HomeMy WebLinkAbout0188 STURBRIDGE DRIVE - Health 188 STURBRIDGE DRIVE, OSTERVILLE
i
7
r� TOWN OF BARNSTABLE
cif bCATION / ���� SEWAGE #
ILLAGE ASSESSOR'S MAP & LOT
INSTALLER'S NAME&PHONE NO.1A :Iddimek ��of
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) (size)
NO.OF BEDROOMS
RULPER-6R OWNER L 6¢1&A&L
lo,
PERMITDATE: COMPLIANCE DATE: 015- OS
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
A
Page 10 of I 1 t
F;
OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C'
SYSTEM INFORMATION(continued)
Property Address: 188 St!rbrid4e Drive -
Ostervi ll .
Owner. Dalton Stevens
Date of Ins eclion-
SKETCH OF SEWAGE DISPOSAL SYSTEM
provide a sketch of the sewage disposal system including lies to at least two pennntmens rcfumce landmarks or
be uddharks.Locate all wells within 100 feet.Locate where public water supply ecr the building.
3—Ci
3 /A-3 —'1.3
3 A •
t t
1 V
.LOCATION SEWAGE PERMIT NO.
VILLAGE loe
l() INSTA LLER'S NAME i ADDRESS
y� JOHN A. AALTO BACKHOE SERVICE
l tso L Stpeet
West Barnstable, Mass. 02668
�( 8UILDER OR OWNER
U dcLh.O� 1
0 DATE PERMIT ISSUED
DATE COMPLIANCE ISSUED g�
l
tr :
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� � e a �% i
� ��\ Aq % � a o�
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No.--gS...... .. ..............................
THE COMMONWEALTH OF MASSACHUSETTS
BOAR% OF HEALTH
,-1 0.L_V..Q..............OF.. 04-35.. 4-.........-----......................._...
Appliratiou for Uispwi al Works Tomi rurtiura ramit
Application is hereby made for a Permit to Construct (n) or Repair ( ) an Individual Sewage Disposal
System: �= -`�- 9 8 ?�� P-(a��.�Cam`- � .�_.....�, ` �����.0 - -••-----••-•-•. ••-- .........................................
Location•Address {'��o�r Lott No.
fib- V11..ap...............................................
Owner 0 ,� , ^Address
1: .. a'---------------------------------------- ----------------- G---•--- .---..-.`[- ..- � .� l I _.....
a
Installer Address \
.14 Type of Build i i Size Lot.... fSq. feet
U Dwelling—No. of Bedrooms............ .........................Expansion Attic ( Garbage Grinder (C-4—
`4 Other—Type of Building No. of persons............................ Showers — Cafeteria
Other fixtures -....----------------------------------•---•-.---- .
w Design Flow....................... ..........gallons per person per day. Total daily flow......... r .Q...................gallons.
WSeptic Tank—Liquid capacity.11" gallons Length................ Width................ Diameter................ Depth................
x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No.........-G��.__.. iameter........liO.... Depth below inlet.....� ...... Total leaching area...53y•-sq. ft.
Z Other Distribution box I ) Dosing t4pk
aPercolation Test Results Performed by.___...
Test Pit No. 1.....__..`t minutes per inch Depth of Test Pit-__._ .*. ......... Depth to ground water.._o�e>Y-I
(Tq Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
a ..............a-------------------------------------------------•-----------.--.------------•-----------------------------:.....-------•-•...........--------
0 Description of Soil...._. ......---4,z Cib-,SO/ -- --------
------ -----
d7�-...._.. � . ---•--• ---- .....GtJ ....
w
UNature 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 iITIZ 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operatio n '1 qr%l�f..Of
to C plian a has been is a by the board of health.
Sned............... _.._------ .._.....� ............. S
Da e
Application pproved �- �!!-1.._ -... ............ Datef
Application Disapproved for the f ollo n reasons:........................................................................................
