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HomeMy WebLinkAbout0099 FLEETWOOD PATH - Health 212 Camelback Road,Marstons Mills J I TROY WILLIAMS SEPTIC INSPECTIONS TO Certified by MA Department of Environmental Protection (508).760-1819 40 Old Bass River Road South Dennis,MA 02660 4 8 3 a CaTmonweatth of Massachusetts �~ 14* D Executive Office of Erwlrorxnerttot Affairs - 8 p� Department of /c. Environmental Protection , Wlplam F.W9Id L".A a �d t)•vldtrw}ma SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION /I.;Hs_ Property Address: 1/a Ca-c/ a c k oqu. ^/f rS l°'�s Address of Owner. /GI. `/ 4 /V o✓ k; Date of Inspection: / ISM!6 (if different) Name of Inspectors—j ro y (iJ: 1 1;�- s C/a S°C Yin r'^y,—N d?E Company Name,Address ind Telephone Number: . y 3 T C.9 SG� G 1%0,i—. CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,aocurate 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: asses _ Conditionally Passes _ Needs Further Evaluation By the local Approving Authority Fails Inspector's Signature: Date: 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: Ai ,SYSSTTEM PASSES: V 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. e] SYSTEM CONDITIONALLY PASSES: One or more system components need to be replaced or repaired. The system, upon conviction of the replacemerht or repair, passes inspection. 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, 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 conforming septic tank as approved by the Board of Health. �revr•cd �/15/951 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: (9/.2 C ci Owner: )i'/v w ;'-k Date of Inspection: f B] SYSTEM CONDITIONALLY PASSES (continued) 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 CI 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 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 (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: The s-slem nas a septic tank ano son aosorption system and is within 100 feet to a surft LE wale( supply or tributarj 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 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 that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than S PPm. 'i SYSTEM FAILS: I have determined that the system violates one or more of the following failure criteria as defined 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- _ 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 —ised 8/15/9Si 2 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: oZ a Cam,w, 6,, Owner. /\/p w L-"k Date of Inspection: D] SYSTEM FAILS(continued): Static liquid level in the distribution box above outlet invert due to an overloaded or dogged 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 dogged or obstructed pipe(s). Number of times pumped Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I of.a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is 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 LARGE SYSTEM FAILS: The following criteria apply to large systems in addition to the criteria above: The design flow of 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: 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) i he owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program ,equirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. evisea eiIs/9S) 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART 6 CHECKLIST Property Address: o2lol (fe-^< " e JA� Owner. w:c_k Date of Inspection: Check'if the following have been done: ✓Pumping information was requested of the owner, occupant, and Board of Health. ✓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. ✓As built plans have been obtained and examined. Note if they are not available with WA. "The facility or dwelling was inspected for signs of sewage back-up. V"The system does not receive non-sanitary or industrial waste flow Z 1 he site was inspected for signs of breakout. _ZAll 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 baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. ✓The size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods. The facility ow (a^d occupanic. if different from owner) were provided with information on the proper maintenance of Sub- Surface Disposal System. evlsed 8/15/95) < I