter Street a Boston,Massachusetts 02108 a FAX(617)556-1049 a Telephone(617)292-5500
Printed on Recycled Paper
• SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(oontinuod)
PropertyAddros+c 362A Seapuit Road Osterville ,Mass .
Owner. Lou & Linda McKnight
Date of Inspection: 3/3 p/9 6
BJ SYSTEM CONDITIONALLY PASSES (continued)
Sewage backup or breakout or hA static water level observed in the distribution box is due to broken or obstructed pipe(s)
or due to a broken,settlod 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 bo:is lsyslled or replaced
The system required pumping more than four times a�you 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] FURTHFR EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
` I
V0 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:
tib Cesspool or privy is within 60 feet of a surface water
AS Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
Z) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER,IF APPROPRIATE)
DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND
SAFETY AND THE ENVIRONME?PI:
A)0 The system has a septic tank and soil absorption system and is within 100 feet to a turfacs water supply or tributary to a
surface water supply.
The system has a septic tank and soil absorption system and is within a Zone I of a public water supply well.
[yam The system has a septic tank and soil absorption system and is within 60 feet of a private water supply well.
The system has a septic tank and soil absorption system and is less than 100 feet but 60 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 b ppm.
3) OTHER
(revised 11/03/95) 2
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(oontinuod)
PropertyAddreas: 362A Seapuit Road Osterville,Mass .
Owner. Lou & Linda McKnight
Date of Inspeotioa:3/3 0/9 6 e
•
D) SYSTEM FAILS: •
•
A),O I have determined that the system violatee one or more of the following failure criteria as defined in 310 C11dIt 15 303. The basin for
this determination is identified below. The Board of Health should be contacted to determine what will be neoessary to correct the
failure. � � i
Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool.
A)Q Discharge or poading 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.
dW Liquid depth in cesspool is less than 6"below invert or available volume is less than W day flow.
�^D Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped
ti Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation.
�I Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
00 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 60 feet of a private water supply well.
do Any portion of a cesspool or privy is leas than 100 feet but greater than 60 feet from a private water supply well with tto
acceptable water quality analysis. If the well has been analyzed to be acceptable,attach copy of wall water analysis for
ooliform bacteria,volatile organic compounds,ammonia nitrogen and nitrate nitrogen.
E)LARGE SYSTEM FAILS:
The following criteria apply to large systems in addition to the criteria above:
A The system serves a facility with a desizu flow of 10,000 gpd or greater(LArp 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
ALk the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area(IWPA)or a mapped Zone II of a public
water•uPPIY wall)
The owner or operator of any such system sluill bring the system and facility into full eompliancs with the groundwater treatmsat program
requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.,
(revised 11/03/95) 3
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 362A SeaP uit Road Osterville ,Mass .'
owaer. p Lou & Linda Mcl�ight '
Date of Inspeotlon:3/3 0/9 6
Check if the following have been done:
,,/P=ping information was requested of the owner, occupant,and Board of Health.
Ions of the system components have been pumped for t 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.
4#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
ZThe site was inspected for signs of breakout.
system components,4&luding the Soil Absorption'System, have been located on the site.
467&1 l'he 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.
2Tb&size and location of the Soil Absorption System on the site has been determined based on existing information or
ZThe
roximated by non•intrusive methods.
facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of Sub.
,Surface Disposal System.
(revised 11/03/95) 4
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
PropertyAddresa: 362A Seapuit Road Osterville ,Mass .
Owner. Lou & Linda McKnight
Date of Inspection:3/3 0/9 6.
FLOW CONDITIONS
RESIDENTIAL: •
Design flow: :ID—gallons�°-dAy •
Number of bedrooms:
Number of current resident,• 0
Garbage grinder(yes or no) /
Laundry connected.to syst�pm(yes or no): AJt
Seasonal use(yes or no):
Water meter readings,if available: Gt344gP 16 ►07717--Ied
Last date of occupanry:_1_/'W_.1W r
COMMERCIAL NDUSTRIAL:
Type of establishment: A)ff
Design flow: A3A ,gallons/day
Grease trap present: (yes or no)&A
Industrial Waste Holding Tank present: (yes or no)
-� Non-sanitary waste discharged to the Title 5 system: (yea or no)&a
Water meter readings, if available: 41
Last date of occupancy: IU
OTHER:(Describe) IVA
Last date of occupancy: V
GENERAL INFORMATION
PUMPING RECORDS and pourof information:
1U0r"N. fW 19.11.r4j,�,� -
System pumped as part of inspection: (yes or no)"
If yes,volume pumped: i> gallons
Reason for pumping:
TYPE OF SYSTEM
VSingptic tank/distribution box/soil abscrption system
le
cesspool
Overflow cesspool
Privy
Shared system(yea or no) (if yes, attach previous inspection records, if any)
Other(explain)
APPROXIMATE AGE of all components, date installed(if known)and source of information: ��
I _
Sewage odors detected when arriving at the site: (yes or no) Al
(revised 11/03/95) 6
- D 1 71 rue •��r v•u..�...... �..........___. /�
C/
PropertyAddresa: 362A Seapuit Road 9sterville,Mass .
