HomeMy WebLinkAbout0035 TANSY CIRCLE - Health 35 'Tansy Circle
Osterville> P
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COMMONWEALTH"OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL P O �NED
'I
J U L 3 1 2003
TOWN OF BARNSTABLE
HEALTH DEPT.
TITLE 5
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 35 Tansy Circle
Osterville, AM 02655
Owner's Name: Jeff&Mary talesman
Owner's Address: 3 Allen Bend Place
Decatur, IL 62527"
Date of Inspection: July 16, 2003
Name of Inspector: (Please Print) James M. Ford
Company Name: James M. Ford Map: 121
Mailing Address: it P.O. Box 49 Parcel: 071
Osterville,MA 02655-0049 Lot: 18
Telephone Number:l, (508)862-9400. "
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
eds Further Evaluation by the Local Approving Authority
a is
Inspector's Signature:\u�'b
Date: Jul 20 2003The system inspector,shit 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 to the buyer, if applicable, and the approving
authority.
Notes and Commentsl'
****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: 35 Tansy Circle
Osterville, AM
Owner: Jeff&Mary Glesman
Date of Inspection: July 16, 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:
B. System Conditionally Passes:
y y
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) in 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 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 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:
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):
broken pipe(s)are replaced
obstruction is removed
ND explain:
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Page 3 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 35 Tansy Circle
Osterville, MA
Owner: Jeff&Mary Glesman
Date of Inspection: July 16, 2003
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 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 a 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 I of a 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 determine 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:
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Page 4 of 1 I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 35 Tansy Circle
Osterville, MA
Owner: Jeff&Mary Glesman
Date of Inspection: July 16, 2003
D. System Failure Criteria applicable to all systems:
You must indicate either"yes"or"no"to each of the following for all inspections:
Yes No
_ ✓ Backup 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
clogged SAS or cesspool
✓ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
✓ Liquid depth in cesspool is less than 6" below invert or available volume is less than ''/z 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 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 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 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.]
No (Yes/No)The system fails. .I 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 System:
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000
gpd•
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)
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
If you 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 failed. The owner or operator of any large system considered a
significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
15.304. The system owner should contact the appropriate regional office of the Department.
4
Page 5 of 11
OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 35 Tansy Circle
Osterville, MA
Owner: Jeff&Mary Glesman
Date of Inspection: July 16, 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 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 ?
✓ _ 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 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 35 Tansy Circle
Osterville, AM
Owner: Jeff&Mary Glesman
Date of Inspection: July 16,'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 x#of bedrooms): 330
Number of current residents: 2
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): No
Seasonal use(yes or no): Yes
Water meter readings, if available(last 2 years usage(gpd)): Unavailable
Sump Pump(yes or no): No
Last date of occupancy: Currently occupied
COMMERCLUJINDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): gpd
Basis of design flow(seats/persons/sgft,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 readingsi, if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information: Unavailable
Was system pumped as part of the inspection (yes or no): No
If yes, volume pumped: _gallons-- How was quantity pumped determined?
Reason for pumping:
i
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)
Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be
obtained from systemiowner)
Tight Tank Attach a copy of the DEP approval
Other(describe):
Approximate age of all components,date installed(if known)and source of information:
May 5177-per as built card
Were sewage odors detected when arriving at the site(yes or no): No
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Page 7 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 35 Tansy Circle
Osterville, MA
Owner: Jeff&Mary Glesman
Date of Inspection: July 16, 2003
BUILDING SEWER(locate on site plan)
Depth below grade:
Materials of construction: _cast iron _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 on site plan)
Depth below grade: 2'
Material of construction: ✓ concrete _metal _fiberglass _polyethylene
_other(explain)
If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of
certificate)
Dimensions: 1500 gal.
Sludge depth: 2
Distance from top of sludge to bottom of outlet tee or baffle: 30"
Scum thickness: 2"
Distance from top of scum to top of outlet tee or baffle: 8"
Distance from bottom of scum to bottom of outlet tee or baffle: 12"
How were dimensions determined: Measuring stick
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert,evidence of leakage, etc.):
Tees were present. The liquid level was even with the outlet invert. There were no signs of leakage.