.................................................................... .._.._.................__..................___...._......._._..............._�/_�
Date
Permit No......................................3............... Issued...........
-r °�ate
No......................... Fxs....................-........
THE COMMONWEALTH OF MASSACHUSETTS
BOA R4 OF HEALTH
T
, pphration' fux; ispos al Works Tonstrnrtiun ramit
Application is hereby,,made for a Permit to Construct (X) or Repair ( ) an Individual Sewage Disposal
System at � _...� � � .:... �..... C.. > 11
.... .... z: .. .. ............. ..........................................
�,,, Location-Address t _ '�or�Lo�t No.
• �� '� —5"'-i 1 _- �. ---•.............. . �` Q f . ----..3�'.S!t!..........._..----•----.._.._.........._'^-
Owner / Address
Installer Address
d Type of Building Size Lot_.__: . . . ' 'Sq. feet
v Dwelling—No. of Bedrooms............ T_________________________Expansion Attic ( 5 Garbage Grinder (gym-•)-•-
pa•, Other—Type of Building ............................ No. of persons---------------------------- Showers ( ) — Cafeteria ( )
W Other fixtures
d ::P, -------------------------- -
W Design Flow....................�_.�.............gallons per person per day. Total daily flow......... ...................gallons.
WSeptic Tank—Liquid capacity_5 gallons Length................ Width................ Diameter................ Depth................
x Disposal Trench—N . . Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No,--------- �-. .Dia meter........ .#6�-__- Depth below inlet.......4_- �...... Total leaching area._t_._ ...sq. ft.
Z Other Distribution box ('` ) Dosing k (
Percolation Test Results Performed by..___._� _ ..... .. 1 .._._ '' .......... Date. _�=.......
aTest Pit No. L.�-_. .=nminutes per inch Depth of Test Pit-__-_J.f_�_-....._ Depth to ground water..__`::!" 'i�'..
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
. ---- ---- --- ............................................................................
O Description of Soil..... ..........
x �� '.... "�,r ::.....✓ .: �"------------- r ----- ...........................................
W -------------------------- ..................................................................................=-------------------•--••------------•----------------•--------------------•--------••---
VNature of Repairs or Alterations—Answer when applicable...............................................................................................
---•--------------------------------------------------•------•-----••••-•---------------------•-•----....•----••----•-••-•----•••-•-•----•••---•--•-••••-•••••--••••-••-•••......---•--•----_•----
Agreement:
A The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TIT 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operat{o���"N Celt* to of� plia ce has been i ed y the board of health. �
S ned
r .- . ...-- --- --•- ----- ------- - --
- s...
_ C D to
Application_Approvgd By-----• •-----------•• •.. ....... ✓ - � _'_. ..�
Date
Application Disapproved for the f ollo i reasons------------------------------------------------------------------------------------------------•---•---.......--
�>sfn`�
---------------------------------
Date
.... -7-----------------------------
- Issued_......... -----------------
THE COMMONWEALTH OF MASSACHUSETTS
BOARD,; OF HEALTH
..........................................OF.....................................................................................
Tntifiratr of 111intpliatta
THIS IS 0 RTIFY,=;vidual Sewage Disposal System constructed ( ) or Repairedby_---•__---•----------_- --- t-------- ...................--•-..................................................................................................
Inst ler C
at......................... ---4----- ------- � ---
has been installe in a ord nce with the provi ions of T I; 5 f he State Sanitary Code as described inthe
application for Disposal Works Construction Permit No----------------------------------------- da.ted-...............................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CON TRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE.......... `U -----------------•--------------------•------ Inspector..........- . •---- ..._..
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..........................................OF.....................................................................................
�i��nn�tl nrk� �.nn�trnrtilan rrntit -
Permission is hereby granted.............. r7-•�Y--------
��.�'-I - - -------••--•--------------------------------------•_-_•________._------
to Construct ( ) or Repair ( ) an In Ividual Sewage'I71sposal ystem
at No....... .--•-•-O--.--.....5--'-tRV3-R40�4 ---_- r steer
as shown on the application,for Disposal Works Construction Permit -. Dated__6 __ ...............