Owner. Lou & Linda McKnight
Date of Inspection:3/3 0/9 6
SEPTIC,TANI{:.&¢&, e e
(locate on site plan)
Depth below grade- A)'t
Material of construction: Aconcrete metal_FRP_other(ezplain)
_
Dimensions: A)
Sludge depth:
Distance fiom top of sludge to bottom of outlet tee or balTIg:
Scum thickness: AiA
Distance from top of scum to top of outlet tee or baMe:04
Distance from bottom of scum to bottom of outlet tee or baffle: AYF1
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.)'
/VLACe ryll9'!�� 5
GREASE TRAP: act
(locate on site plan)
Depth below grade:ti0
Material of construction:Chooncrete_metal_FRP_other(ezplein)
Dimensions-_ A:
Scum thickness:-_
f scum to to
Distance from top o of outlet too or baffle:
p
Distance from bottom of scum to bottom of outlet tee or baffle:_
Comments:
(recommendation for pumping,condition of inlet and outlet tees or banes,depth of liquid level in relation to outlet invert,structural integrity,
evidence of leakage,etc.)
(revised 11/03/95) 6
mot.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (oontlnued)
PropertyAddrws: 362A Seapuit Road Osterville ,Mass .
Owner. Lou & Linda McKnight
Date of Inspeotlon: 3/3 0/9 6
TIGHT OR HOLDING TANX-k64t.. e '
(locate on site plan) r
Depth below grads jld
Material of oonstructio • �'boncrets_metal_FRP--other(explain)
Dimensions:- Ala
Capacity: AM galions
Design Aow: A2d gal1ons/day
Alarm level:, A)A
Comments:
(condition of inlet tee,condition of alarm and float switches,etc.)
Q, Cfm✓N ywr7 '
DISTRIBUTION BOX-A ive—
(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:l&J(�
(locate on site plan)
Pumps in working order:(yes or uo)_.&A
Comments:
(n condition of pump chamber;condition of pumps and appurtenances, etc.)
(revised 11/03/95) 7
SUBSURFACE eKWACr DISPOSAL SYSTEM INSPECTION FORM
SYST::
Property Address:
Owner
Date of Inspections ,�,,•,.�;:,'i Y:. ......
BOIL ABSORPTION SYSTEM(SA9):2 ' .
Cocate on site plan,if possible;ezcavatlon not requir�,but may be approximated by non•iatruslve methods):
It not determined to be prwant,explain:
: leaching pits,numberQ
leachingchambere,number: ► 1;.,,
>iallarlee,number:
--r--
. leaching trenches,aumber,length:
kuhing fields,number,dipsions:�_--
overflow cesspool,cumber. CCL
Comments:(note condition of soil,signs of hydraulic failure, I^,•r! "^ condition of vegetatioNete.)
/20)
CESSPOOLS: _.
(locate on site plan)
Number and configuration
Depth-top of liquid to t iavwt•
Depth of solids layw-_
Depth of scum layer:
Dimensions of cesspool
Materials of construction: r '
Indication of groundwater..
• inflow(cesspool must be pumped as part of
Comments:(note condition of soil, of u�c i�itro, condition of vegetation,etc.) _
Loam sand to mediumsand; No signs of hydraulic failure or ponding;
All veee a ion is normai. No rerpairs-_ nppdpd q.t t.hi s time.
PRIVY:
(locate on site plan)
Material of construction: Dimensions:
Depth of solids:_&g - ---
CO (note con
d
i
ti
on of soil,sips of kvdmulic tauro, of vegetation,etc.)
(revised 11/03195)• 8
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(oontinued)
PrcpertyAddresx 362A Seapuit Road Osterville,Mass .