GREASE TRAP: None (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 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.):
7
Page 8 of 1 I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
i
Property Address: 35 Tansy Circle
Osterville, MA
Owner: Jeff&Mary Glesman
Date of Inspection: July 16, 2003
TIGHT or HOLDING TANK: None (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: Alarm in working order(yes or no):
Date of last pumping:
Comments(condition of alarm and float switches,etc.):
DISTRIBUTION BOX: None (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: None locate on site n( tep]a )
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.):
f
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Page 9 of 1 I t
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 35 Tansy Circle
Osterville, MA
Owner: Jeff&Mary Glesman
Date of Inspection: July 16, 2003
SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on;site plan,excavation not required)
If SAS not located explain why:
Type
✓ leaching pits, number: 1 -6'x 6'(1000 gal.)
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.):
The pit had 2'6"of water on the bottom. There were.no signs offailure. The bottom to grade was 9. The cover was 30"below
grade.
CESSPOOLS: None (cesspool must be pumped as part of inspection)(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(yes or no):
Comments (note condition of soil, signs of hydraulic failure,level of ponding,condition of vegetation, etc.):
PRIVY: None (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.):
Page 10 of 1 1
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 35 Tansy Circle
Osterville, MA
Owner: Jeff&Mary Glesman
Date of Inspection: July 16, 2003
Map: 121
Parcel: 071
SKETCH OF SEWAGE DISPOSAL SYSTEM Lot: 18
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.
a
O O
a y y aq 3
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Page 1 I of 1 I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 35 Tansy Circle
Osterville, MA
Owner: Jeff&Mary Glesman
Date of Inspection: July 16, 2003
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water 30 +/- 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: topographic and water contours maps
Checked with local excavators, installers-(attach documentation)
Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Using the Barnstable topographic map and the Cape Cod Commission water contours map,the maps were showing approximately
30'+/-to ground water at this site.
This report has been prepared and the system inspected and passed as of the date of inspection. This report is
not a warranty or guarantee that the system will function properly in the future. There have been no warranties
or guarantees, either expressed, written or implied, relating to the system, the inspection and/or this report.
11
1e r\
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�-� COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS John Graci
DEPARTMENT OF ENVIRONMENTAL PROTECTION DEP Title V Septic Inspector
ONE WINTER STREET BOSTON MA 02108(617)292-3500 P.O.Box 2119
TeaTicket,Ma.
(508)564-6813
TRUDY COXE
Secretary
ARGEO PAUL CELLUCCI DAVID B.STRUHS
Governor Commissioner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
Property Address: 35 TANSY CIRCLE OSTERVILLE I -6, i - U-1 k _�rJY
Name of Owner JIM MELLEN _
Address of Owner: UNIT 334 146 PINCKNEY ST.BOSTON MA.02114
Date of Inspection: 4/27199 Name of Inspector:(Please Print)JOHN GRACI 1999
1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000) sj Company Name: nla Mailing Address: n/a
Telephone Number: n/a
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate
and complete as of the time of inspection.The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems.The system:
X Passes The inpection is based on criteria defined in Title V
_ Conditionally Pass. s code 310 CMR 15,303.My findings are of how the system is
Needs Further Evaluation By the Local Approving Authority performing at the time of the inspection.My inspection does
_ Fails not imply any warranty or guarantee of the longgevity of the
septic system and any of its components useful life.
Inspector's Signature: fubmIta
tDate:4/28/99
The System Inspector shall 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
THE SYSTEM PASSES TITLE V INSPECTION.RECOMMEND PUMPING SYSTEM EVERY TWO YEARS TO PROLONG THE SYSTEM'USEFULL LIFE.