I r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: ;i2 l.2' Owner. /V o w; c-/ti Date of Inspection: �s RESIDENTIAL: FLOW CONDITIONS Design flow: ?a v gallons Number of bedrooms: a Number of Current residents: O Garbage grinder (yes or no): /Vo Laundry connected to system (yes or no): `/F S seasonal use (yes or no): No Water meter readings, if available: ast date of occupancy: ✓U(, , 4— COMMERCIAUINDUSTRIAL• N49 ype of establishment: )esign flow: gallons/day irease trap present: (yes or no)_ ndustrial Waste Holding Tank present: (yes or no)_ Non-sanitary waste discharged to the Title 5 system: (yes or no)_ .eater meter readings, if available: ast date of occupancy: )THER: (Describe) ast date of occupancy: GENERAL INFORMATION "UMPING RECORDS and source of information:- (4 b/ / 1 1�6 i!¢ 1 f L TL c- QQ r I�1 S b �-c� �i��� -A, 7 System pumped as padof inspection: (yes or no) IV U If yes. volume pumped gallons Reason for pumping TYPE O SYSTEM Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Puivy Shared system (yes or no) (if yes, attach previous inspection record"s, if any) Other (explain) APPROXIMATE AGE of all components, date installed (if known) and source of information •ewage odors detected when arriving at the site: (yes or no) N° :e�ised E/:S/9S; S li, SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property rt Address: o211 Co.r►,d L _k Owner: /1/0 w*' c k Date of Inspection: /s S SEPTIC TANK:_ (locate on site plan) Depth below grade: a Material of construction: -L-.,C'Oncrete _metal _FRP—other(explain) Dimensions:_ S X i>- y Sludge depth: '/" Distance from top of sludge to bottom of outlet tee or baffle: o? Scum thickness: o?" Distance from top of scum to top of outlet tee or baffle: G Distance from bottom of scum to bottom 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 ,ntegrity, evidence of leakage, etc.) /.�� s ?�� �a �, (�� ;„ w or �.. o,- � �l/ aI 4- : s GREASE TRAP:L//,4 locate on site plan) Depth below grade: -iaterial of construction: _concrete _metal _FRP _other(explain) ),mensions: cum thl6ness: ),stance from top of scum to top of outlet tee or baffle: .tance from bottom M crllm In hOttnm OI 01,111?I tee O, t)ame omments: ecommendation for pumping, condition of Inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural liegrlty, evidence of leakage. etc.i evl sect 8i 1S/951 6 r ' - S SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: o?/a Gck.w, . Owner. -A,/o a/, c-t , Date of Inspection: �_57 G TIGHT OR HOLDING TANK._/-/�� ilocate on site plan) . Depth below grade: Material of construction: _concrete_metal _FRP other(explain) Dimensions: rapacity: gallons Design flow: gallons/day -Niarm level: :omments: condition of inlet tee, condition of alarm and'float switches, etc.) DISTRIBUTION BOX: jocate on site plan) ?epth of liquid level above outlet invert: )Lu-e �- omments: ;rote if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) -s i h i ,ov y✓r.Ct,✓ UMP CHAMBER:�1 ,ocate on site plan) umps in working order.(yes or no) omments: rote condition of pump chamber, condition of pumps and appurtenances, etc.) revised 8/]5/95) 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: f�b w C- Date of Inspection: 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: G �X 6 �� z o .n G✓ 07 S h leaching chambers, number:_ leaching galleries, number: leaching trenches, number,length: leaching fields, number, dimensions: overflow cesspool, number: :omments: (note condition of soil, signs of hydraulic failure, I"vel of ponding, condition ofyegetation,etc.) Sa ell K CESSPOOLS: A1119 jocate on site plan) "umber and configuration: )epth-top of liquid to inlet invert: )epth of solids layer: )epth of scum layer: )lmensions of cesspool: laterials of construction: dication of groundwater: inflow (cesspool must be pumped as part of inspection) omments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) R I VY: /✓1i9 ,,sate on site plan) laterials of construction: Dimensions: lepth of solids: omments: (note condition of soil, signs of hydraulic failure, level of pondirig, condition of vegetation, etc.) I e�ised 8/15/951 8 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (con lnued) #', Property Address: a/d e Owner. '" �/ Date of Inspection;N SKETCH OF