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HomeMy WebLinkAbout0020 LOVELL'S LANE - Health 20 Lovell's Lane, M rstons Mills A - 7 �' - 6 el < COMMONWEALTH OF MASSACHU'SETTS � 9 / y / EXECUTIVE OFFICE OF ENVIRONMENTAL AFF .' DEPARTMENT OF ENVIRONMENTAL PRO TIOVfCEl VE; ONE WINTER STREET. BOSTON. NIA 02108 617-292.5,0 i7 cEP 8 1997 ;L TOWNHEALTH DEPTABLE TRU,DY�,OXE WILLIA�I F.WELD - � Govemo: �dS cretary ARGEO PAUL CELLUCCI A prtV D .STRUHS Lt.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM E Commissioner PART A �t CERTIFICATION Property Address: !Z D L O✓Q/�s Lu y Z� �u *r' ''s Al'/A Address of Owner: Date of Inspection: y- 41,`3 7 (If different) STer li Name of Inspector: JOLT- A, Ai eft I am a DEP approved s stem ins ector pursuant to Section 15.340 of Title 5 (310 CMR 15.000) Company Name: 70�n « ly X,k Awe Mailing Address: /S!7 itla nH7 Sri Telephone Number: -2 $ -C/5 Y.5- CERTIFICATION STATEMENT I ceni y that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: _I"-Passes _ Conditionally Passes . _ Needs Further Evaluation By the Local Approving Authority Fail 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: 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. COMMENTS: r BJ SYSTEM CONDITIONALLY PASSES: 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 conforming septic tank as approved by the Board of Health. (revised 04/25/97) Page l of 10 DEP on the World Wide Web: http://www.magnet.state.ma.us/dep Printed on Recycled Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART'A CERTIFICATION (continued) Property Address: Owner: le Date of Inspection: BJ 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). Describe observations: broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced i . system_ The system required pumping more than four times a year due to broken or obstructed p pe(s) The 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 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 PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet to a surface water supply or tributary to a surface water supply. _ The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well. _ The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine distance (approximation.not valid). 3) OTHER (revised 04/25/97) Page"2 of 10 I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 2U P/lS L+4"yto Ap6"o- s rc=7 t /y�/2/s -411G_ Owner: Date of Inspection: 9- y y D) SYSTEM FAILS: You must indicate either "Yes" or "No" as to each of the following: 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. Yes No 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 clMed 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 waver 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 ponion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supp#'y 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: You must indicate either "Yes" or "No" as to each of the following: , The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No 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 it 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 treatn ent program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 04/25 97 ?aQa 3 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST /////JJ3 A41. Property Address: O ,-�- 1 �lls L�,.,� �� �s Owner: /f� Date of Inspection: 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 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 sof breakout. If — All system components, earelad,Ag 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: ✓ The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of Sub-Surface Disposal System. — Existing information. Ex. 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 unacceptable) (15.302(3)(b)) (zevimed 04/25/97) Page 4 of 10 L } • • SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: �o 4,%% e��s �4,,� /y/�viT•,s /y�i//s��� Owner: /=!�/J /-(;�)742%iC70' Date of Inspection: FLOW CONDITIONS RESIDENTIAL: Design flow: .p.d./bedroom for S.A.S. Number of bedrooms: Number of current residents: 2 Garbage gnr.der (yes or no):—.&V Laundry connected to system ;yes or no):�ri Seasonal use tyes or no):� Water meter readings, if available (last two (2)year usage (gpd): Sump Pump (yes or no): Last date of occupancy: OCC COMMERCIAL/INDUSTRIAL: Type of establishment: Design flow: gallons./day Grease trap present: (yes or no)_ Industrial Waste Holding Tank present: (ves or no)_ Non-sanitary waste discharged r.o the Title 5 system: (yes or no)_ Water meter readings, if available Lastdate of o•_cupancv: OTHER: ;Describe) Last date of occupant)-: GENERAL INFORMATION PUMPING RECORDS and source of informat;o 19 92 �ocv .rr System pumped as part of tns ection: (yes or no)­go —� If yes, volume pumped: 'O(>V allons Reason for pumping TYPE OF SYSTEM Septic tan iI absorption system Single cesspool Overflow cesspool Privy Shared system (yes or no) (if yes, attach previous inspection records, if any) I/A Technology etc. Copy of up to date contract? Other APPROXIMATE AGE of all components, date installed (if known) and source of information: �;S �JJGirS Sewage odors detected when arriving at the site: (yes or no) (revised 04/25/97) Page 5 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM IN—F�O-RMATION (continued) Property Address: IIf Owner: fir p Pe')7 .,*c,yr Date of Inspection: �1' Lj_ BUILDING SEWER: (Locate on site plan) Depth below grade: ';O Material of construction: _cast iron OPVC _other (explain) Distance from private water supply well or suction line 2y' Diameter y Comments: (condition of joints, venting, evidence of leakage, etc.) SEPTIC TANK: (locate on site plan) Depth below grade: 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: g S� Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: 3 Scum thickness: Arv,-z Distance from top of scum to top of outlet tee or baffle: C) Distance from bottom of scum to bottom of outlet tee or baffle: t7" How dimensions were determined: r"�e> 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.) illy lam+A 11" al!94 �J ti as [n -,c Yi`t.