------ ------------------------
B ad f H It
DATE___ t S.s --
FORM 1255 HOBBS & WARREN, INC.. PUBLI HE -
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COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS .
DEPARTMENT OF ENVIRONMENTAL PROTECTION
TITLE 5 E
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
�n
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A c "�
4t
CERTIFICATION --
Property Address: 188 Sturbridge Drive ; r
Osterville
Owner's Name: Walton Stevens
Owner's Address:
Date of Inspection: S—® 5
Name of Inspector:(please print) Wi 1 1 ' am _ • Robinson Sr.
Company Name: William E. Robinson Septic Service
Mailing Address: P O Box 1 089
Centerville, MA
Telephone Number: (508) 775-8776
CERTIFICATION STATEMENT
i certify that I have personally inspected the sewage disposal system at this address and that the information reported.
below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my
training and experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system:
Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: Date: Y
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Heatihvr
DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000
gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the
DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving
authority.
Notes and Comments
****This report only describes conditions at the time of inspection and under the conditions of use at that
time.This inspection does not address how the system will perform in the future under the same or different
conditions of use.
Title 5 Inspection Form 6/15/2000 page I
Page 2 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 188 Sturbridge Drive
Ostervil e
Owner. Walton Stevens
Date of Inspection: —:7 l—o 3
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes--
have not found any information which indicates that any of the failure criteria described in 310 CMR
15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below.
Comments:
B. Sys m Conditionally Passes:
'e ..
On or more system components as described in the Conditional Pass„section need to be replaced or
repaired. 1� a system,upon completion of the replacement or repair,as approved by the Board of Health,will pass.
Answer yes,no or not determined(Y,N,ND)in the for the following statements.If"not determined"please
explain.
The eptic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally
unsound,e l ibits substantial infiltration or exfiltration or tank failure is imminent_System will pass inspection if the
existing tank is replaced with a complying septic tank as approved by the Board of Health.
•A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicating&t 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
obstruded pipe(s)or due to a broken,settled or uneven distribution box.System will pass inspection if(with
appro dal of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND a ,plain:
`The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will
pass mspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction isnm vcd
ND expla'lnl
Page 3 of I 1
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address:- 188 Sturbridge Drive
Osterville
Owner: Walton .Stevens
Date of Inspection: s°-6
G Furl er 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 a1rotect 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:
_ Ce?spool or privy is within 50 feet of a surface water
_ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the
system is h,nctioning 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
surfac1�water supply or tributary to a surface water supply.
IT'he
system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply.
he system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more front a
/acria
vate water supply well•• Method used to determine distance
This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform
and volatile organic compounds indicates that the well is free from pollution from that facility and
presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
lure criteria are triggered.A copy of the analysis must be attached to this form.
3. Other:
3
Page 4 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address• 188 Sturbridge Drive
s ervi e
Owner: Walton STevens
Date of Inspection: ,` --d
D. Sys a Failure Criteria applicable to all systems:
You must dicate"yes"or"no"to each of the following for all inspections:
Yes No
_ ackup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
cogged 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'/,day flow
R!quired pumping more than 4 times in the last year.NOT due to clogged or obstructed pipe(s).Number
o 7times pumped
Aiy portion of the SAS,cesspool or privy is below high ground water elevation.
A�y portion of cesspool or privy is within 100.feet of a surface water supply or tributary to a surface
�{ater supply.
y portion of a cesspool or privy is within a Zone 1 of a public well.
y portion of a cesspool or privy is within 50 feet of a private water supply well.
y portion of a cesspool or privy is less than 100 feet but greater than 50 f^_et 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(lie 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 forma
(Yes/No)The system fails. 1 have determined that one or more of the above failure criteria exist as
described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of
Health to determine what will be necessary to correct the failure.