SEWAGE DISPOSAL SYSTEM: indude ties to at least two permanent references landmarks or benchmarks locate all wells within 100' � ys G3 of �r6ok wj .2 ' Sh�„t . ,EPTH TO GROUNDWATER ,epth to groundwater: feet :;adjusted high groundwater level Method of determination or approximation: /-7p rc, p eviied 8/15/951 9 I` L - - TOWN OF BARNSTABLE LOCATION �I a2 t�� a . �_ G. (t d _ SEWAGE# D 6 Y -D 7 VILLAGE ASSESSOR'S MAP&LOT INSTALLER'S NAME&PHONE NO. ::fL 0-D 4�.,d• j SEPTIC TANK CAPACITY /°® a LEACHING FACELITY: (type) •14�21 '~ (size) b/ NO.OF BEDROOMS BUILDER OR OWNER PERMUDATE: L Z2 V 16 2 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;u ►^, s I � � L i yy ' 3�, 30' s 63` . , .• � '� � ���®� ``'"gym �y . o . �� ,. ' , . ,' � � � %�6��'� ►^, a � S�a�.4 ��- TOWN OF BARNSTABLE LOCATION 1671y� ����� y%�/�� SEWAGE VILLAGE 6/ � I�fir . //�� ASSESSOR'S MAP & LOT lJ'G 4i- G INSTALLER'S NAME PHONE NO. ��,//rj/ �X P,Q�,��lz///.3' SEPTIC TANK CAPACITY /0 ZJ� G FACILITY: (size) /0 Q 0 LEACHING t( ype) NO. OF BEDROOMS PRIVATE WELL OR UBLIC WATER BUILDER OR OWNER /140 CO vv /—" 0 DATE PERMIT ISSUED: DATE ,COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No �-� e � i No... ..W�tY Fss .`. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEA T OF App iration for Disposal Works Toustrnrtiun ramit Application is hereby made for a Permit to Construct ( j or Repair ( ) an Individual Sewage Disposal Sy tem at: Locatio -Add ess o t No. W Address .l-D`-Y....... ................ . Installer � Address U Type of Building Size Lot.". _,,yy X..Sq. feet Dwelling—No. of Bedrooms...............I------...__............Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building .P No. of persons___..._._.------------- Showers �) — Cafeteria ( ) Otherfixt s -- --••-•••-•------•••-•-.•••--•--•----••-----•---•-•--•-----•-•••--......--•------••-------------•----•-•-•............. W Design Flow........ . gallons per person of day. Total dailg fWW-------&J-Q-__-_.-••----_--_--gal,1bnis/ WSeptic Tank—Liquid capacity gallons Length_._P._ Width__ p.. Diameter________________ Depth_ x Disposal Trench—No..................... Width_. __ ....... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No.....I-------------- Diameter.._._ Depth below inlet...... Total leaching area.4417...sq. ft. Z Other Distribution box (I ) Dosing t ( ) aPercolation Test Results Performed by. � __./ � �24�,( J-, -- Date..... :' ...... Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water.._ _ ___,�_./. ...__ f4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground wate>Al�_w ... O Descriptionof Soil....--------••�� �---....... �13 ----'--•----- ---------•-------------------••--------•............._.. x W VNature 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 iITIS 5 of the State Sanitary Code— The ndersigned further agrees not to place the system in ope atio until a C r 'fi of pliance has bee issued by th boar of hea . /� ,� Date A cation pproved By•••-------•--••-•••-•........•. :.. •........ -- I L r -- Ca Date_ . Application Disapproved for the following reasons:•------••••----•--'--------------------------------'•-•-------•--•----•--•-•--.....-••-••......--• -•--..._... ----------•---------••----------•------...---•---••--•-----••------------•--------------•..-•••--......... Date Permit No.---�'- 1 cLl-1�?------- Issued_....................................................... Date ► THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH i Appliratiun for Disposal Works Tonstru.rtiun Vrrmit Application is hereby made for a Permit to Construct (I or Repair ( ) an Individual Sewage Disposal System at: _._.�.. ....... ..........................«.._...... ... .............. Location Address -- -- ------------�--:---l----- ....-- -....._...---•--- Owner. ............................................................. .^ = " J //?Address j`rrf1 ..................._ :......:. :__..:-'........... ................................................................•......._.................•... Installer Address UType of Building Size Lot---_----:----j-`------Sq. feet a Dwelling—No. of Bedrooms............... .........._.._...._.....Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building _ I1t/ ...... No. of persons..........1-:y ............. Showers (.