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HomeMy WebLinkAbout0170 WIANNO CIRCLE - Health 970 VIlianno Circle OsterviHe = 140 110 , ° u Y , ° -� TOWN OF BARNSTABLE a� LC;:ATION ✓70 UJAg .:o SEWAGE # Cttl VIT,.:.AGE ASSESSOR'S MAP & LOT IVO —//0 INSTALLER'S NAME&PHONE NO. 7t SEPTIC TANK CAPACITY j tmzv e LEACHING FACILITY: (type) Coo �> 14 (size) NO.OF BEDROOMS 3 BUILDER OR OWNER �. PERMITDATE:�_ I`f COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by O I TO OF BARNSTABLE LCCATION /�O (,f.// n17(0, 71IMl� SEWAGE # VU3.IAGE( s/0-01 Ile, ASSESS 'S MAP & LOT 00 �lb 11.6P7d �C7jQS'NAME&PHONE NOb TU /,. SEPTIC TANK CAPACITY C OC) 00 // LEACHING FACILITY: (type) �. ( � (size) D 0 . NO.OF BEDROOMS—2--77-- BUILDER O OWNER vC..t PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by i nn i nb � V 1� No. 117 Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: es PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 2ppficatiou for Migool *p!tem Congtruction Permit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. 00 Owne 's Name,Address and Tel. o. Assessor's Map/Parcel 2 q0 //r /�Z O �d�Gv►-c�r�U 7 5-.2— Installer's N Address. d Tel.No. Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size • '`��q.ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued b oard of Health. Signed Date Application Approved by Date 7 Application Disapproved for the fo wing reasons Permit No. / '� - ! 7 Date Issued 6 No.�7 � � �,.. � { Fee—� THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS ZIpprication for Zigozal *potem Congtructiou i3ermit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. no w-c4,;vv+.o Q,,�rA Owner's �Nam e,Address and Tel. Assessor's MapTarcel (,I� VJ <: C�.t— 0 Installer's Nam Address,and Tel.No. Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms 3 Lot Size - 3/O"q.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank - Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of`Compliance has been issued by this-Board of Health. Signed ` J � Date Application Approved by x Date Application Disapproved for the fol ing riLons Permit No. ��5 Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of (Compliance j THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired ("Upgraded( ) Abandoned( )by , p40 at 1-7 k rl 4 n_4AZW411 1A /,ram, has been constructed in accordance with the provisions of Title 5 andxhe for Disposal System Construction Permit No. 7 dated Installer .10A*a Designer The issuance of this permit shall not be construed as a guarantee that the system will function as designed. Date �� Inspector --------------------------------------- No. Fee _ THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS Mwi000al *?Aem Con5tructiou Vermit Permission is hereby granted to Construct( )Repair( Jpgrade( )Abandon( ) System located at I o tl1.<444414 4 6L.4-ee and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided: Construction must be completed within three years of the date of this permit. Date: ?— z�v_,q rl Approved by NOTICE: This Form is to be used for the Repair of Failed Septic Systcros Only CERTIFICATION OF SKET1I AND APPLICATION FORA DISPOSAL NVORKS CONSTRUCTION PERMIT (WITIIOU'I' DESIGNED PLANSI hereby certify that the application for disposal works construction permit signed by me dated " , concerning the property located at 1 ,70 meets all of the following criteria: There are no wetlands within 300 feet of the proposed septic system • There are no private wells within 150 feet of the proposed septic system The observed groundwater table is 14 feet or greater below the bottom of the leaching facility • There is no increase in flow and/or change in use proposed "fliere are no variances requested or needed. SIGNED: DATE: 3 �'F 7 LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER [Attach a sketch plan of the proposed system.Also if the licensed installer posesses a certified plot plan, this plan should be submitted]. j:ccrt o .45 ._.-_---.-------.-.-----__._._-_._._.._._._....___..._._.._ � "� f Zz-q, � f jjj BOItTOLOTTI CONS'TW)CTION, INC. ' 765 WAl{EBY ROAD, MAIISTONS MILLS, MA 02648 508-771-93919 508-428-8926 FAX.: 508-428-9399 SUBSURFACE SEWAGE [DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: `1 Date of Inspection• Inspector's N nae: - 94yner's Name Address: z�--- LW U' Cn ('Fit_TrFI� ATION STATFMENTs I certify that I have personally inspected the sewage disposal system at this address and that the informa- tion reported below is true,accurate and complete as of the time of inspection. The inspection was per- formed based on my training and experience in the proper ffmction and maintenance of on-site sewage disposal systems. The System: Passes Conditionally Passes —/—Needs Further Fvalmnfinn By tl Local_ -oving Authority LIr ii Fails Inspectors Signature: 1bDate:_ y' The System Inspector shall submit a copy of this inspection report to the Approving authority within thir- ty(30)days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority. INSPECTION M AItY• A)SYSTEM PASSES: I 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; One or more system components need to be replaced or repaired. The system, upon comple- tion of the replacement or repair, passes inspection. Indicate yes, nor,or not determined(Y,N,Oil ND). Describe basis of determination in all instances. If "not determined",explain why not. The septic tank is metal,cracked, structurally unsound, Shows substantial infiltration or exfiltration,or tank failure is imminent. The system will pass inspection if the existing sep- tic tank is replaced with a conforming septic tank as approved by The Board of Health. Sewage backkup or breakout or high static water level o0served in the distribution box is due to broken or obstructed pipe(s)or due to a broken, settled or e.meven distribution box. The system will pass inspection if(with approval of The l3oard of Health): - I - it R SUBSURFACE SEWAGE DISPOSAL,SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Broken pipe(s)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 pipe(s)are replaced Obstruction is removed C)FURTHER EVALUATION,IS REQUIRED BY T11E BOARD OF HEALTH: Conditions exist which require fintber eyaliaatioki 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 11EALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL,PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 Feet of a surface water Cesspool or privy is within 50 Feet of a bordering vegetated wetland or a salt marsh. 