Owner. Lou & Linda McKnight
Date of Inspection:3/3 0/9 6
SKETCH OF SEWAGE DISPOSAL SYSTEM: ••
inc2u le ties to at leant two permanent references landmarks or benchmarks
]case au wev,within lOO' Centerville Osterville Marston's Mills Water Company
428-6691
6 ` I
�+
i
DEPTH TO GROUNDWATER
Depth to groundwater-_ I + feet
method of determination or approximation: _h►x 1 O c P R_ s4)()nj _-_N0 i n i r a+.; n„ of ground w t P r
(revised 11/03/95) 9
L
THE COMMONWEALTH OF MASSACHUSETTS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
BE IT KNOWN THAT
4
Joseph P. Macomber, Jr.
Has satisfied the Department's qualifications as required and is hereby
authorized to use the title
CERTIFIED TITLE 5 SYSTEM INSPECTOR
as provided in 310 CMR 15.340 and Section 13 of Chapter 21A of the
General Laws. Issued by The Department of Environmental Protection.
June 8, 1995
Acting Director of the ' ' •ion of Water Pollution Control
r
SUHHUFACE TOWN OF Rqrj2stn'h1P BOARD OF HEALTH
-TYPE OR PRINT CI.EARLY-
PROPERTY INSPECTED
STREET ADDRESS 362A Off Seapuit Road Osterville ,Mass .
ASSESSORS HAP , BLOCK AN� PARCEL #
NAME OF .JNSPECTOR Joseph P. Macomber Jr.,
COMPANY NAME J.P.Macomber & Son Inc .
Street Town or City State LIP
COMPANY TELEPHONE FAX
CERTIFICATION STATEMENT
I certify that I have personally inspected the oe*ugm diopoo ' system at
this address and that the information reported is true / accurate , and
complete as of the time of /inspection . The inspection was performed and any
recommendations re8ordioQ upgrade , maintenance , and repair are consistent
with my training and experience in the proper function and maintenance of ou- ^
aite oawugo disposal systems .
Check one : ' :
.
' -- -)
,.X}D[M8yate6 PASS--fD .
The inspection which I have conducted has not found any information
which indicates that the system fails to adequat-ely protect public
})oalL}' or L>}e environment as def ined in 310 CHR 15 . 303 . &Dy'. fui|«re
criteria not evaluated are as stated in the FAILURE CRITERIA section of
this form . '
^
*
System FAILED
'
The inspection whic>, I have oonduoted 'hua found that 'the system fails to
protect the public health and the environment in accordance with ?itle
5 , 310 CHR 15 . 303 . and as specifically noted on PART C - FAILURE
CRITERIA of this inspection form . '
---,.~ ~.^ .^g.^~~.^ .
'*-'---7er ti f i c a t i o n must be provided to the OWNER, the BUYER
One copy of this
( where applicable ) and the 130ARD OF HEALI'll.
~ If the inspection rAzLoo' t +- '
within one year of t) date of the
t��o�r or npmr^tor shall «n�rudu � tb� n�ntcm
»e
otherwise oo provideinw3eO»CNRhe51nePeot1on ' «oleaa allowed or required
.I TOWN OF BARNSTABLE - UNDERGROUND FUEL AND CHEMICAL STORAGE REGISTRATION
MAP NO. / PARCEL NO. d
ADDRESS OF TANK: *. " � w VILLAGE: DT76)6 yiG t'
' Number ®tr��t
MAILING ADDRESS ( IF DIFFERENT FROM ABOVE) : �^ �' �_
OWNER NAME: '�JG'Ui,� t—/. � �x��C���� PHONE:
INSTALLATION DATE: BY:
INSTALLER ADDRESS: UrJ/r��/��� � ' CERT.NO: -.
*TANK LOCATION: L r� f4e 4�` /'% fN. ,. ffUuS� T
(D¢OCRIDQ TANK LOCATION WITM, FRUMP-MCT TO OUILDINO>
CAPACITY 'G�' = TYPE OF TANK - AGE- ti =YRS.=FUEL/CHEMICAL � OIL"
TESTING CERTIFICATION Ck PASS [ ] FAIL DATE
LEAK DETECTION IF N/A TYPE/BRAND, �
ZONE OF CONTRIBUTION [ I YES [ ✓]"'NO . DATE TO BE REMOVED ": _,?40�
FIRE DEPT. PERMIT ISSUED [ I`] YES [ 3 NO DATE
s�
CONSERVATION Etl CHECK IF N/A)�13 I* DATE
HOARD OF HEALTH TAG N0. [ /�17
"] DATE f � ' -
* PLEASE PROVIDE A SKETCH SHOWING THE TANK LOCATION ON THE BACK OF THIS CARD
z
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c a �
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to
. �---��
4i �
oFtllerc TOWN OF BARNSTABLE
` OFFICE OF
1 IRAR19TABLE
88..