�) — Cafeteria ( ) Other fixt .>es •-----••----------- t ;.. Desi n Flow----....._....--- -.. �� 1 W g ....--- q gallons per person per day. Total daily flow------- ....:.......................gallons. WSeptic Tank—Liquid capacity+/!�r_te.gallons Length... I..... Width__f'y._!..... Diameter________________ Depth................ x Disposal Trench—.No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. 3 Seepage Pit No------.............. Diameter.._...; .......... Depth below inlet......4......... Total leaching area..............-....sq. ft. Z Other Distribution box ( 1 ) Dosing tank t `-' Percolation Test Results Performed b ......:, ..............................................................-/" ,'`"1^ C %I - �a 7 ,-1 Y �.. Date ... .� Test Pit No. 1................minutes per inch Depth of Test Pit_................. Depth to ground water-_--_-..........._._---- f Test Pit No. 2................minutes per inch Depth of Test Pit._........ Depth to ground water.__r_' ....... O Description of Soil - ' jl..r :.. -..'`._..-------•---•` s 11 = ----••- --- ----------------- •................................................................. -------•••---------------------------------------------- x •----•-------------------------------•------------•----•------------•--------•---•--------•-----•------•---•--------•--•----•--•---•-•----•-----•----------------•---••-......----•------...-•-------- V 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 TITLi4 5 of the State Sanitary Code— The undersigned further agrees not to place the system in opera on til a Cer.tic`at , f Co nce has been,.issued by th board of health.` �.•--••"^""_" Date .... APPfi . tion Approved BY _ _ ,{ . . ...........:...... ... � .. Application Disapproved for the following reasons:..................................... Date ..............................................----••----•-•------•••-•----••-----•-•••--•---•--•-•------ ----•-- Date Permit No.__." y. --- ....... Issued Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ,r x ................`... i,. ..` . ..OF.......1 .. 1 7. Trrtifirttte of f ompl attrr THIS IS TO CERTIFY,That the Individual Sewage DisposalSystem constructed ( ) or Repaired ( ) by------------------ �'+ 'r= -= �:. C -_r r f .x Installer / ...................................... at.............`_ ...... -...r�. r __ _ r}fPd�t f f Cfy 1 has been installed in accordance with the provisions of TITIZ. 5 o T State Sanitary Code. -� -,.-_ dese ' in the application for Disposal Works Construction Permit No._ ' --"__ --------- dated-------- s ... THE �--- --� ---•-----•- ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE............................•-....... 3 "� h.... .................. Inspector.................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ....................." No. V ......� .......<.......r.....2.......l./.............G.......-.t.�.. -..-..t..'........... ---:• .. Disposal Workii T FEE..... .....unstrt iurt rrutl� j Permission is hereby granted......... "'�r.... /!........................................ •.--•................... to Construct ( )�or-Repair ( ) an Individual Sewage Disposal,System �,at No.----.. .�. /' E� r°'.F' 7/r f Street as shown on the a plication for Disposal Works Construction Permit No�Z& Dated Board of He DATE Board 1255 A. M. SULKIN, INC., BOSTON .. �'�.:> ;,j R.. ie.w l It A tea/ O.r+ f 4.y r 4 -r`..._._ ::<-.:_._�s._..� �8 __-.�._ :_:•,,-::.b .... _ ,•,,: I. A�� E.�.Ed/A7"IONS �'HOt�3r�I ,ARE ..f � To A55u,m E-D nA u M Z. FBITC�° A� 4, L>'!d -0 .A I,!!itlIAWIff OF /8 �F 7- _�_. . : _ b �, ® UNL,E"5'S OTHE1 411SE vSPEC/F"IEP Z4,1P A/ IlV T E Y S'HAI,IG 3 0 Q? D O 0 0 � D .� , IPE�.. TO �� H ST�� R _ _ {_ a.,,�� _ _ _ 0 .d G SEP "/ ' .4t�ll;S; DISTr�r'/BUT/ONt •A'EFS, . 1+/O 4£,4CH/t�6 FIT .�I.144L 9E' ,6,516 Q FIt' I .�O 14 h EE(, ,C Q.4RIIYG S FIE N � 0 0 0 O ZINAe-R PWV c. E - � #f `, :: �} .� �.. �:• :Q ` z I -� -'' 1 0 � RtE'r�'O$�E' 4�� Cr'.NSUI�".4B�,E ,�ATE'I�'/�?l..• �A►1 c� \ 4 , I - � 66 N "..4 T, f�'E' I1I E 'AT /� IU � i ./:j,5'ANITWFY TEEJ @ @ v 0 O 0 (3 OFF rHE tPIAFrzlsopi 5 cog .4 PIsTA/VCE or Q. I ® 10 A6VP .4CKFII_ , ,t�VATFI C4AY-FREE' 15 ,5-4NP.4NP GRAVE1. 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