HomeMy WebLinkAbout0035 SHERYLE'S WAY - Health 35-SHERYL'S WAY, 'MkctI 715 aY✓1 r L Ls
A= _
1
V.
17
{ ` . F F-B 2 5 2000
TO"DF BARNSTABLE
HEALTHDEPT.
i
BORTOL01711 CONS'1'RU("PION, INC. w"'� , •j
45 INDUSTRY ROAD, MARSTONS MILLS, MA 02648 { d
508-771-9399 508-428-8926 FAX: 508-428-9399
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM.
PART A
CERTIFICATION
Property Address:c&5sw
leaqz,D lC/
Date Of Inspection =DLIV U Ins ector� ame:
Owner's Name and Address:-T '
r4 Co
CERTIFICATION STATEMENT:
I Certify that I have personally Inspected the Sewage Disposal System at this address and that the informa-
tion reported below is true,accurate and complete as of the time of Inspection. The Inspection was perform-
ed based on my Training and Experience in the Proper Function and Maintenance of On-Site Sewage Dis-
posal Systems.TI system:
✓ Passes
Condit,ionalll.. ses
Needs Ful i� va tio► ,y the Local Approving Authority
Failure'
Inspector's Signature / Date:
The System Inspec shall subm' a copy of this Inspection Report to the Approving Authority with'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:
A) SYSTF, I PASSES:
T/ I have not found any Information which indicates that the System violates any of the fail-
ure criteria as defined in 310 CMR 15.303. Any Failure Criteria not evaluated are indi-
cated below.
- B) SYSTEM CONDITIONALLY PASSES:
One or more System Components need to be Replaced or Repaired. The System,upon
completion of the Replacement or Repair,Passes Inspection.
Indicate yes,nor,or not determined(Y,N,OR ND). Describe bases of determination in all instances. if"not
determined",explain why not.
The Septic Tank is Metal,Cracked,Structurally Unsound,shows Substantial Infiltration or exfil-
tration,or Tank Failure is innuinent. The System will Pass Inspection if Existing Septic Tank
is Replaced with a conforming 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):
- 1 -
SUBSURFACE."'ISEWAGE,,DISPOSAL SYSTEM; INSPECTION .FORM
PART A
CERTIFICATION (continued)
Broken pipe(s)replaced
Obstruction is removed
Distribution Box is leveled or replaced
The System required pumping more than four times a year clue 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)FURTHER EVALUATION 1S REQUIRED BY THE BOARD OF HEALTH:
Conditions exist which require further evaluation by the Board Of Health in order to determine it'
the System is failing to protect the Public Health,Safety and the Environment.
1)SYSTEM WILL PASS UNLESS BOARD OF HELATH 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 FUNCTION
ING IN.A,M.ANNER'=hHAT,PROTECTS'THE P.UBLIGHEAL;IH AND SAFETY.AND THE
ENVIRONMENT:
The system has a Septic.l'ank,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 with a Zone 1 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 from pollution from
the facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less
than 5 ppm.
D)SYSTEM FAILS:
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 overload 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 distr.ibution.box aboye,outlet invert due.to an overloaded or clot;-
ged SAS or.cesspool: 1 �'
depth'in:cesspool,is:less than 6,"beloww in rFt or available.volume is less tlian 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
- 2 -
SUBSURFACE SEWAC,'E'_DISPOSAL SYSTEM.INStECTION •FORM
PART A
CERTIFICATION (continued)
Any portion of the Soil Absorption Sys(em,cesspool or privy is below the high groundwater
elevation.
Any portion of a cesspool or privy is within 100 Feet of a surface water suply 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
f 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.
E) LARGE SYSTEM FAILS:
The following criteria apply to a large system in addition to the criteria above:
The design flow of a system is 10,000 ggd 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 asurtace drinking water supply
The system is located in a nitrogen sensitive area Interim Well head'Protection Area
(IWPA)or a mapped Zone 11 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 treatment program requirements of 315 CMR 5.00 and 6.00. Please consult the local
regional office of the Department for further information.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
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 atleast 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 site.