2)SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH II (AND PUBLIC WATER SUPPLIER,IF APPROPRIATE)DETERMINES THAT TILE SYSTEM IS FUNCTION- ING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: 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. The system has a septic tank and soil absorption systen,►and is with a Zone I of a public water supply well. The system has a septic tank and soil absorption system and is within 50 Feet of a private water supply well. The system has a septic tank and soil absorption system and is less than 100 Feet but 50 Feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from the facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. D)S TEM FAILS: I have determined that the system violates one or more of the following failure criteria as defined in 310.CNW..15.30.3. The basis for this determination is identified below. The Board of Health shou}d be contacted to determine what will be necessary to correct the failure. ,/ Backup of sewage into facility or system coniponent due t.o.an overloaded or clogged SAS or cesspool. Discharge or ponding of efluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. Static liquid level in the distribution box above outlet invert.due to an overloaded or clog- ged SAS or cesspool. Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow. Required pumping more than 4 times in the last year NO,h due to clogged or obstructed pipe(s). Number of times pumped -2- u' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM y. PART A CERTIFICATION (continued) Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 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. 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 a large system in addition to the criteria above: The design flow of a system is 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: ' s 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 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. SUBSURFACE SEWAGE DISPOSAL SYSTEM.INSPECTION FORM PART B. CHECKLIST. Check if the following have been done: l/Pumping information was requested of the owner,occupant, and Board of Health. None of the system components have been pumped for atleast two weeks and the system has been receiving normal flow_rates during that period. Large volumes'of water have not been introduced into the system recently or as part of this inspection _eLAs-built plans have been obtained and examined. Note if they are not available with N/A. _ The facility or dwelling was inspected for signs of sewage back-up. The system does not receive non-sanitary or industrial waste flow. (,-The site was inspected for signs of breakout. -"All system components,excluding the Soil Absorption System, have been located on site. LZMe septic tank manholes were uncovered,opened,and the interior of the septic tank was fin- ed 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 Absorptioni System on the site has been determined based on existing information or approximated by non-intrusive methods. -3- r Y4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST(continued) yThe facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of Subsurface Disposal System SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION FLOW CONDITIONS RFSIDENTLAi Design Flow: gallons Number of Bedrooms: V3 Number of Current Residents:_ Garbage Grinder: Laundry Connected To System: Seasonal Use::�Jr} Water Meter Readi s,if ilable: — Z 41m Last Date of Occupancy: COMMERCLAL/IND 1ST IAL.: Type of Establishment: Design Flow: allons/day Grease Trap Present: (yes or no) Industrial Waste Holding Tank Present: Non-Sanitary Waste Discharged To The Title V System: Water Meter Readings, If Available: Last Date of Occupancy: OTHER: Describe) Last Date of Occupancy: GENE FORMATION PUMPING RECORDS and source of information: System Pumped as part of inspection: If yes,volume imped: gallons Reason for pumping: TYPE OF SYSTEM: Septic Tank/Distribution Box/Soil Absorption System - Single Cesspool Overflow Cesspool Privy S�dred System(If yes,attach previoys inspe tion records, if any) — Other(explain):f�/hf2 ' To OXIMATE AGE of all compone ts,date installed(if known)and source of information: AZ Sewage odors detect when arriving at the e: -4- { SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM s PART C GENERAL INFORMATION (continued) SEPTIC TANK: y Depth below grader Material of Construction: concrete metal FRP—Other (explain) Dimisions:Z;:5j'XCA )( J Sludge Depth: & Scum Thickness: Distance from top of sludge to bottom of outlet tee or baffle:. 13z. Distance from bottom of scum to bottom of outlet tee or bade: Comments:.