E. Large Systems:
To be considered a large system the system must serve a facility with a design now of 10,000 gpd to 15,000
gPd-
You )the
indicate either"yes"or"no"to each of the following:
(Die foilwing criteria apply to large systems in addition to lute criteria above)
yes
the system is within 400 feet of a surface drinking water supply ;
system is within 200 feet of a tribunary to a smtace drinking water supply
the system is located in a nitrogen sensitive area(interim Wellhead Protection Area—IWPA)or a mapped
Zone I of a public water supply well
If yo have answered"yes"to any question in Section E the system is considered a significant threat,or answered
"yes"in Section D above the large system has famed.The vwrt�or operator of arry large system considered a
signi scant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
15.3 4.The system owner should contact the appropriate regional office of the Department.
t/L 4
Page 5 of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 188.-Sturbridge Drive
Osterville
Owner. Walton Stevens
Date of Inspection:- — —0
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
t//Were any of the system components pumped out in the previous two weeks?
Has the system received normal flows in the previous two week period?
_ Have large volumes of water been introduced to the system recently or as part of this inspection?
_ Were as built plans of the system obtained and examined?(If they were not available note as N/A)
Was the facility or dwelling inspected for signs of sewage back up?
Was the site inspected for signs of break out?
// _ Were all system components,excluding the SAS,located on site?
_ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition
of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum 7
Was the facility owner(and occupants if different from owner)provided with information on the proper
maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has been determined based on:
Yes .no/
_ ✓ Existing information.For example,a plan at the Board of Health.
_ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance
is unacceptable)[310 CMR 15.302(3)(b))
5
Page 6 of 1 i
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 188 Sturbridge Drive
Osterville
Owner: Walton Stevpnq
Date of Inspection: r77 oA J-e
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design):L Number of bedrooms(actual):
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): S 5 6
Number of current residents:
Does residence have a garbage grinder(yes or no): A/ D
Is laundry on a separate sewage system(yes or no): Ale)[if yes separate inspection required]
Laundry system inspected(yes or no):/t-0
Seasonal use:(yes or no): .& d
Water meter readings,if available(last 2 years usage(gpd)): 2004 - 89, 000
Sump pump(yes or no): . /U 2 0 0 3 - ,0 0 0
Last date or occupancy:
COMMERCPUINDUSTRIAL
Type of esta ishment:
Design flow(based on 310 CUR 15.203): gpd
Basis of de ign flow(seats/persons/sgft,etc.):
Greasjtr present(yes or no):Induswaste holding tank present(yes or no):Non-sary waste discharged to the Title 5 system(yes or no):Waterter readings,if available:
Last dof occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information: .�
Was system pumped asp "of the inspection(yes or no): J
If yes,volume pumped:_gallons--How was quantity pumped determined?
Reason for pumping:
TTYP �OF SYSTEM
Septic tank,distribution box,soil absorption system
_Single cesspool
Overflow cesspool
Privy
_Shared system(yes or no)(if yes,attach previous inspection records,if any)
Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be
ob_tained from system owner) -
_Tight tank Attach a copy of the DEP approval
—Other(describe):
Approximate age of all components,date installed(if known)and source of information:
_lCt 136IJ SSA
Were sewage odors detected when arriving at the site(yes or no): .L1
6
)'age 7 of I I
1
OFFICIAL INSPECTION FOI01—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION F0101
PART C
SYSTEM INF011MATION (continued)
Property Address: 188 Sturbridge Drive
Osterville '
Owncr: Walton Stevens
Date of Inspection.. ^p S
BUILDING/SEIWVR(locale on site plan)
Depth belowMaterials ofction:_cast iron 40 PVC other(explain):
Distance frote water supply well or suction lute:
Comments( ition of joins,venting,evidence of leakage,ctc.):
SEPTIC TANK: "Y`(locate on site plan)
Depth below grade:- l r �
Material of construction: ./Fvncrete metal fiberglass J,olyethylene
_othcr(explain) _
If tank is meta)list age,:— Is age confinned•by a Certificate of Compliance(yes or no):_(attach a copy of
certificate) t it
Dimensions:
Sludge depth:: J —
Distance from top of sludge to bottom of outlet tee or bafllc: '
Scum thickness: � `/ t, r
Distance from top of scum to top of outlet tee or baffle:--E:
Distance Gorn bottom of scum to bottom of outlet to or bafl�e:
I Io%v were dimensions determined:. p 6'1 w �yd..