� 7•?v `•� Tee L e y z tr�5e GREASE TRAP: (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 baffler 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.) _ (revised 04/25/97) Pag• 6 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: O �u✓ ? � 4'e" y�ClrS f..s /y/if�S .kll Owner: / `:-'le Date of Inspection: y_ Lj -c7 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/da� 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:_JVVA e _ (locate on site plan) 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.) �J,;�•� ,� vd> ��ve,:. 1 �'r�•<ti^' T k Tom_ LPwt. 4 ,7; 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, condition of pumps and appurtenances, etc.) (revised 04/25/97) Page 7 of 10 IL SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: :2 p oo�z/�s fie.•�� �Y���`�fi��s /1��i��S�/V�4 Owner: /_4'te Pe Date of Inspection:p 7— � ?— , 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: 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 hydr lic failure, level of nding, condition of vegetation, etc.) CESSPOOLS: _+ (locate on site plan) Number and configuration: Depth-top of liquid to inlet invert. Depth of solids layer: Depth of scum layer. Dimensions of cesspool: Materials of construction: Indication of groundwater: inflow (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 04/25/97) Page a of 10 f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address:. 2p .�v✓ ��s e A-14? Owners le .� a .�. Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) well ,J.0 -� 3 3y8 (revived 04/25/97) Page 9 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: v L I•v e I/y Owner: fiv. Date of Inspection: Depth to Groundwater Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observation of Site (Abutting property, observation hole, basement sump etc.) Determine it from local conditions Check with local Board of health Check FEMA Maps Check pumping records Check local excavators, installers Use USGS Data 1 S Describe in your own words how ,you established the High Groundwater Elevation. Must be completed) US,'d 1 St /193 Cs 7A 4 f.L v fi ��a vs, fr v G? i S 47 6 7, 3 2`1. _ y7J (revised 04/25/97) Page 10 of 10 TOWN OF BARNSTABLE LOCATION 20 La9e-lIS L:JU SEWAGE # VILLAGEIIlwasmroO As-iIlS ASSESSOR'S MAP & LOT INSTALLER'S NAME & PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY:(type) (size) NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATERi BUILDER OR OWNER �L, l,t,�► DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No r 16 G s� �� 7 . --........_ ni''rEt3 CLN`AY.; I ILK I // I .II oE,�'r' r3or3r.R UL_ 1 ► HOOK ! ,rl , I A(A. zeta ETrGR:330N, SHIRLEY F, E. 1gA1 r,AUF I`'LAI\I HOOK I r,I PA(A. -3-1 1 01.,1 ,ANT.c:���HGE FORu --- - _ _,_�`�`�I `�S(.)k-, I 'I AIJ I 'I .OI MORTGAGL INSITC-1-I0TA 1 )1_A1\1 (�;)-5. 1•�If1IIS"/ Y7/V� n1I1 1 .'- 1� 1: } SCALE: 1 II._.30 LO r 6 «� r r t ' f ' III a 5" —r---- —-- - fl!) 1 ;A Ill 1 , _ LONIIJG UC.I I_IZMINnI IUf l THE LOCATION OF THE ORIGINAL DWELLING SHOWNIIJ Ill-01J I:.IIIII WAS IH COMPHANCI= WIIII LOCAL APPLICABLE ZONING BYLAWS IN EFFECT WI ILN CONS 1 IZtJC 11.D Willi R1.51'LC I 10 1 IORIZON IAL DIMENSIONAL REQUIREMENTS ONLY OR IS LXEMII I- L ROM VIOL AI IO11 LNI 0PLIALld 1 AC I ION UNDLR MASS,. G.L. TITLE VII, CHAP,� OA, SEC. 7, UNLLSS 011 Il_RWIS1= 11011"I) 01? `.;I IUW1J I IL:IlI:U� . A COPJF1121�1A101�Y . INSTRUMENT SURVEY IS ADVISED WHEN S 11AX,I URFS ARI- SI IOWN I O I it: OfJI- 1 001 OI? LF_SS F ROM PROPERTY OR REQUIRED ZONING SLl BACK LINES. LOUD I)E I LfZM11-AA l ION THE DWELLING SHOWN HERE DOES Nor FnU_ W111I11! A SI'I c;IAI 1 1 001) 1IA/Alll) /HNF AS DCI_INI-AIEO ON A MAP OF COMMONIIY // 250001 001r-- r' AS IOIdI +' I)AII1) HY 1111' 14A11ONAl_ FLOOD INSURANCE PROGRAM CERTIFICATION0 of I CERTIFY Tn 1Z1:VIN tr. DAVIU, ESO. , /,�� ►lC) �rttrUc WEBSTER FIRST FEDERAL CREDIT UNION (iDlctr ►lirttr illrtttcl t� (IIn: ,t+�, D tuvU LTS TITLE I ISURANCE CONPANY, THAT (Ilea 01rlbtl 1Rutth 'i ' CARTEf3 THERE ARE NO VISIBLE ENCROACHMENTS Near webrorli !d111 L1�7,1`�r .�, r►,3`r?of . OR EASDIENTS EXCEPT AS S1101rt! AND THAT �t '�'9ti °lcsston� THIS PTANT KAS PI?EPAVED 11711C;'R t1" r� ►k, "� ;1 IMIEDIATE SUPERVIS ION. 3tt x 1 —it tl tl—�1 J;1— _)ll l , GENERAL NOTES: This mortgage inspection plan was prepared for (lie above mentioned client as of this dale Gild is not intended or represented to be a land or property liar- survey. t10 corner; were set. It cannot be used for prepotiny deed descriptions, con.itruction or establishing fence, hedge or building lines." the land as shown hereon is based on client furnished informcrlion and may be subject to further out salr: , (okiny, casements onr) fight of way. ?do responsibility is extended to the land owner or occupant. It. is not intended to be recorded.