The septic tank manholes were uncovered,opened,and the interior of the,septic tank was in-
spected'for'condition of baffles or tees,material of construction dimensions,depth of liquid,
/ depth of sludge,depth of scum.
VVV 'File size and location of the Soil Absorption System on the site has been determined based on
existing information or approximated by non-intrusive methods.
_ 3 _
,SUBSURFACE SEWAGE DISPOSAL- SYS'I EM,r.INSP,EC'I:ION FORM
PART B
CHECKLIST(con(inue,l),'
'� The facility owner(and occupants,if different from owner)were provided with information on
the proper maintenance of Subsurface Disposal System.,
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
FLOW CONDITIONS
RESIDENTIAL:
Design Flow: gallons Number of Bedrooms: Number of Current Residents:
Garbage Grinder: - Laundry Connected'To System: Seasonal Use:
Water Meter Readi gs,if available:
Last Date of Occupancy:
COMMERCIAL/INDUSTRIAL: .
Type•of Establishment:
Design-Flow;;_. ._ gallons/day.-.Grease Trap Present:`(yes or no)':
IndustrialWaste Holding Tank Present:.._..__
Non-Sanitary-Waste Discharged To The-Title V System:-
Water Meter Readings,If Available: Last Date of Occupancy:
OTHER: (Describe)
Last Date of Occupancy:
GENERAL INFORMATION
PUMPING RECORDS any source of information:�r� �/Y
System Pumped as part of inspection: 42,69 If yes,volume pumped: gallons
Reason for Pumping:
TYPE OF SYSTEM:
Septic Tank/Distribution Box/Soil Absorption System
Single Cesspool
Overflow Cesspool
Privy
Shared System(If yes ;ttach previous inspection records,if any)
_�Z_Other(explain): S. A-S•
PROXIMAT GE of all m onents, ate i stalled(if known)and source of information `
°
0142
Se age odors detected when arriving at the site:
-4-
it
SUBSURFACE, SEWAGE 'DISPOSAL-SYSTEM.ANSPECTION FORM
PA11T C
/ GENERAL INFORMATION (continued)
SEPTIC TANK: ✓ /
Depth below grade: /R,� Material of Construction: k/ concrete metal Fill, Olber
(explain)
Dimensions: Sludge Depth: Scum Thickness:
Distance from top of sludge to bottom of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Continents: (recommendation for pumping,conditioin of inlet and outlet t es or baffles,depth of liquid level
i relation too et invert,structural integrity,ev' ence of leakage,e72
(Qlj u
GREASE TRAPV--
Depth Below Grade: Material of Construction: concrete metal FRP Other
(explain):
Dimensions: Scum Thickness:
Distance from top of scum to top of outlet tee or baffle:
Continents: (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) ...•. .
'TIGHT OR HOLDING TANK
Depth Below Grade: Material of Construction: concrete metal FRP Other
(explain): -
Dimensions: Capacity: gallons Design Flow: gallons/day
Alarm Level:
Comments: (condition of inlet tee,condition of alarm and float switches,etc.)
DISTRIBUTION BOX:
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.)
PUMP CHAMBER:
Pump is in working order:
Continents: (note condition of pump chamber,condition of pumps and appurtenances,etc.)
- 5 -
w
SUBSURFACE 'SEWAGE'DISPOSAL"'SYSTEM'`INSPEC`FION 7 FORM
% PART C
SYSTEM. INFORMATION(continued)
SOIL ABSORPTION SYSTEM(SAS):
(Locate on site plan,if possible; excavation not required,but may be approximately by non-intrusive
me(hods) if not determined to be present,explain:
Type:
Leaching pits,number:_ Leaching chambers, number: Leaching galleries,number:
Leacahing trenches,number,length: `
Leaching fields,number,dimensions:
Overflow cesspool,number:
'onuuents: (note conidtion of oil,signs of hydraulic failur level of pond' 19,condition of v etation,etc.)_
060
3�I
CESSPOOLS: -
Number and configuration: Depth-top of liquid to inlet invert:
Depth of solids layer: Depth of scorn layer: Dimensions of Cesspool:,`•.