Comments(on pumping recommendations,inlet and outlet tee or ballic condition,structural integrity,liquid levels
as related to outlet invert,evidence,of Icakkage,etc
L
is
GREASE T P:_(locate on site plan)
Depth bolo% grade:_
Material o construction:_concrete_metal_fiberglass polyelllylene__ollner .
(explain):
Dimcnsi ns:
Scum 11 ickness:
Dista c from top of scum to top of outlet(cc or baMc:_
Dista cc from bottom of scum to bottom of outlet Ice or baffle:
Dal of last pumping:
Co intents(on pumping reconttnendations,inlet and outlet ice or baffle condition,structural integrity,liquid levels
related to outlet invert,evidence of leakage,etc.):
7
'age 8 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 188 Sturbridge Drive
s ervi e
Owner: Walton Stevens
Date or Inspection:
TIGHT or IIOLDING' ANK: (tartk must be pumped at time of inspection)(locate on site plan)
Depth below grade:
Material of construe on:_concrete_metal_fiberglass olyethylene other(explaut):
Dimensions:
Capacity: gallons
Design Flow: gallons/day
Alan»present YYCs or no):
Alarm level: Alann in working ordcr(yes or no):—
Dat um
c of last ping:
Comments condition of alarm and float switches,etc.):
DISTRIBUTION BOX: (if present must be opcncd)(locate on site plan)
Depth of liquid level above outlet invert: C)
Conunents(note if box is level and distribu ion to outlets equal,any evidence of solids carryover,any evidence of
leakage into or out of box,c(c.):
PUMP C11AN1/DER: (locate on site'plan)
Pumps in workes or no):Alarms in workes or no):Conunents(notof pump cha►nber,cundition of pumps and appurtenances,etc.):
_ J
- " Page 9 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 188 Sturbridge Drive
s ervi e
Owner: Walton Stevens
Date of Inspection:
SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required)
If SAS not located explain why:
Type
_leaching pits,number:/A b 0
leaching chambers,number:
leaching galleries,number:
leaching trenches,number,length:
leaching fields,number,dimensions:
overflow cesspool,number: t
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.).
CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan)
Number and co figuration:
Depth—top o iquid to inlet invert:
Depth of sol' slayer:
Depth of sc m layer:
Dimensio s of cesspool:
Material of construction:
Indicati n of groundwater inflow(yes or no):
Comm nts(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
PRIVY: ocate on site plan)
Materials of construction:
Dimensio :
Depth of olids:
Comme is(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
9
Page 10 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 188 Sturbridge Drive
Osterville
Owner: Walton Stevens
Date of Inspection:
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or
benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building.
ci
r �
94-41
r3_3 �� �
10
Page 11 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 188 Sturbrdige Drive
Osterville
Owner. Walton Stevens
Date.of Inspection: B`-�.S-cs
SITE EXAM
Slope
Surface water
Check cellar.
