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HomeMy WebLinkAbout0056 BRIGANTINE AVENUE - Health 56 Brigantine Avenue, Marstons Mills i i I ' 12 I —n rn Commonwealth of Massachusetts Executive Office of Environmental Affairs Department of o� -pN Environmental Protect! Wllllam F.Weld Coxe (iowmor Sam" Argeo Paul Cellucci ` 9 B.Struhs U.Goarnor Commbalorw SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A - CERTIFICATION /��bFR.S cl�te S na�tLLS 56 Brigantine Ave, r.� ,-v - e;MA:` Father Peter Property Address: Address of Owner. Date of Inspection: 07 `/"57 i' (If different) Ch r i s a f i d e r s Name of Inspector. W.E. Robinson SR 10 Etna Place Company Name,Address and Telephone Number. ( 5 0 8 ) 7 7 5-8 7 7 6 Lynn, MA 01904 W.E. Robinson Septic Service P.O. Box 1089 Centerville MA CERTIFICATION STATEMENT I certify that I have personally inspectec 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 sew disposal systems. The system: t/Passes Conditionally Passes Needs Further:Evaluation By the Local Approving Authority _ Fails Inspector's Signature: ! J G� Date: 7, The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority. INSPECTION SUMMARY: Check A, B, C,or D: A) :SY7S*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 componer is need to be replaced or repaired. The system,upon completion of the replacement or repair,passes inspection. Indicate yea,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, 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 Fonforming septic tank as approved by the Board of Health. (revised 11/03/95) 1 One Winter Street a Boston,Massachusetts 02108 a FAX(617)SWID49 a Telephone(617)292-SSW iAJ Printed on Recycled Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 56 Brigantine Ave, Osterville, MA Owner. Father Peter Chrisafiders Date of Inspection: _4!-,gr / B)SYSTEM CONDITIONALLY PASSES (continued) Sewage backup or breakout or high static water level observed in the distribution boa 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 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) FUR ER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: nditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the blic health,safety and the environment. 1) STEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: 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. Z) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER,IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: IThe 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 system and is within a Zone I of a public water supp)y 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 leas than 100 feet but 50 feet or more from a private water supply well,unless.s well water analysis for ooliform 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 lass than 5 ppm. 3) ITHER (revised 11/03/95) 2 SUBSURFACE SEWAGE DISPOSAL SYSTEM.INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 56 Brigantine Ave, Osterville, MA Owner. Father Peter Chrisafiders Date of Inspection: _z�^ q - D] B STEM FAILS: I determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for t ' determination is identified below. The Board of Health should be contacted to determine what will be necessary to Correct the ure. 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 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 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 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. EJ LARG SYSTEM FAILS:, e following criteria apply to large systems in addition to the criteria above: 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 and safety and the environment because one or more of the following conditions exist: the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area(IWPA)or a mapped Zone II of a public water supply well) The owner or operator of any such system shall bring the system and facility into dill compliance with the groundwater treatment program requireme of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.. (revised 11/03/95) 3 L SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 56 Brigant--ne Ave, OSterville, MA Owner. Father Peter Chrisafiders Date of Inspeodon: Check if the following have been done: mping information was requested of the owner,occupant,and Board of Health. Zone 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. 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. system does not receive non-sanitary or industrial waste flow _L/The site was inspected for signs of breakout. system components,excluding the Soil Absorption System, have been located on the site. 'he septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge,depth of scum. _Zt/h,size and location of the Soil Absorption System on the site has been determined based on existing information or ted by non-intrusive-methods. app ty owner(and occupants, if different from owner)were provided with information on the proper maintenance of Sub- Surface Disposal System. (revised 11/03/95) 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION property Address: 56 Brigantine Ave, Osterville, MA Owner. Father Peter Chrisafiders Date of Inspection: r FLOW CONDITIONS RESIDENTIAL:- Design flow: '' _gallons Number of bedrooms: 7 Number of current residents: Garbage grinder(ryes or no): A-6 Laundry connected to system(yes or Seasonal use(yes or no):.j::�LS 1995 - 0 Water meter readings,if available: 1996 - 0 Last date of occupancy: /of L f COMMERCIALANDUSTRIAL: Type of establishment: Design flow: gallons/day 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 of information: - Iv//a System pumped as part of inspection: (yes or no)_ If yes,*volume pumped: gallons Reason for pumping- TYPE OF TEM 