Materials of construction: Indication of groundwater: f
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.)
PwvY:-' �--
Materials of construction: Dimensions:
Depth of Solids:
Comments: (note condition of soil,signs of hyddraulic failure,level of ponding,condition of vegetation,
etc.)
[V
r '
h
- 6 -
'StIliSURFAC;L'SEWAGE DISI'OSAI, SYS'I'li',M�:IN'SI'E("l'ION'TORM
PART C
SYSTEM INFORMATION (conlinucd)
SKETCII OF SEWAGE DISPOSAL SYSTEM:
Include ties to atleast two permanent references,landmarks or benchmarks.
Locate all wells within 100 Feet.
6
DEPTH TO GROUNDWATER: 1
Depth to groundwater: 3 Z Feet
Metl of Determination or A pro imatio 1:
- 7 -
-} T64O BARNSTABLE y�
LOCATION zOT� Sh'�Rf 1 f may SEWAGE # 9`/- '
VILLAGE ASSESSOR'S MAP fz LOTOxc- 40 Y5;p
INSTALLER'S NAME & PHONE NO.
SEPTIC TANK CAPACITY /0p6?
LEACHING FACILITY:(type) /od D (size) 6 X/O
NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER
BUILDER OR OWNER �Aa a�i no 6 f
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No
21
�ar
T /000 s>
y,
4 6 L/
No.J.L,...... Ymx
t THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.........TO.WoJ.............OF....... .......................................
------- ---- --- .............. ........
Appliration for 11hipusal Works (foustrurtion ramit
Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal
System at:
...............V.A,
.. ..................... ........................ ..........................
...................
,,-)Location-Address or Lot No.
.................................... ---------------------------------------- .................................................................................................
0 Address
1W
Installer Address
Type of Building Size Lot....` AQo-----Sq. feet t
U Dwelling—No. of Bedrooms...._._..........3...........................Expansion Attic Garbage Grinder (
44 Other—Type of Building ............................ No. of persons...._....................... Showers Cafeteria (
P4 Other fixtures ...................................191.1 ,
.................................. ........... .............................................................
Design Flow________________Ito -3-16. - '. " I
............ gallons per4Uk der day. Total flow....._
..........'-.."".gallons.
1:4 Septic Tank—Liquid capacity"i 'gallons Length.!@...-O.-... Width.4`1719�. Diameter.......... Depth.S..74-".
Disposal Trench—No..................... Width__._................ Total Length._......... ._...:. Total leaching area....._._._........_sq. ft.L I
Seepage Pit No..................... Diameter......! ......... Depth below inlet.....!;?:........... Total leaching area.J�7.-.2..sq. ft.
Z Other Distribution box Dosing ta k
'CCC> .............. Date..
Percolation Test Results Performed by..................... ................... V,---- ......................................
Test Pit No. I...�Z-----minutes per inch Depth of Test Pit...�*A....... Depth to ground water------...............
Test Pit No. 2................minutes per inch Depth of Test Pit.-----..........__.. Depth to ground water....................---.
.........................................................................................................................................................
0 Description of Soil........ sy��.................................................................................................................
..........I-I.L.L................................................................................................................................ ..........
I 4-e Me>. �;Pwjo
........................................................................................................................................................................................................
U Nature of'Repairs or Alterations—Answer when applicable.........................................:�....................................................
--------------------------------*-'**-----------------------------------*-----------*......*------------*--------------------------------*-----------------*-----------------------------------
Agreement:
The undersigned agrees to install the aforedescribed Individual S6- age Dispos'al System in accordance with
the provisions of iITLE 5 of the State Sanitary Code— The undersignied"further.agrees not to place the system in
operation until a Certificate of Compliance has be s d by the board of he.�th.
Signed........ ............... ............................................... ....
Date
as__beas d
d. .. .........
Application Approved By.......... ..... ...... .........
Date
Application Disapproved for the following reasons:...............................................................................................................