(recommendation for pumping,condition of inlet and outlet tees or b es,depth of liquid level in relation to outlet invert,structural integrity,a 'deuce of leakage,et ) o (,lam l(JC.I'J ii two_ i� GREASE TRAP: Depth Below Grade: Material of Construction: coricrcl.e metal FRP - Other (explain) — — — — Dimensions: Scum Thickness: Distance from top of scum to top of outlet tee or baffle: 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.) TIGHT OR HOLDING TANK: Depth Below Grade: Material of Construction:—concrete metal FRP—Other(explain) j Dimensions: Capacity: gallons Design Flow: gallons/day Alarm Level: Comments: (condition of inlet tee,condition of alarm and float switclies, etc.) DISTRIBUTION BOX: Wo 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.) r PUMP CHAMBER: AA Pump is in working order: ` Comments: (note condition of pump chamber,condition of pumps and appurtenances,etc.) -5- T SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) SOIL ABSORPTION SYSTEM(SAS): (Locate on site plan, if possible;excavation not required,but may be approximated by non-intrusive methods) If not determined to be present,explain: Type: Leaching pits, number: I Leaching chambers, number:_ Leaching galleries,number: Leaching trenches, number,length: Leaching fields,number,diinensions: Overflow cesspool, number: Comments: (note condition of soil, igns of hydraufi failure lev l of po►dir ,conditi n of vegetation, etc. .a �- /000 CESSPOOLS: A Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of Cesspool: Materials of construction: Indication of groundwater: Inflow(cesspool must be pumped as part of inspection) Comments: (note condition of soilk, signs of hydraulic failure, level of ponding,condition of vegetation, etc.) PRIVY: MaterialAconstruction: Dimensions: Depth of Solids: Comments: (note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.) -6 - 3 g SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM:INFORMATION (coi thwed) SKETCH OF SEWAGE DISPOSAL SYSTEM: Include ties to atleast two permanent references, landmarks or benchmarks. Locate all wells within 100 Feet. i r9 � 0 00`,� DEPTH TO GROUNDWATER: I Depth to groundwater: /,j Feet Method of DetRernunatt n or A�pPprcximat on:21 CV ltJ f -7- o q TOWN OF BARNSTABLE LOCATION SEWAGE # 1 y VILLAGE ASSESSOR'S MAP& LOT/V10 `//O INSTALLER'S NAME&PRONE NO. _ SEPTIC TANK CAPACITY v LEACHING FACILny: (type)_(DO ��c y X� (size) NO.OF BEDROOMS 3 BUILDER OR OWNER PERIyITTDATE:_- ,S — /`I�COMPLIANCE DATE: .- Separation Distance Between the: 9 7 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) Edge of Wetland and Leaching Facility(If any wetlands exist Feet within 300 feet of leaching facility) Furnished by Feet j I �c COMMONWEALTH OF MASSACHUSETTS 2 3 , EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION MAP PARCEL `10 LOT _ TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM j PART A 7: CERTIFICATION Property Address: 170 Wianno Circle 4 Osterville Owner's Name: Keith Nightingale w Owner's Address: cU r— rn Date of Inspection: 7/20/2004 Name of Inspector: (please print) Patrick T. Sullivan Company Name: Ready Rooter Mailing Address: P.O.Box 371 Sandwich,MA 02563 Telephone Number: (508)888-6055 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. 1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The System: asses Conditionally Passes Needs Further Evaluation by the Local Authority Fails Inspector's Signature: Date: ' The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent 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. Page 2 of 11 OFFICIAL INSPECTION FORM=NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 170 Wianno Circle Osterville Owner: Keith Nightingale Date of Inspection: ction: 7/20/2004 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D C. System Passes: �ave 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: One or more system components as described in the"Conditional Pass"section need be replaced or m upon completion of the replacement or repair,as approved b the B and of Health,will ass. repaired.The system, p p p p pp Y P i Answer yes,no or not determined (Y,N,ND)in the for the following statemd/nts. If"not determined"please explain. , f , e 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 in minent. 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 pi e(s)are replaced obstruction is removed m distribution box is leveled or replaced ND explain: f The system required pumping more than 4 times a yeas 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 ; Page 3 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 170 Wianno Circle Osterville Owner: Keith Nightingale Date of Inspection: 7/20/2004 C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board ealth 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 determin in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which w' protect public health,safety and the environment: _Cesspool or privy is within 50 feet o surface water Cesspool or privy is within 50 fe 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 enviroryrbent: i _The system has a septic tank and soil absorption system(SAS)and the SAS"is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone'1 of a public water supply. —The system has a septic tank and SAS and the SAS is within 5,0`feet of a private water supply well. _The system has a septic tank and SAS and the SAS is les4,fhan 100 feet but 50 feet or more from a private water supply well". Method used to determine distbnce "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 i5 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: % 1. i i j� Page 4 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 170 Wianno Circle Osterville Owner: Keith Nightingale Date of Inspection: 7/20/2004 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No _ Backup of sewage into facility or system 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 and overloaded or clogged SAS or cesspool , Z 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 _uZ 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. Z Any portion of a cesspool or privy is within a Zone I of a public well. Any portion of a cesspool or privy is 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.] (Yes/No)The system fails. I have determined that one or more of the above 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,clesign flow of 10,000 gpd to 15,000 lgpd. 