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HomeMy WebLinkAbout1124 OST.-W.BARN. RD - Health 1124 Osfi, V1 m Marstons Mills A tb-j- TOWN OF BARNSTABLE LOCATION l C� I 'Irv- � � SEWAGE # VILLAGE / r ASSESSOR'S MAP &LOT 5 INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY O© l LEACHING FACILITY: (type) ze) NO.OF BEDROOMS e BUILDER OR OWNER PERMIT DATE: COMPLIANCE DATE: Separation Distance Between the: G U) �4 1 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 6 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET, BOSTON, MA 02108 617-292.5500 WILLIAM F.i•ELD TRUDY CORE Governor 2 � Secretan ARGEO PAUL CELLUCCI e; ` �� D'A�YIDfB.STRUFIS Lt.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM 0 CommIMioner PART A = /3�( •� CERTIFICATION Property Address: `3 ""0.�NSA �(� d�C(,1. ars�nsol��' 6 1998 P rh ` Address of Owner: F E B � Date of Inspection: IAA. al)I a QZ• + (If different) -. Name of Inspector: (�)� I�-. (il jr, dOF BAP.ii1STABLE C� ALTH DEPT am a DEP approved system inspectpr pur want to Section 15.340 of Title 5 (310 CMR 15.000) f Company Name: Q C- Caulq1TO C iorl Mailing.Address: 0 { Telephone Number: 1 02 - y aD0 s CERTIFICATION STATEMENT I certify that I have personally insp 4d the sewage disposal system at this address and that the information.reported below is true, accurate and complete as of the time o spection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site se ge disposal systems. The system: _ Passes _ Conditionally Passes Needs Further Evaluation ails By e'Local Approving Authority F 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 2 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.] SYSTE PASSES: I have not found any information whits 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: B] SYSTEM CONDITIONALLY PASSES: One or more system components as described the "Conditional Pa section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approv by the Bo of Health, will pass. Indicate yes, no, or not determined (Y, N, or N91. Describe ba determination in all instances. If"not determined", explain why not. The septic tank is metal, un:oss the own or operas has provided the system inspector with a copy of a Certificate of Compliance (attached) indicating th a tank was inst d within twenty (20) years.prior to the date of the inspection; or the septic tank, whether or not eta[, is cracked, structura unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The s ern will pass inspection if the exis septic tank is replaced with a conforming septic tank as approved by the B d of Health. (revised 04/25/97) + Page 1 of 10 j DEN,n the World Wide Web: http:I/www.magnet.state.ma.us/dep ej Printed on Recycled Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: /44 QdrmB ct bhe �r Mct rs4O9lS 01 Al S Owner: �L V Ce P e C d Date of Inspection:J(Xn, a') B) SYSTE 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 du to.a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Hea h). Describe observations: broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced The systejrqu,4ed pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspectioh approval of the Board of Health): broken pipe(s) are replaced obstruction is removed CJ F RTHER 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) SSTEM 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 E VIRONMENT: 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). I OT R (revised 04/25/97) Page 2 of 10 I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A I.' /� ((�� CERTIFICATION y(pc�ontinued) Property ddress: 'T W , Qarn Sf4 re Q• I►6 f$+onv /rt r I IS Owner: fOW Re i d Date of Inspection:�0A D] SYSTEM FAILS: d` Yo must indicate ei;!,er "Yes" or "No" as to each of the following: I ave determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis fo this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes N _ Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspo 1.ol. 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 o 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 I 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. L4GE 5 STEM FAILS: u ust i dicate either "Yes" or "No" as to each of the following: T e following criteria apply to large systems in addition to the criteria above: T e system serves a facility with a design flow of 10,000 gpd or greater (Large System) and the system is a significant threat to p blic health and safety and the environment because one or more of the following conditions exist: Ys o 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) Th own or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program Ireq irem nts of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 04/25/97) Page 3 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B +l �1 _ nn CHECKLIST Property Address: I T'1 W t d7Clf �CICI L� 1` 'V`0.fBY1S Owner: �(b� Date of Inspection: Check if a lollowing have been done- You must indicate either "Yes" or "No" as to each of the following: 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 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 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)J I i (revised 04/25/97) Page 4 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: lff�� W,Qa��Sae �d. 0.r S QhS A r 6l s Owner: Q f U Ce Date of Inspection:. FLOW CONDITIONS RESIDENTIAL �) Design flo (/ .p. /bedroom fo .A.S. Number of b oms: Number of rrent rest nts: Garbage grinder (yes or no): Laundry connected to systegn yes or no): Seasonal use (yes or no): Water meter readings, if ilable (last two (2)year usage (gpd): T Sump Pump (yes or no) Last date of occupancy: 9� COMMERCIAUI NDUSTRIAL: Type of establishment: Design flow:,_gallons/day Grease trap present: (yes or no)_ Industrial Waste Holding Tank pres nt: ( s/orno)— Non-sanitary waste discharged to the Titl 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: 4 fo m V d CJ / System pumped as part cf inspection: (yes or no) JLyes,volume pumped: gallon Reason for ping: �T �h f.