THE LEACH PIT HAS NOT HAD MORE THAN 2'OF WATER IN IT.
revised 9/2/98 Page 1 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 35 TANSY CIRCLE OSTERVILLE
Owner: JIM MELLEN
Date of Inspection:4/27/99
INSPECTION SUMMARY: Check A, B, C, or D:
A. SYSTEM 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:
System passes Title V inspection
B. SYSTEM CONDITIONALLY PASSES:
n1a 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.
Indicate yes,no,or not determined(Y,N,or ND). Describe basis of determination in all instances. If"not determined",explain why not.
Dta 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 septic tank,whether or not metal,is cracked,structurally unsound,shows substantial infiltration or exfiltration,or tank
failure is imminent.The system will pass inspection if the existing septic tank is replaced with a complying septic tank as
approved by the Board of Health.
n1a Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s)
or due to a broken,settled or uneven distribution box.The system will pass inspection if(with approval of the Board of Health).
broken pipe(s)are replaced
obstruction is removed
distribution box is levelled or replaced
Wa The system required pumping more than four times a year due to broken or obstructed pipe(s).The system will pass
inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
revised 9/2/98 Page 2 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 35 TANSY CIRCLE OSTERVILLE
Owner: JIM MELLEN
Date of Inspection:4127/99
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 IN 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.
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 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 I of a public water supply well.
The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well,
The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a
private water supply well,unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the
well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less
than 5 ppm,Method used to determine distance nta_ (approximation not valid).
3) OTHER
Wa
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revised 9/2/98 Page 3 of 11
i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued) `
Property Address: 35 TANSY CIRCLE OSTERVILLE
Owner: JIM MELLEN , r
Date of Inspection:4/27/99
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 determination is
identified below.The Board of Health should be contacted to determine what will be necessary to correct the failure.
Yes No
X Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool.`
X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool.
X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
X Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow,
X Required pumping,more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped Wa.
X Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation..
X Any portion of a cesspool or privy is within 100 feet of a surface'water supply or tributary to a surface water supply.
X Any portion of a cesspool or privy is within a Zone 1 of a public well. N
X Any portion of a cesspool or privy is within 50 feet of a private water supply well,
X Any portion of a cesspool or privy is less-than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality
analysis.If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic ompounds,
ammonia nitrogen and nitrate nitrogen.
X The liquid level in the SAS is over the invert pipe,is in Hydraulic Failure. k
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 gpd,or greater(Large System)and the system is a_ significant threat to public health and
safety and the environment because one or more of the following conditions exist:
Yes No
X the system is within'400 feet of a surface drinking water supply
X the system is within 200 feet of a tributary to a surface drinking water supply
X the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone II of a public
water supply well)
The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.30412).Please consult the local regional office of the
Department for further information. -
'revised 9/2/98 Page 4 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION'FORM.
v PART B
CHECKLIST
Property Address: 35 TANSY CIRCLE OSTERVILLE
Owner: JIM MELLEN
Date of Inspection:4/27/99 ,
Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following: '
Yes No
X Pumping information was provided by the owner,occupant,or Board of Health.
X 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.'
X As built plans have been obtained and examined.Note if they are not available with N/A, Y: '
X The facility or dwelling was inspected for signs of sewage back-up.
X The system}does not receive non-sanitary or industrial waste flow.
X The site was inspected for signs of breakout,
X All system components,excluding the Soil Absorption*System,have been located on the site`
X 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:
X Existing information,For example,Plan at B4O,H;
X Determined in the field(if any of the failure criteria related to`Part C is at issue,approximation of distance is unacceptable)
11 5.302(3)(b)1
X The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of.
SubSurface.Disposal Systems.