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 drinkingvater supply f/ the system is within 200 feet of a tributary toA surface drinking water supply _the system is located in a nitrogen sensit a area(Interim Wellhead Protection Area—IWPA)or a mapped Zone 11 of a public water supply well If you have answered"yes"to any questioaln Section E the system is considered a significant threat,or answered "yes"in Section D above the large systet has failed.The owner or operator of any large system considered a significant threat under Section E or fled 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. Page 5 of 1 I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 170 Wianno Circle Osterville Owner: Keith Nightingale Date of Inspection: 7/20/2004 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 than 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. _\,Z _ 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)] a Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 170 Wianno Circle Osterville Owner: Keith Nightingale Date of Inspection: 7/20/2004 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): Number of current residents:Q Does residence have a garbage grinder(yes or no): Is laundry on a separate sewage system(yes or no):��o[if yes separate inspection required] Laundry system inspected(yes or no): — Seasonal use:(yes or no):�cc� ---, = Water meter readings, if available(last 2 years usage(gpd)):" 0�9 o Sump Pump(yes or no): Last date of occupancy:C. COMMERCIAL/INDUSTRIAL , 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 o o): Non-sanitary waste discharged to the Tit 5 system(yes or no):_ Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: s <p y�.r..� .. ►'� z� *- � >> Q Was system pumped as part of the inspection(yes or no): If yes,volume pumped: cxmca allons--How was quantity pumped determined? ova Reason for pumping: ,t,'�o�arc w.��•. -'r L 1�-o �.�t •C'r 0 S, 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 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: t� Were sewage odors detected when arriving at the site(yes or no):.�� Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) r Property Address: 170 Wianno Circle Osterville Owner: Keith Nightingale Date of Inspection: 7/20/2004 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction:-Zc-ast 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: Material of construction:Azconcrete_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: S7 S Sludge depth: I d" Distance from the top of sludge to bottom of outlet tee or baffle:Z 3 , Scum thickness: 8 Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: c� " How were dimensions determined-�,�,,�� Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,,,etc.): l c^,c.i�:c—�. ��w u`U.A• 1 •. Q: S(� ,.1?� ©w `"►�\may w. dv'�C�?i:. �J:Tw:v�. G�' �'7 �'� GREASE TRAP:_(locate on site plan) Depth below grade: Material of construction:_concrete_metal_fiberglass norlyethylene_other (explain): 7 Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle,' Distance from bottom of scum to bottom of outlet tze or baffle: Date of last pumping: ; Comments(on pumping recommendations, rx(et and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): f Page 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 170 Wianno Circle Osterville Owner: Keith Nightingale Date of Inspection: 7/20/2004 TIGHT or HOLDING TANK: (tank must be pumped at time of inspectio (locate on site plan) Depth below grade: Material of construction:_concrete metal_fiberglass_p)lye lene_other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order s or no): Date of last pumping: Comments(condition of alarm and float itches,etc.): DISTRIBUTION BOX:z(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: C)" Comments(not if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): L1 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, ondition of pumps and appurtenances,etc.): t Page 9 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 170 Wianno Circle Osterville Owner: Keith Nightingale Date of Inspection: 7/20/2004 SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number:_ leaching chambers,number: leaching galleries,number: leaching trenches,number, length: x �© 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.): CESSPOOLS: (cesspool must be pumped as part mspection)(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 inflo (yes or no): Comments(note condition of oil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): PRIVY: (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydrau ' failure, level of ponding,condition of vegetation,etc.): Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 170 Wianno Circle Osterville Owner: Keith Nightingale Date of Inspection: 7/20/2004 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. D .'�:. C 10-: O CSC �.�` Page 11 of 11 • ' OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 170 Wianno Circle Osterville Owner: Keith Nightingale Date of Inspection: 7/20/2004 SITE EXAM Slope Surface water Check cellar t/_ Shallow wells Estimated depth to ground water>I feet Please indicate(check)all methods used to determine the high ground water elevation: _SZObtained from system design plans on record—If checked,date of design plan reviewed: `ly%A_r Observed site(abutting property/observation hole within 150 feet of SAS) Checked with the local Board of Health-explain: Checked with local excavators, installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: l `