........................................................................................................................................................................................................
Date
Permit No........!TL/.........Ly..'s ............. Issued........................................................
Date
No................-.....-- FEs..........................._
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.......... . ..............OF.......��.�2115T/�13L�;
Appliration for Diupoual Works Tontrurtion rrutit
Application is hereby made for a Permit to Construct ( X) or Repair ( ) an Individual Sewage Disposal
System at:
Location-Address or Lot No.
__......................��-� <�.rA. ..... ....- ...............Owner -Address
W
Installer Address
Type of Building Size Lot.-_.`�:-6Uu Sq. feet
Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
'4 Other—Type T e of Building .............. No. of ersons............................ Showers — Cafeteria
a YP g -------------- P ( ) ( )
Q, Other fixtures ..................................._
-----------------------------------------------......
..
W
Design Flow................ .....................gallons per peFsan per day. Total daily flow........... _ ........................gallons.
WSeptic Tank—Liquid capacity!.QA_.gallons Length_3.... ... Width.`' _.!!�.. Diameter________________ Depth.5_..4__.
x Disposal Trench—No. .................... Width.................... Total Length........... Total leaching area....................sq. ft.
Seepage Pit No-------------------- Diameter......0......... Depth below inlet..... .......... Total leaching area.-.�-.O..sq. ft.
z Other Distribution box ( X) Dosing to ( ) - _
`-' Percolation Test Results Performed by._........'.`:.:-..:...a...............................................�� I2.,1 9-S'
Date........................................
aTest Pit No. 1... Z'......minutes per inch Depth of Test Pit...i:A ...... Depth to ground water------- -_---.
tT., Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water---._________-__---._--_
94 ----------------------------------------------------------•---••----------------------•--------•--.....-•-•--.....-------•---------------------......_..----
O Description of Soil-------- ..-----• ---
T.DI� 4S v rj
-• ------------------------------------------------------------------------------------------------------------------------------------
x z�- (.
. ---•-----•)-.....--�------------
w (00- 1,-& r10:>. 5/-"tjL)
----------------------------------------------------------------------------------------------------------------- --------------------------------------------------------------------------------------
UNature 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 TIT iE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has beVnps d by the board of he th.
Signed--- ----• -----
Date
Application Approved By..........�/'�"_'..--- r`
Date
Application Disapproved for the following reasons:----••----------------------------------------------•----------------------...-•------------------•--•....•-•---
--•------•-------------------•----...----............---...---•------------------•-------....----------.........._....-••---•----....------------------------._...-•-•--------------------..-•--••---•---
Date
PermitNo........ r .............. Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
e.........OF.............1a4A....................................
(Irrtif iratr of Tomphanrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed $,-) or Repaired ( )
by.............................................................................................---------•--•....•-•-••...---•-•-----._...._._....•--••----------•._......-•••-•--•-•----••_.....
��.._ T Installer
at � .'�� t3 �' '1 �` .�.. -------------------------------------------•----------•---- _----.------
has been installed in accordance with the provisions of TITt5 o'f The State Sanitary Code as described in the
application for Disposal Works Construction Permit No......... ...../ .__ ... ... dated................................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONST UED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION S�SFACTORY.
DATE..... .�� �.� � .
......- •---._...---- ..................•---•---......_.. Inspector....----•-••- •---....- ---.._...._....._....._..............._....
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.
...................:-�r�r!L..........oF............ 4......................................
No.... . .. 7 >.6 FEE....
I..................
Disposal Worko Toni ion Famit
Permission is hereby granted.............. t- ---..............................................................................
to Construct or Repair ( ) an Indi (dual Sewage Disposal System
atNo.........1-,_c 4----- -5.14 '�..f .....................................................................................
Street qq1� / q
as shown on the application for Disposal Works Construction Permit No.l.t.., . Dated_.____. f�---.--_---
' Board of Health
C
DATE------------ ..... -3...�1 -----------..-----------------
FORM 1255 HOBBS & WARREN. INC., PUBLISHERS