- {
revised W2/98' Page 5 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C µ
SYSTEM INFORMATION r
Property Address: 35 TANSY CIRCLE OSTERVILLE, � $` ` K t , •e i
z
Owner: JIM MELLEN V a
Date of Inspection:4/27/99 "
o-
w4
'FLOW CONDITIONS
RESIDENTIAL: `- :. f_
Design flow:-=g.p.d./bedroom
Number of bedrooms(design): 3; Number of bedrooms(actual)
Total DESIGN flow: IV w '
Number of current residents:Il s
Garbage grinder(yes or no):
Laundry(separate system)(yes or no):NQ If yes,'separate inspection required
Laundry system inspected(yes or no):-NQ
Seasonal use(yes or no): YES
Water meter readings,if available(last two year's usage(gpd). n&x
Sump Pump(yes or no): NQ
Last date of occupancy: Wa
COMMERCIAL/INDUST�/R,�IAL 1JL8 . .'
c _
' Type of establishment: _ �; i• ,
Design flow: Wa gpd(Based on 15.203)
Basis of design flow: n(a
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)'NQ
Water meter readings.if available:DLa Q
Last date of occupancy: Wa
p
OTHER: (Describe) '
n/A `
Last date of occupancy: nta #r y+ 4
GENERALINFORMATION -
'.
PUMPING RECORDS and source of information: 4 °
Y T M WAS A T PUMPED YEARS OLD-
System pumped as part of inspection:(yes or no).No
If yes,volume pumped iila_ gallons, � w
# f %
Reason for pumping: nta
TYPE OF SYSTEM ` r , u ..
E
X Septic tankidistribution 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 f �`
.Other: nta •h .ua f. i # •F -f J�`., .k„�s P.. s {,: � . - - '.
APPROXIMATE AGE of all components,date installed(if known)and source of information
THE SYSTEM WAS INSTALLED IN 1977 PERMIT 77-63 ,
Sewage odors detected when arnving`at the`'site (yes or no) NQ
3
revised 9098 ry Page 6 of 11
E
1
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 36 TANSY CIRCLE OSTERVILLE
Owner: JIM MELLEN
Date of Inspection:4/27/99
BUILDING SEWER:
(Locate on site plan)
Depth below grade: 2'E
Material of construction:_ cast iron _ 40 PVC X other(explain)
Distance from private water supply well or suction line: TOWN
Diameter: nLa
Comments: (condition of joints,venting,evidence of leakage,etc.)
nLa
SEPTIC TANK: X
(locate on site plan)
Depth below grade: 2'
Material of construction:X concrete_ metal_ Fiberglass _ Polyethylene _ other(explain)
nLa
If lank is metal,list age Is age confirmed by Certificate of Compliance(Yes/No): MQ
n(a
Dimensions: L 8'6"H 6'7"W 4'10"
Sludge depth r
Distance from top of sludge to bottom of outlet tee or baffle: 3z
Scum thickness
Distance from top of scum to top of outlet tee or baffle:6'
Distance from bottom of scum to bottom of outlet tee or baffle: 1Z
How dimensions were determined: MEASURED
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.)
SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND RECOMMEND PUMPING SYSTEM EVERY TWO YEARS
GREASE TRAP:
(locate on site plan)
Depth below grade:
Material of construction:_concrete_ metal_ Fiberglass _ Polyethylene_other(explain)
Wa
Dimensions: Wa
Scum thickness: Wa
Distance from lop of scum to top of outlet tee or baffle:-nLa
Distance from bottom of scum to bottom of outlet tee or baffle Wa
Date of last pumping: nLa
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.)
Wa
revised 9/2/98 Page 7 of 11
I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
¢ SYSTEM INFORMATION(continued)
Property Address: 35 TANSY CIRCLE OSTERVILLE
Owner: JIM MELLEN
Date of Inspection:4/27/99
TIGHT OR HOLDING TANK: NO (Tank must be pumped prior to,or at time of,inspection) '
(locate on site plan) '
Depth below grade: nta
Material of construction:_ concrete_ metal_ Fiberglass _Polyethylene_ other(explain)
nla
;•
Dimensions: nLa _
Capacity: nta gallons
Design flow: n(a gallons/day,
Alarm present: DLO
Alarm level:jila- Alarm in working order:Yes_No N-Q
Date of previous pumping: n/a
Comments:
(condition of inlet tee,condition of alarm and float switches,etc.)
nta
DISTRIBUTION BOX: _ <.