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) Other(explain) APPROXIMATE AGE of all components,date installed(if known)and source of information: i/a Sewage odors detected when arriving at the site: (yes or no) CS (revised 11/03/95) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 56 Brigantine Ave, OSterville, MA Owner. Father PEter Chrisafiders Date of Inspection: SEPTIC TANK (locate on rite plan) Depth below grade: G Material of construction:=(/ ncrete_metal_FRP_other(e:plain) Dimensions: 77.fir Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: /_/ b' Scum thickness:�M , , Distance from top of scum to top of cutlet tee or baffle:_F� , Distance from bottom of scum to bottom of cutlet tee or baffle: ) c 1 Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to cutlet invert,structural integrity, evidence of leakage,etc.) !li c;�[.cJ C o C"( GRII E TRAP:_ (locate n site plan) Depth low grade: Material of construction:_concrete_metal_FRP—other(explain) Dime no: Scum egg: from top of scum to top of outlet tee or baffle: from bottom of scum to bottom of cutlet tee or baffle: Comm e� (reoomnidpdation for pumping,condition of inlet and cutlet tees or bathes,depth of liquid level in relation to cutlet invert,structural integrity, evidence tf leakage,etc.) (revised 11/03/95) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) PropertyAddrese: 56 Brigantine Ave, Osterville, MA Owner. Father Peter Chrisafiders Date of Inspection: '] MIT OR HOLDING TANK_ ( on site plan) Depth grade: Material construction:_concrete_metal_FU_other(explam) Dimensio Capaci gallons Design w: gallons/day Alarm 1 1: Cowmen : (conditio of inlet tee,condition of alarm and float switches,etc.) DISTRIBUTION BOX:_ (locate on site plan) Depth of liquid level above outlet invert: Q Comments: (note iflevel and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.) lL PUMP C BER:_ (kxate on ' plan) Pumps in wor ' order-(yes or no) Comments: (note oondi' n of pump chamber,condition of pumps and appurtenances,etc.) (revised 11/03/95) 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(oontinued) Property Address: 56 Brigatine Ave, OSterville, MA Owner. Father Peter Chrisafiders Date of InspecUon: ;)--4/—1 ]SOIL ABSORPTION SYSTEM (SAS): L / (locate on site plan,if possible;excavation not required,but may be approximated by non-intrusive methods) If not determined to be present,explain: leaching pits,number: leaching chambers,number:_ leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number: Comments: (note condition of soil,signs of hydraulic failure,level of pondin$$,condition of vegetation,etc.) 6 &—Q Al tom. — 0 & -F lom� t ."AKca afw Li CES� LS-_ (locate site plan) Number d configuration: Depth- of liquid to inlet invert: Depth solids layer. Depth of layer: Dime ns of cesspool: Mate ' of construction: lath ' n of groundwater: )7fi� (cesspool must be pumped as part of inspection) Comments: note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc. PRIVY:_ (locate on plan) Materials of nstnrction: Dimensions: Depth of so Comments:(n condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.) (revised 11/03/95) 8 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(oontinued) Property Address: 56 Brigatine Ave, OSterville, MA Owner. Father Peter Chrisafiders Date of Inspection: f_q SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' A-- V� f� � Y Ll DEPTH TO GROUNDWATER Depth to groundwater:`k feet method of determination or approximation: (revised 11/03/95) 9 I r L0 AT SEWAGE PERMIT p0• . ,,:R , "7a6 V 11 L A.G E. 4)) `-r oly:s w/zl-z ALL ER'S NAME b ADDRESS �, �� t�..�✓!�-GC Lam!// GUILDER OR OIpNER DATE PERMIT ISSUED C/ 2- v DKT`E ISSUED- 0 Qif 9 box 14 0 LJ OPI No.._.. . 7 r� `� FEs.... ........ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Town.. oF.......Barnstable • ................................................... Applirtation for Bi"oii al Works Tonstrartinn Famit Application is hereby made for a Permit to Construct (X) or Repair ( ) an Individual Sewage Disposal System at: ..-_..Lot 5 Brigantine Ave. , Osterville, Ma. ..._....... ................ --........ ------....------...------•-----------..............------......_.......---......-- Locatiop-Address Lot No. Theo Construction Co. 24 Great Pond br. , So. Yarmouth, Ma. Qwner Address W Theo Construction Co. 24 Great Pond Dr. , So. Yarmouth Ma. Installer Address U Type of Building 3 Size Lot.... 0 000 Sq. feet �., Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) aa Other—T e of Building No. of persons............................ Showers YP g ----------•--•-•------------ P ( ) — Cafeteria ( ) d Other fixtures -------••------•--------------------------------------••-••••--••--••----•••........................•. ...........................................55 . Design Flow.................................'10 0 0-gallons per person per day. Total daily flow...-3 3 0 gallons. WSeptic Tank—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 ( ) a Percolation Test Results Performed by.....Norman Grossman P.E. Date..9/16/8 2 Test Pit No. 1........2......minutes per inch Depth of Test Pit 11'-6". Depth to ground water _none 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a' n �� --- n _ n rr is O Description of Soil_........- ...$------subsof1,__................ ...___._graver,-__2?�. _.13... ..mecI...-'sa'ricl---•----- U --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------•---•---•-•...------•... W -----------------------------------------------------------------------------------------------------------------------------------------•-----------------------...------------------------------..... M. Nature 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 TITLE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been i ed by the b and of iealth. Signed.. ........... .......... -- 3 7i ..... •-�........... Date Application Approved By._...