`0 ce :TYPE F STEM Septic tank/distr�iution /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. Copy of up to date contract? Other APPROXIMATE AGE of all components, date installed (if known) and source of information: Sewage odors detected when arriving at the site: (yes or n6 (revised 04/25/97) Page 5 of to SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION `f (continued) Property Address: IG-4 �ari\ttck IN,r ks NJIS Owner: SruV ; Act Date of Inspection:cu jgctg BUILDING SEWERA� i (Locate on site pla Depth below grade Material of Construn _40 V _o er ain) Distance from p ' wa r sup y well or coon line Diameter Commen s: (�d titio of joints, verting, eviden leakage, etc.) i l SEPTIC TANK:_ / (locate on site plan) l Depth below grader , Material of construction: _concrete _m tal _Fib glas _ ye e e _ er(explain) If tank is metal, list age _ Is age confirmed by Certificate of Compliance _(Yes/No) Dimensions: Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: �v Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: U How dimensions were determined: 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.) GREASE TRAP: (locate on site plan) Depth below grade: J Material of construction: _concrete _meta\— glas _P/hylenether(explain) Dimensions: Scum thickness: Distance from top of scum to top of outlet/al Distance from bottom of scum to bottom o :Date of last pumping: Comments: (recommendation for pumping, condition oes or baffles, dept of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) (revised 04/25/97) Page 6 of 10 r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C II ,�pp SYSTEM INFORMATION (continued) II'Property Address: n��� 8arAjAle )4. Owner: 6(uce Ie la Date of Inspection:Tan'of I Me 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 _met Fiberglass. _Polyethylene _other(explain) Dimensions: Capacity: gallons Design flow: gallons/day Alarm level: Alarm in working order _ Yes; No Date of previous pumping: Comments: (condition of inlet tee, condition of alarm and float.switches, et ) DISTRIBUTION BOX:_ (locate on site plan) Depth of liquid level above outlet invert: Comments: (note if level and distribution is equal, evidence of soli carryover, evidence of leakage into or out of box, etc.) j. /f PUMP CHAMBER:_ (locate on site plan) Pumps in working order: (Yes or No) i Alarms in working order (Yes or No) Comments: (note condition of pump chamber, ci ndition of pumps and appurtenances, etc.) i (revised 04/25/97) Page 7 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) �� Property Address: "F w, �3ccfns a�fe .. /r 4recrl ' m. '/S Owner: g f oce Reid Date of inspection:Tap, ref)iggl6 � SOIL ABSORPTION SYSTEM (SAS): (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) If not de:ermined to be present, explain: Type: 1 leaching pits, number: L 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 hydrauli failure, level of ponding, condition of vegetation, tc.) 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 inspe ion) Comments: (note condition of soil, signs of hydraulic failure,/Iel f ponding, condition of vegetation, etc.) PRIVY:_ (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments: (note condition of soil, signs of,liydraulic failure, level of ponding, condition of vegetation, etc.) (revised 04/25/97) Page 8 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C l r� �,1j t (�,SjYSTEMy�INFORMATION (continued) Property Address: / Jaq �/1�,uQr 5t�D�N Rij l arAOIIS Owner: V vice IZ&l d Date of Inspection:Jai a! ) We 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) pal (revised 04/25/97) Page 9 of 10 6�J (� I(�aa� -3 �, � e L� I - ` � 00 a / � � �<� R�� SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C 1 SYSTEM INFORMATION (continued) Property Address: r y�� �J 130fASl,g&de fflA19 ®VS M / Owner: I j f V C.P I�,, q Date of Inspection:T at Q,�c I 6 Depth to Groundwaterj�eet 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 C ck with local Board of health ZCheck FEMA Maps Check pumping records C k local excavators, installers Use USGS Data Describe in your own words how you established the High Groundwater Elevation. Must be completed) ".4t (revised 04/25/97) Page 10 of 10 i TOWN OF BARNSTABLE - UNDERGROUND FUEL AND CHEMICAL STORAGE REGISTRATION ,-OWNER AND INSTALLER INFORMATION Jr ADDRESS: 1 ��/ 1 ".s'a I 60PDA81,�- MAP NO. _ PARCEL NO. OWNER NAME:, let)0 �f1 a_' P IT VILLAGE: Mo&-)us INSTALLATION DATE: sr� �q BY: CA k . ADDRESS: , CERT. NO. �/jv Aj = , C, `T L TANK I NFORMAT I ON LOCATION O/F� TANK: �_ �) ./ CAPACITY r'�l . TYPEx � "' AGE1� FUEL/CHEMICAL"1' rlkt TESTING CERTIFICATION C ] PASS C ] FAIL DATE LEAK DETECTION C ] CHECK IF N/A TYPE/BRAND ZONE OF CONTRIBUTION C YES C ] NO DATE TO BE REMOVED 1 FIRE 'DEPT. PERMIT ISSUED CA YES C . ] NO DATE CONSERVATION C ] CHECK IF, N/A DATE BOARD OF HEALTH TAG NO. J ]C ]C ]C ] DATE ,PLEASE:; PROVIDE A ,SKETCH ,SHOWING,. THE TANK LOCATION ON THE BACK OF THIS CARD µ