(locate on site plan) ,
Depth of liquid level above outlet invert:n a
Comments:
(note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc:)' ..
nLa
.:�
PUMP CHAMBER: DLO _ t
(locate on site plan)
Pumps in working order:(Yes or No): DLO
Alarms in working order(Yes or No): NO fi
Comments:
(note condition of pump chamber,condition of pumps and appurtenances.etc.)
nLd
revised 9/2198 Page 8 of 11
{ .
k
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
4 SYSTEM INFORMATION(continued) "
Property Address: 35 TANSY CIRCLE OSTERVILLE }
Owner: JIM MELLEN
Date of Inspection:4127/99
SOIL ABSORPTION SYSTEM(SAS): X
(locate on site plan,if possible;excavation not required,location may be approximated by non-intrusive methods)
If not located,explain:
nLa n ,
Type:
leaching pits,number: 1000 GALLON LEACH PIT
leaching chambers,number: jiLa
leaching galleries,number: jiLaV
leaching trenches,number,length: nta
leaching fields,number,dimensions: Wa A
overflow cesspool,number: nLa
Alternative system: n/a
Name of Technology: -nLa
Comments:
(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.)
THE LEACH PIT IS STRUCTURALLY SOUND AND FUNCTIONING PROPERLY-PIT l"►AS MPTY %T THE TIME OF TH WSP TION N VER MORE
THAN 2'IN
CESSPOOLS: _
(locate on site plan)
Number and configuration:
Depth-top of liquid to inlet invert: nLa
Depth of solids layer: Wa
Depth of scum layer. nLa '
Dimensions of cesspool: nLa
Materials of construction: nLa
Indication of groundwater: nLa inflow(cesspool must be pumped as part of inspection)nLa
Comments: e
(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.)
PRIVY:
(locate on site plan)
Materials of construction:n& Dimensions:nLa ,
Depth of solids:
Comments: `
(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.)
nLa
revised 9/2/98 Page 9 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 35 TANSY CIRCLE OSTERVILLE ,
Owner: JIM MELLEN
Date of Inspection:4/27/99
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) u
} (6 a
revised 9098 Page 10 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM'
PART C `
SYSTEM INFORMATION(continued) .
Property Address: 35 TANSY CIRCLE OSTERVILLE
Owner: JIM MELLEN
Date of Inspection:4/27/99
NRCS Report name: nta
Soil Type: nLa
Typical depth to groundwater: nta
USGS Date website visited: Wa `
Observation Wells checked: NQ
Groundwater depth:Shallow _ Moderate Deep _
SITE EXAM _ Slope
_ Surface water
_ Check Cella*
Shallow wells a,
Estimated Depth to Groundwater 12 Feet ,
Please indicate all the methods used to determine High Groundwater Elevation:
_ Obtained from Design Plans on record "
X Observed Site{Abutting property,observation hole,basement sump etc:)
_ Determined from local conditions
_ Checked with local Board of health
_ Checked FEMA Maps *,
Checked pumping records _
Checked local excavators,installers
X Used USGS Data
Describe how you established the High Groundwater Elevation.(Must be completed)
USGS MAPS AND CHARTS-12+FEET
revised 912198 Page 11 of 11
_ V
TOWN OF BARrN-STABLE
LOCATION lAr Gjrc't - SEWAGE #
VILLAGE ASSESSOR'S Gt yt�`'� ASSESSOR'S MAP & LOT/a/— 0'7
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY / rd
LEACHING FACILITY: (type) �O'X�OI 74/ (size) r
NO.OF BEDROOMS
I UILDER OR OWNER I69MA11
PERMITDATE: COMPLIANCE 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 leachin facility) Feet
Furnished by �^S GG7i on FO��
F'7 V
a
0 O
a yy aq O 3
3 S° `y'
L0,C A T 101M EWA G E PERMIT NO.
o
lt/
VILLAGE
INSTAL - ER'S ME & ADDRESS
1
ti
B UI*LDE R. OR OWNER
r-
DATE PERMIT ISSUED -/J�7-7
DATE COMPLIANCE ISSUED 27
�� � ���
`�
� �
.. ti � ���
No.. `� F�s....i.. .....