-- '�'—�_�...�.,Cr%%/% _ �f . ....... ate Application Disapproved for the following reasons-------------•--•-------------------------------------------•----------------••-•-------------------------....._ -----------------------------------------•-------------------------------------------........------....---••----•---•-••----•-----••--------------•-••••--••-----••----•-•••••------•-•••••-•-•...------ Date Permit No......................................................... Issued-............ `7a No..... .7�:� Fps..... : .._... 4_ THE COMMONWEALTH\OF MASSACHUSETTS BOARD OF HEALTH Town OF...-...Barnstable ......................................................................... ApplirFation for Disposal Works Tontrurtion Frrmit Application is hereby made for a Permit to Construct ( X) or Repair ( ) an Individual Sewage Disposal System at: Lot5 :Brigantine ........................................ ........----•••-•--••-•--.................----........-----•----------.........._...........--•... Location-Address or Lot No. •-- ThTheo Construction Co 24 Great Fond lir. , So. Yarmouth, rla. eo -- .................. .....•--------•--•---...............•----..... •••••-.......---..........-•-..... ...........----- .................._......... gwner •Address W Theo Construction Co. 24 Great Pond llr. , So. Yarmouth Ma. a ..............•••..............-•-•-•--•----•--•-•-----.....................----------------...... , Installer Address 40 GOG U Type of Building 3 Size Lot----------------------------S feet .., Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) a`4 Other—T e of Building No. of persons............................ Showers YP g ---------------•------------ P ( ) — Cafeteria (----)- dOther.fixtures ---------------------------------------•-------.....------••--••-•-•-•••---•-•-•--••... ••-•••••- W Design Flow................................i_...0 0--gallons per person per day. Total daily flow---.:�....................................gallons. 1.iJ WSeptic Tank—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 ( ) '-' Percolation Test Results Performed by......Norman GxC...... n P.E. 9/lG/S2 M Test Pit No. I........2......minutes per inch Depth of Test Pit................ Depth to ground water......non.................. f� Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Olt - ld i .... . -......ODescription of Soil........ .6 8subsol , Cf, �rav��, Z4 a11� . -- --•------------------•-•--...--•-•-••-------•--•---------------------------------------------....------.......•----------.......------...V ..............................................------•-•--------•-----•-•-.........-•-....................------•-•----•......--•--------•--....•---•--••••-------------•••-------•-------......--••---- W U Nature 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 A IT',': 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Signed...................................................................................... .......................... Date .Application Approved By.......--ex��' � _{.e!` _ 1�------................... te Application Disapproved for the following reasons:-----•---------------•-•----••--•-----------------------------•-------------•---------..........--•--••-•--••. .........................••-•....•-•--••-••--••-•------•.....-------•-•----••-•-•-•----•--•--•-----•-----••---•------•-••-•••---•---••-•------•----•................................................... Date PermitNo.......................................................- Issued-....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ........ Town Barnstable .............................O F....... ..... ......................................................................... Trrtifirate of wiantpliFanrr THIS IS TO CERTI , That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) by-_ < ... It ....... •� r Installer ' at................. S...... .. ZZ,ZlZ214.......0 ...--------....(:as =.............----------------------•---------------------------- has been installed in accordance he provisions of TITLE 5 of The 5tate Sanitary Code as des r' ed in the application for Disposal Works Construction Permit No.--....... ...... dated...-------6/1.... !.........-M•......... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE AS A GUARANTEE THAT THE SYSTEM WILL UN ION SATISFACTORY. DATE..... -.2 _. ! ................................................ Inspector..... ..... ••----•••-----•••-----------.......-----•-----•----•--•--•--•-.....--- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH �/ Town Barnstable V"e Pe? ...........................................OF..................................................................................... No.... '............. FEE... .............. Disposal Works Tonotrnrttion Frrmit Theo Construction Co. Permissionis hereby granted...............................................--••--••--------••--•-•-•-••--...----•-••----.......•-•...........................--•---....... to Construct (X ) or Repair ( ) an Individual Sewage Disposal System at No.......T C:L..5 r J _a!lt i n - e.A .._... - ....... . ---•-- .---.......••-•---•--...•-••--......-••---•--•............................ Street ©© / as shown on the application for Disposal Works Construction Permit No...a '. Dat d........... �.►__ a / -✓ ---- 'y�' / ......................................... � B`DATE................................................................................ of Health FORM 1255 HOBBS & WARREN, INC., PUBLISHERS : - • - p`. ter. . „ -' :,: _ ,. i ' -._A1.L EL EBB. 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