Shallow wells
Estimated depth to ground water 0 feet
Please indicate(check)all methods used to determine the high ground water elevation:
Obtained from system design plans on record-If checked,date of design plan reviewed:
Observed site(abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health-explain:
Checked with local excavators,installers-(attach documentation)
Accessed USGS database-explain:
You must escribe how you established the high ground water elevation:
s' 0"a---
C
/
11
COMIYIONWE"ALTH OF MASSACHUSETT'S
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
ONE WINTER STREET,BOSTON MA 02108 (617)292.5500
TRUDY CORE
Secretary
ARGEO PAUL CELLUCCI DAVID B.STRUHS
Governor Commissioner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTIONS FORM
PART A
- CERTIFICATION
Property Address: r i S
Name of Owner rr 6//s'1/7sr
�ti(y1iiIII �4 ( Address of Owner: ypiv�
Data of Inspection:
Name of Inspector:(Please Prim)- ,4-, G-
"1 am a DEP ved system ins purw�rrt to Section 15.340 of Title 5(310.CMR 15.000)
Company Name: : tl hd'.SBry�c i
Marring Address:
Telephone Number: Sal? '!7 z— 9 S S'
CERTIFICATION STATWENT
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
T' Needs Further Evaluation By the Local Approving Authority
_ F s
4usy�clors Signature: Data: J
V4:System Inspector hall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within thirty(30)days of
completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner
shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the
system owner and copies sent to the buyer,If applicable,and the approving authority.
NOTES AND COMMENTS
l 1'1
164-1
. •y :.� ti���s� 000
revised 9/2/98 Page I of 11
G,
r
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART'A
II. . .._ :;..; ....`.CERTIFICATION(continued)
Property Addrass:
Owner: /� "iSTiGiv' )�s :..fir/4%R`� 5 ��/7�i.
Own : 5d," Srr,�t•o e�.':,.
Data of Inspection:
INSPECTION SUMMARY: Check A, B, C, or A
A. STEM PASSES:
I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist. Any failure
criteria not evaluated are indicated below.
COMMENTS:
B. SYSTEM CONDITIONALLY PASSES:
One or more system components as described.Iq the;"Conditional Pass" section need to be replaced or repaired. The system, upon
completion of the replacement or repair,as approved by the Board of Health, will pass.
Indicate yes,no, or not determined(Y, N, or ND). Describe basis of determination In all Instances. If"not determined", explain why not.
The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of
Compliance (attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection;or'
the a ptic.tank,whether or not metal,is cracked,structurally unsound,shows substantial infiltration or exfiltration, or tank
`failure is imminent. The system will pass inspection if the existing septic tank is replaced with a complying septic tank as
approved by the Board of Health.
Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe($)
or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of
Health).
broken pips(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 pipes)are replaced
obstruction is removed
r
revised' 9/2/98 Page 2of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address:
Owner: agbh ,
Date of 4upect)on:
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 W ACCORDANCE WITH 310 CMR 15.303(1)(b)THAT THE SYSTEM
IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
Cesspool or privy is within 50 feet of surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
J
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER,IF ANY)DETERMINES THAT THE SYSTEM IS
FUNCTIONING W A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
The system has a septic tank and soil absorption system(SAS)and the SAS Is within 100 feet of 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 l 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
>,`�'t'•''"''' rivate water supply I well,unless'a well water analysis for coliform bacteria and volatile organic compounds indicates that the
.n ,• P
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).
3) OTHER
revised 9/2/98 P2ge3of11
a
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Addra z: 8 8 JAW r
owner: 11112f,y
Data of Impaction:
D. SYSTEM FAILS:.
You must Indicate either"Yes" or"No" to each of the following:
I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this
determinatlon is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure.
Yes No
Backup of sewage into facility or system component due-to an overloaded or clogged SAS or cesspool.
Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or
cesspoof--
Static liquid level in the distribution box above outlet invert due town 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 IGSs•than 100 feet but greater than 50 feet from a private water supply well with no
,.acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for
•coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
E. LARGE SYSTEM FAILS:
You must indicate either "Yes".or "No" 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 g0 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 11 of a public
water supply well)
The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional
office of the Department for further information.
revised 9/2/98 Page4ofll
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address:
Owner: ,0,jv/SLv
Date of Inspection: 9 w0
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. .
v • _ None of the system components have been pumped for-at least two weeks and-the system has been-receiving•nvrmal flow
rates during that period. Large volumes 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 si ns of breakout.