THE COMMONWEALTH OF-MASSACHUSETTS
BOARD O HE A TH g
_.. -- .OF........... .. ---------------------------------
Appliratiou -fear Bhip sal Vorks Tomitrurtiou Vamit .
Application is hereby'made for,.,� Permit to Construct ( ) or Repair ( } an Individual Sewage Disposal
System at: 3 �`nS� c e
........•. ...........................................••• ....
....................,ion. ddress or Lot No.
o -erc i - s " • -ei ��� e Tou ?o!y
Imo'' :.. 1.............•--•------ ..- --- 5 `���
caner Address
,a
Installer Address
d Type of Build' Size Lot./�_?3_` ----Sq. feet
U Dwelling No. of Bedrooms-----3..................................Expansion Attic ( ) Garbage Grinder (!/J
1
aOther—Type of Building'_121.�.�.��_Ll----.___ No. of persons.------ ______.......... Showers (q) — Cafeteria
dOther fixtures --------------- ---------------------------------- ------------------_--- -------------------------------•-----------------------------------------
w Desi n Flow.. ............a _._� _ gallons per et-son per day. Total daily. flow....... ' -----____._.____-_gallons.
g �--------------------g� P P P Y• Y
WSeptic T«nk(-Liquid capacity/$- -gallons Length---------------- Width................ Diameter---------------- Depth.--._____-_.
x Disposal Trench—No..................... Width.................... Total Length-------------_...... Total leaching area--------------------sq. ft.
Seepage Pit No--------------------- Diameter.................... Depth below inlet_...... __.__-___• Total leaching area______.______•-__sq. ft.
Z Other Distribution box ( ) Dosing tank ( ) d px-10C 2 - 7 7
'-, Percolation Test Results Performed by------ -------------------................................................ Date----------------------------------------
Test Pit No. 1-----------------minutes per inch Depth of Test Pit._._____•___--_•-._. Depth to ground water--._____._____._____----
fTq Test Pit No. 2................minutes per inch Depth of Test Pit____-__-_---______ Depth to ground water__.__.______________----
a' ` . • - -
O �. r -G -.y .- .er�4�Description of Soil-----; -- ------- -------
- ---------
/a
W ---- ------------------------------- --------------- --------------------------------=------------------------------------------------------------ ----------------- ------- --------------------------
UNature of Repairs or A'_terations—Answer when applicable----------------------------------------------------------------------:.... -------------------
--------------------------------------------- ---------------------------------------•------------------------------------- -----------------------------.-...
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has b iss ed by the
board of health.
Sign .= ---------- ----"."- �'-„-------------- •---•----------•-•--•-•---••--
Date
Application Approved By______. _.._
- ----------- ------------ �3�1� D?7----------
Application Disapproved for the following reasons____________________•_-----___-__-______-.-__--_-_______--_____---_--____-___________-_______
----------------------------------------------------------------------------------------------------•----•----•••-•-•--•-•••--------•-•--••-------------•••---------............••-•---••----•-•-......
Date
PermitNo........................................................ Issued----. =S L .................
Date
No........... -_.. Fine .................
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
OF YO000041
_.... .._..-.
a �
97
Applirtttiun -for Bi�ipwial Works Tonstrurtiott Prrmit
Application is hereby'made, for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
�
Ii ••.!v_6* ov 2/v S /PAC /Gc e
Yam..= -----...--•�............ . �� L --- ._...----------•-----1 . ---------------------------------------
Lo ion•Address / _ _or Lot No.
Owner _ F Address
" . ly Q 5 c=�' Tr a ................../ham.../...........
Installer Address
Q Type of Building ; Size Lot..lf,3.3_ /._Sq. feet
,_..
Dwelling-�No. of Bedrooms.................................. _Expansion.-Attic ( ) Garbage Grinder (vf
a Other—Type of Building /z.l �_�?_-_-____ No. of per,ons.,._.R' �______________ Showers.,(a) — Cafeteria ( )
-------------- ":�._ .
