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HomeMy WebLinkAbout3701 FALMOUTH ROAD/RTE 28 - Health W, MARSTON1vMILLs - _ A=058 037 - T.� _=��t_�_T_T_tJ\.CI.fT�♦r_T_ TOWN OF BARNSTABLE LOCATION 3'7® 1 to elo k)\ SEWAGE # VILLAGE Eo#U II ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY IOy O A� LEACHING FACILITY: (type) (size) Pl NO.OF BEDROOMS���' BUILDER OR OWNER W I-Um A PRATE: b/(-r 7 COMPLIANCE DATE: Separation Distance Between the: I Maximum Adjusted Groundwater Table Fcec Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) 0(1* Fe:tc Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) n: Fe=• Furnished by I -370 un e, O � Z f 1 tI COMMONWEALTH OF NL-,�SSACHL,-SETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE R\INTER STREET. BOSTON NIA 0210E (611) 292--500 TRUDY COX--- 8 Secreca7 n ARGEO PALL CELLUCCI DA%'ID" TP. 'r.; �a Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM °a rl PART A i/�/�� ? c -b-) n�� CERTIFICATION to Property Address: 37©1 Name of Owner Lt r—A—cl Q �"'Address of Owner: ' -1 99 Date of Inspection:. (c��� / , / Tt;a Name of Inspector:(Please Prim) C it Q C �I EC uU C^_wi�t .340 of Trtie 5(310 CMR 15.000) am a DEP approved system inspector pursuant to Section 15 A&c�c 7� Company Name: s-1,2 �lcv�,'J^���e_C �.'�u t� � ,y t Marling Address:��_A n + L� L� ��S N�F!= I�� �z�4' Telephone Number: _6 Scz? ) 44 3 Z-G CERTIFICATION STATEMENT 1 certify that 1 have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: Passes _ Conditionally Passes _ Needs Further Evaluation By the Local Approving Authority Fails inspector's Signature: Date: . S 7 The System Inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within thirty (30) days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to ttre system owner and copies sent to the buyer, if applicable, and the approving authority. NOTES AND COMMENTS revised 9/2/98 Page iortl tLi Pnnted on R"Ird Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) property Address: S I o t (; 010 Jwner: t1 l cu I eS z&-a L-j Date of Inspection: f/ `77 , INSPECTION SUMMARY: Check A, B, C, or D: A. SYSTEM PASSES- I have not M found any information which indicates that any of the failure conditions described in•310 CR 15.303 exist. Any failure criteria not evaluated_ are indicated below. COMMENTS:""4 �i B. SYSTEM CONDITIONALLY PASSES: >A . 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. _ 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. _ 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 _ 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 2of11 r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Owner: Date of Inspection: 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' the system is failing to protect the public health, safety and the environment. 11 SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WIT 310 CMR 15.303(1)(b)THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH A D 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 salt marsh. 21 SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND BLIC WATER SUPPLIER,IF ANY)DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLI HEALTH AND SAFETY AND THE ENVIRONMENT: _ The system has a septic tank and soil absorpti 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 absor tion system and the SAS is within a Zone I of a public water supply well. _ The system has a septic tank and soil abs ption system and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and soil ab orption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well ater analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that f ility and the is of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to deter ne distance (approximation not valid). 3) OTHER revised /2/98 Page 3of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) property Address: Owner: Date of Inspection: D. SYSTEM FAILS: You must indicate either "Yes" or "No" to each of the following: have determined that one or more of the following failure conditions exist as ascribed in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted determine what will be necessary to correct the failure. Yes No _ Backup of sewage into facility or system component due toe overloaded or cogged SAS or cesspool. _ Discharge or ponding of effluent to the surface of the gro d or surface waters due to an overloaded or clogged SAS or cesspool. Static liquid level in the distribution box above outlet nvert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6" below in rt or available volume is less than 112 day flow. _ Required pumping more than 4 times in the la year NOT due to clogged or obstructed pipe(s). Number of times pumped_. _ Any portion of the Soil Absorption Syste , cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is rthin 100 feet of a-surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy ' within a Zone I of a public well. Any portion of a cesspool or pri y is within 50 feet of a private water supply well. Any portion of a cesspool or rivy is less-than 100 feet but greater than 50 feet from a private water supply well.with no acceptable water quality a lysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile rganic compounds, ammonia nitrogen and nitrate nitrogen. E. LARGE SYSTEM FAILS: You must indicate either "Yes" or "No" to each of the following: The following criteria apply large systems in addition to the criteria above: The system serves a facil, y 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 th environment because one or more of the following conditions exist: Yes No the syste is within 400 feet of a surface drinking water supply _ the syst m is within 200 feet of a tributary to a surface drinking water supply the sy tem is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA) or a mapped Zone 11 of a public wate supply well) The owner or operator f any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional office of the Departm t for further information. revised 9/2/98 P>age4lor11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 31() Owner: /r'/ to A25 1"a-I Date of.lnspettion: Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Yes No Pumping information was provided by the owner, occupant, or Board of Health. None of the system components have been pumped for at least two weeks and-the system has been receiving normal flow t`c rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. �( As built plans have been obtained and examined. Note if they are not available with N,A. The facility or dwelling was inspected for signs of sewage back-up. _ The system does not receive non-sanitary or industrial waste flow. The site was inspected for signs of breakout. All system components, excluding the Soil Absorption System, have been located on the site. The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of batfles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. The size and location of the Soil Absorption System on the site has been determined based on: Existing information. For example, Plan at B.O.H. Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptablei 115.302(3)(b)1 The facility owner (and occupants, if differeni from owner) were provided with information on the propermaintenaa"-of Subsurface Disposal Systems. revised 9/2/98 Page 5of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION / Sims I�-1, ��5 'roperty Address: 370 Y tiv� Slav � ko Owner: k- / (,(�rt?S Date of Inspection: ! 5 ` FLOW CONDITIONS RESIDENTIAL: Design flow:3{)g•p•d•/bedr om. Number of bedrooms (design): Number of bedrooms(actual).03 Total DESIGN flow 3C) Number of current residents: Q Garbage grinder(yes or no): Laundry(separate system) ( or no): If yes, separate inspection required Laundry system inspected es r no) Seasonal use (yes or no): Water meter readings, if Ravilabble (last two year's usage(gpd).Sump Pump (yes or no): Last date of occupancy: V"W,01-11L US COMMERCIAL/INDUSTRIAL: Type of establishment: Design flow: 9pd I Based on 15.203) Basis of design flow Grease trap present: (yes or no)_ Industrial Waste Holding Tank present: (yes or no)_ Non-sanitary waste discharged to the Title 5 system: (yes or no)_ Water meter readings, if available: Last date of occupancy: OTHER:(Describe) _ Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of�jnforma&io :System pumped as part es or no) If yes, volume pumped: gallons Reason for pumping: TYPE OF SYSTEM " V'— Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no) (if yes, attach previous inspection records,if any) I/A Technology etc. Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other APPROXIMATE AGE of all components, date installed(if known) and source of information: Sewage odors detected when arriving at the site: (yes or no) revised 9/2/98 Page 6(if II SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) 'roperty Address: ,370 Owner: Date of Inspection: BUILDING SEWER: (Locate on site plan) Depth below grade:_ Material of construction:_cast iron_40 PVC_other (explain) Distance from private water supply well or suction line Diameter Comments: (condition of joints, venting, evidence of leakage, etc.) SEPTIC TANK:_ (locate on site plan) Depth below grade:_U� Material of construction:,concrete_metal _Fiberglass _Polyethylene—other(explain) If tank is metal, list age_ Is age confirmed by Certificate of Compliance_ (Yes/No) Dimensions: 1 0y� I Sludge depth:_ Distance from top of sludge dge to bottom of outlet tee or baffle: Scum thickness:_ Distance from top of scum to top of outlet tee or baffle: t Distance from bottom of scum to bottom of outlet teei or baffler How dimensions were determined: omments: (recommendation for pumping, condition of a ar)d outlet tees or baffles,les, depths of liquid level in relation to outlet invert. structur integrity. . evidence of le n age, etc.) ,gyp " G.J' V GREASE TRAP.MI (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: (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.) i revised 9/2/98 Page 7orn r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION:(co�ed)�C 'roperty Address: Owner: �( G�ri ,Ed v Date of Inspection: TIGHT OR HOLDING TANK:_(Tank must be pumped prior to, or 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 Alarm level: Alarm in working order: Yes _ No_ Date of previous pumping: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX: (locate on site plan) I _ Depth of liquid level above outlet invert: Comments: (note if level and distributio 's quaileviden" of solids carryover evidence of akage into or.o t of Oox, etc.) 0. PUMP CHAMBER: t1'1 (locate on site plan) Pumps in working order: (Yes or No) Alarms in working order(Yes or No) Comments: (note condition of pump chamber,•condition of pumps and appurtenances, etc.) revised 9/2/98 P.gcsorn SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (contirwed) �S 4operty Address: a`�G Owner: Q �/C2SfMGc Date of rnapectio,: _/I's- SOIL ABSORPTION SYSTEM(SASX"5 Ilocate on site plan, if possible; excav tion not required, location may be approximated by non-intrusive methods) If not located, explain: Type: leaching pits, number: leaching chambers, number:_ leaching galleries, number:_ leaching trenches, number, length: leaching fields, number, dimensions: overflow cesspool, number:_ Alternative system: Name of Technology: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, C,grditio of veg Qation, etc.) or CESSPOOLS: a (locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: )epth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater: inflow (cesspool must be pumped as part of inspection) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY: (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments: (note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.) revised 9/2/98 Pace 9of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (contirwed) property Address: aj�(� ( �t v� t�� t �Ct.A Date of ection: j S 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) Z i revised 9/2/98 Prgcloorfl SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM IN w INFORMATION (conbred) n 9 roperty Address:`�°1ayv�dti 1�. Va1l^G Owner: / r I r e s tea`'` Date of Inspection: NRCS Report name -- Soil Type_ — — --- -- Typical depth to groundwater_ __ _ y. USGS Date website visited Observation Wells checked Groundwater depth: Shallow Moderate Deep SITE EXAM Slope ��5 Surface water No Check CellartwVI Shallow wells , - l Estimated Depth to Groundwater Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observed Site (Abutting property, observation hole, basement sump etc.) Determined from local conditions Checked with local Board of health Checked FEMA Maps Checked pumping records Checked local excavators, installers Used USGS Data Describe how you established the High Groundwater Elevation. (Must be completed) t � revised 9/2/98 Page II of II IsO.CArION -37p� J SEWAGE PERMIT NO. VILLAGE I N S T A IIER'S NAME A ® DRESS 14,1 11U1lDER OR OWNER DATE PERMIT ISSUED J — / ® ATE CQMPLIANCE ISSUED �'g ���� R,��,,� ;.v�= � ® _3G'�. •' `,.., '1 �Z ��, �, �� �� r�^a ., `.