Mnee. BOARD OF HEALTH
�
f639• 367 MAIN STREET
0 MpY a'
HYANNIS, MASS. 02601
c 1989
Dear
l
ass valve to # _l1_
Enclosed .is brass Please attach to g
. the fill pipe of your underground
You must do the following as indicated:
---- Remove your tank. I have enclosed information for you
regarding tank removal .
m
Have your tank tested starting ITV /_ O_ . You must test
during the 10th, 13th, 15th, 17th and 19th year and
annually thereafter. Removal in the year 6"a . I
have enclosed information regarding tank testing . ** In
order to have your tank tested you must first contact a �C
engineering company (see attached) to have a monitoring
"well installed. Once the monitoring well has been
_ — nstalled 'ybu 'c'a _•then call 362-2511; Ext. 334 %;id ask �^
for Charlotte S tiefel or George Ileufelder at the � U/
Barnstable County Health Department, to have your tank r� �
tested via the Soil Vapor Analysis Test. Currently , the Nl/ >��;
test is done free of charge under the auspices of an EPA C� '�E � �q
grant.
U
Due to the unknown age of your tank we must presume it
is twenty (20) years of age. You must have it tested
every year and remove it by the year 1993 . To have it
tested please follow the procedure as indicated above
from -the ** (asterisk) on.
If you have any questions please feel free to call me at 775-
1120, Extension 183 .
Thank you,
DOIlIla Miorandi
Health Inspector
l
CENTERVILLE OSTERVILLE .• MARSTONS MILLS FIRE DISTRICT
UNDERGROUND TANK REGISTRY PROGRAM s # f
�4i � .• f t' t �. y3
;? Owne�of Pro ert �' 9
t� t p y `T Date of lnstallatio'n:
Address
`931. s` Description}" % .
Installer:
Y s-v o
Certification:.
t
i• Location of Tank:
i,
INSPECTION INFORMATION DATE COMPLETED BY
1 Site Inspection k ��
i AlrTest on Tank Above Ground
y Air.Test on Tank 'within Hole
Test on Ptptng j l
f athodic Protection
C Test
�r Continuous Monitoring System Type
`Backfill Operations.'
*Vent and'Fili Pipes
.. Other:
IR
t t )
Iz feS' (•Y xl _ •�.
y
r t ,
f '
t�
aC "i
1
•u q
l,e" k
d ' +, �
ry
•� S
1 t,4 W.
TESTING OF TANKS AND PIPING: EXISTING TANKS M��z M �.
rF , 10th �9 15th 19th
u f 13th 17th /s 20th
� r
21 st y 22nd 23rd `� 3
` 24th 25th 9 E 26th Y
h 4 r ,it
• 127th � 28th 29th
(30). Removal moo a �
,r EW TANKS: ,: .
15th 20th 22nd At'
24th 26th 28th
,(30) Removal �i x
, ; + Al
Remarks: ,
N
i p'
R ,.
7.
VN
T+•�,, ;,-.S�' r�c',c.�f�, mow, ...�y. 3c�a x
F
rW.4
�y u a
JI ;
All
WA
k` peter+ �&r f''�t< �.�"+ a�rt'�3•, .�` x;
t' !Y
a^
F a���� +t .. ��Sr`�'x'aE�•y we air ��.�!,. ,
ai x
it - ti,af t M„ +.'R•� '''4 v•.
e i.�RG` •#•"%:g A rRa t�.tea °} r 4 i€�
44Al
�`Kam.S� "S, {^ } .. t�� �..t4, k' XS•.��
,.mom._ .♦:x. � .:, .., ,. _ �§+'
:rx;
' CENTERVILLE OSTERVILLE MARSTONS MILLS FIRE DISTRICT
UNDERGROUND TANK REGISTRY PROGRAM
r r Owner of Property: C c7S e yInstallation:—
Address: r 7 C7 ^
APM.,
Date of
- se
r ye
Description: Installer:
r Size: S v o Certification:
Location of Tank:_
INSPECTION INFORMATION DATE COMPLETED BY
Site Inspection
Air Test on Tank—Above Ground
Air Test on Tank—Within Hole
r
Test on Piping
Cathodic Protection Test
.:- ..ontinuous Monitoring System Type
Backfill Operations _
Vent and Fill Pipes
�:�r • Other:
2.
_ I
t
r
Sy
t• - 'F,45
F . ��•*>ram.
r
4
yr•Ix,.. F'*rmC.'�
'Ji`re��v
e_• f D ; fi1
DRYWALL/MASONRY SUPPLIES Inc. `r Pmnq
O277 WHITE'S PATH ' SOUTH YARMOUTH, MA 02664 � ''G a
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