Other fixtures ----------------•----.....,. ,',. .__...�._...__.....--------------=--•--•--••--•---
w Design Flow________________�__o"_________________._gallons,per person per day. Total daily flow.____ ' $J___""
WSeptic Tank I-Liquict capacitvo4POgallons Length________________ Width................ Diameter_-.--...._.-_.-_ Depth----------------
x Disposal Trench—No. ...................... Width---------------_----Total Length.------------------- Total leaching area::::'---------------sq. ft.
Seepage Pit No.... f Diameter_.'t---------------- Depth. below inlet ._.............. Total leaching area-----.------------sq. ft.
Z Other Distribution box�( ) Dosing tank ( � ) o, - 2 • /S"•7'7
Percolation Test Results; Performed b
a Y -------------------------= e�--------------- Date_____-------------------------------.-..
Test Pit No., 1----------------minutes per inch Depth of Test Pit.................... Depth to ground water------------------------
LX, Test Pit No. 2................minutes per inch Depth of T%st_Pit_-__--__________-_ Depth to ground water..._..-----.----------
------------------- ..
I ff
......... - -------- -------- ---
D Description of Soil <�"...�'� ��� R �y r �'� ",f� " �,�
w
�.
U Nature of Repairs or Alterations—Answer when"applfcable-----------------_____________________________________________________________________________ .
Agreement:
The,,undersigned agrees to install the'aforedescribed` Individual Sewage Disposal System in accordance with
the provisions of Artyele NI of the State Sanitary Code— T114e undersigned further agrees not to place the system in
operation`until a Certificate of Compliance has be issued by the board of health.
S. .. �— --------------- ................................
Date
Application Approved BYf l e� �� : -----------
Date
Application Disapproved for the following reasons: ------ ----•--= '< ----------------------------------------------------- -------------------
1
Date
PermitNo.....................`==- ....................... Issued........................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH.,_
,t
�'li';'i......
Trrfif irtttr of amp ittnrr
TH S IS TO CE FY•`Thattth'e Individual Sewage Disposal System constructed (�or Repaired ( )
��7inste
- Installat__. .6r ` � � L' " ' `d a ...has been in accordance w• the provisions of -k �The State Sanitary Code as described in the
application for Dispos�1 Works Construction Permit No.f _ ..�__________________ dated_..._m'4-'_'�7---_____________-__
THE ISSUANCE 'OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE. :...._ _..." 7 Inspector eft ------•-----
• ✓
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF' HEALTH
CIZ) o F/ ................................
I � :
��
No. (.� ._ FEE....
�i���a,�tt �rk� �tt�tr�trti��t rr�tif
-Permission is hereby granted---•= sf1,g6�E ----------------------------------- --•----•----•-- ..........
to Cons
tt t ( j or air, ) n Indiv' al ewage posal Sy ern
at No.-- - --.. ... _
as shown on the application for pisposal Works Construction P Iit'N ____________ ______ Dated..::3�/.,�_" ...............
Ft
---------------------------
- 77
/ ,..
DATE =---••--•---•---- .. --------•------------------- --........
FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS
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REGtSC�i2�D L.+►. JID SUZVEYaZS
"("NIS D'�.AtJ IS �1dT SASE' o� AN t?STER.V1LL.E a MaSS.
tNSi72tl�Et�tT Sc.�ev��r - � c3Fcr5r--rS e'140 L—o APPt.t GA,t.�T j�H Mc C-c .►,�r,.J
F•oT Th OmTmemi sNt= LO-r
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LOCATION : SEWo,GE PERMIT UO.
IWSTQLLER5 IJ&ME ADDRESS
Utz>f_��:�c�_�_�•f �_� ��,�uc �������—
BUILDER 'S tJ &MF— ADDRESS
DA,TE PERVNA T ISSUED
DATE COKAPLI &I ACE ISSUED :
J
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