-11A4.j r'Ie
_ All system components, ewes Me 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:
_ Existing information. For example, Plan at B.O.H..
Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable)
115.302(3)(b))
The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of
Subsurface Disposal Systems.
a
revised 9/2/98 Page 5of11 �
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: /00. ,S7 r�rr cr�! �Y/✓ S CI v/ /P'/Y�!>.
Owner:
Date of Inspection:
FLOW CONDITIONS
RESIDENTIAL:
Design flow: LZ O g.p.d./bedroom.
Number of bedrooms(design):y Number of bedrooms(actual):
Total DESIGN flow Ma
Number of current res(dents:-, Z_
Garbage grinder(yes or no): S
Laundry(separate system) as or no): Na, If yes, separate Inspection required
Laundry system Inspected le or no)
Seasonal use(yes or no):` s i2 d
c pd 98 3s/
Water meter-ieadings,�if av ilable"(last two''year's usage(gpd): "350, _mil
Sump Pump(yes or no): a%O I
Last date of occupancy: OCGk �t.
COMMERCIAL]INDUSTRIAL:
Type of establishment:
Design flow: oad ( Based on 15.203)
Basis of design flow
Grease trap present: (yes or no)_
Industrial Waste Holding Tank present:(yes or no)_
Non-sanitary waste discharged to the Title 5 system: (yes or no)_
• Water meter readings,if available:
Last date of occupancy:
OTHER:(Describe)
Last date of occupancy:
GENERAL INFORMATION
PUMPING:RECORDS and source o Informatio
79
System pumped as pAi of in pection:(yes or no)_
If yes,.volume pumped: gallons
Reason for pumping:
TYPE OF SYSTEM
_ Septic tank/distribution box/soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system(yes or no) (if yes, attach previous inspection records,if any)
I/A Technology etc.Attach copy of up to date operation and maintenance contract
Tight Tank Copy of DEP Approval
Other �-
APPROXIMATE AGE of all components,date Installed(if known)and source of information: / .yQa�S S lQ 7- 9- 8
Sewage odors detected when arriving at the site: (yes or no)
revised . 9/2/98 Page 6of 11
f
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
a ' PART C „
SYSTEM INFORMATION(continued)
Property Addrrem:
Date of Inspection:y"!
S-9-oo
BUILDING SEWER:
(Locate on site plan)
h
Depth below grader
Material of construction:_cast iron 40 PVC_other(explain)
Distance from private water supply well or suction line
Diameter
Comments:(condition of joints,venting, evidence of leakage,etc.)
SEPTIC TANK:—
(locate on site plan)
rr
Depth below grade:1$
Material of construction:_ oncrete metal_Fiberglass ,_Polyethylene—other(explain)
If tank is metal,list age_ .Is.age confirmed by Certificate of Compliance_(Yes/No)
Dimensions: /•O S
Sludge depth: p0'
• Distance from top of sludge to bottom of outlet tee or baffle;lz
Scum thickness:�
Distance from top of scum to top of outlet tee or bafflelei
Distance from bottom of scum to bottom of outlet tee or baffle:
How dimensions were determined: JN?n S t+yi'L4 �o
Comments:
(recommendation for pumping,condition of inlet and outlet tees or baffles,deg h of 'qui level in relation to outlet invert, structural integrity,
vidence of leakage,etc.) ���+ u�a r ��tea a r s �� '
GREASE TRAP:
(locate on site plan)
Depth below grade:_
Material of construction:_concrete_metal,_Fiberglass _Polyethylene_other(explain)
Dimensions: ,• .<.
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tea or baffle:
Date of last pumping: x .
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.)
1
revised 9/2/98 Page 7of11 _
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
.<'PART C
SYSTEM INFORMATION(continued)
Property Address: DS/�/v%AP
Owner: �vLj,4 Sct�L.PN$,r
Data of Inspection:
TIGHT OR HOLDING TANK: (Tank must be pumped prior to, or at time of, inspection)
(locate ion site plan)
Depth below grade:_
Material of construction:_concrete_metal_Fiberglass_Polyethylene_other(explain)
Dimensions ._......._._.._..
Capacity: gallons
Design flow:_gallons/day
Alarm present
Alarm level: Alarm In working order:Yes_ No_
Date of previous pumping:
Comments:
(condition of inlet tee, condition of alarm and float switches,.etc.)
DtSTR113LMON BOX:—
(locate on site plan)
Depth of liquid level above outlet Invert:�y
Comments`'
(note,if level and distribution Is equal, evidence of solids carryover,evi once of leakage into or out b x, etc.)
! '
IV
PUMP CHAMBER: .
(locate on site plan)
Pumps in working order:(Yes or No)
Alarms in working order(Yes or No)
Comments:
(note condition of pump chamber,condition of pumps and appurtenances,etc.)
revised 9/2/98 Page 8ofII
-SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: /88 fyar�riis'�c►a.. Oriv>`' [JSrvi%�e�/L14.
owns.: +4., Scf.t•el',-fy
Date of Irup�` o_n.
SOIL ABSORPTION SYSTEM(SAS)
(locate on site plan,if possible;excavation not required,location may be approximated by non-intrusive methods)
If not located, explain:
Type:
leaching pits,number:Z
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 ofi hydraulic failure,level of p r din , damp,soil, condition of vegetation, etc.)
�f, T yr , (,pve
1vQ v
CESSPOOLS:_
(locate on site plan)
Number and configuration:
Depth-top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater:
inflow(cesspool must be pumped as part of Inspection)
Comments: .
(note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.) w
r
PRIVY _
(locate on site plan)
Materials of construction: Dimensions:
Depth of solids:
Comments:
(note condition of soil,signs of hydraulic failure,level of ponding, condition of vegetation, etc.)
revised 9/2/98 P2ge90fII
.SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
' �7.:•SYSTEM INFORMATION(continued)
Property Address: / STui b v���f (/�'i v♦ �s/t'r yr/1 /�(!,
Owner:. 164H SKiL.2hl y
Date of Inspection:
5�9-Qo
SKETCH OF SEWAGE DISPOSAL SYSTEM'
'
Include ties to at least two permanent reference landmarks or benchmarks
locate all wells within 100' (Locate where public,water supply comes Into house)
Ore 61 f hON.SQ
o
1 Q
C6" 7a
.z p , �8 " 70 t��of 7uNk
y 9', 3''
;Zs L
3
T T
39 3
revised 9/2/98 P2ge10of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: J74 4100 dui
Owner:
Data of Inspection:
NRCS Report name e
Soll Type_
Typical depth to groundwater
USGS Date websitevisited
Observation Wells checked .•.
Groundwater depth: Shallow Moderate Deep m
SITE EXAM Slope
Surface water
Check'Cellar
Shallow wells
Estimated Depth to Groundwater 5 Feet
Please Indicate all the methods used to determine High Groundwater Elevation:
"Obtained from Design Plans on record
Observed Site(Abutting property, observation hole,basement sump etc.)
/ Daterm(ned from local conditions
Checked with local Board of health '
Checked FEMA Maps - P
Checked pumping records
xT_Checked local excavators,Installers
�sed USGS Data
Describe how you established the High Groundwater Elevation. (Must be completed) a,
TT9
�v�t .Toc�y rhos :a � �ef/, -•� , T �. -
nQ �y .� hl,' � of y.dti,,��l wu l�•w �1, 1� '`-• - .` ' _ ,
revised 9/2/98 Page 11 of 11 4