HomeMy WebLinkAbout0169 TIMBER LANE - Health 169 TIMBER LANE,MARSTONS MILLS
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Department of Environmental Management/Division of Water Resources
WELL COMPLETION REPORT
WELL LOCATION GEOGRAPHIC DESCRIPTION
Address 161 l in1'hr I AAJe. D S
N S E OW of
(feet) (circle)
City/TownSTLwS Mti I�5 WU OZb4g L
`('.�1, ��
Well owner 1JO GO,IA (road)
Address 199 'rinblu (,ewe. Z N E W of
t_ AAIS_T0A/s r4jjjS .f A 0204 (mi.in tenths) (circle)
Board of Health permit obtained: yes no Elintersect. (road)
WELL USE WELL DATA
Domestic LW Public❑ Industrial ❑ Total well depth ft.
Monitoring❑ Other Depth to bedrock ft.
Water-bearing rock/unconsolidated material:
Method drill ed 'rj•C• NV S
Description
Date drilled 6
Water-bearing zones:
CASING �+ �J / 1) From To
Type J\ • 1 o yv(— 2) From To
Length ft. Dia(I.D.) in. 3) From To
Length into bedrock ft. Gravel pack well: dia.
Protective well seal: .dia.
Screen:
Grout ❑ Other Slot# S length 3—from '41S to
STATIC WATER LEVEL (all wells) C ,
Static water level below land surface ZJ ft. Date u ��
WELL TEST(production wells) c
Drawdown0ft. after pumping hr. l�min. at v gpm
How measured R-41- Recovery `A'Aff. after_ hr.—min.
--Ape
LOG of FORMATIONS COMMENTS
0
Materials Froml To
CD
COAISIL Driller .%a
Firm _DA ScAIdMC Il
SAA, 15' t Address P P• 160
City/Town � MA &7LQ 01
`
Supervising Driller Reg.# G3T
Signature of sup�ng registered well driller
Please print firmly
BOARD OF HEALTH COPY.
TOWN OF BARNSTABLE
L-G`'► D SEWAGE#
VILLAGE- ASSESSOR'S MAP& LOT �1q
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY tco
LEACHING FACILl TY: ty )-�\eCCtS�' (size), 0Qo
NO.OF BEDROOMS
BUILDER OR OWNER �M�IS ���`� `C A
PERMUDATE: 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 �c`U
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Commonwealth of Massachusetts
Executive Office of Environmental Affairs IN
Uip Dept. of Environmental Protection John Grad
One winter Street,Boston,Ma. 02108 D.E.P. Title V Septic Inspector
P.O. Box 2119
Teaticke 02536
.(508)564-6813
WILLIAM F.WELD
Governor f,
ARGEO PAUL CELLUCCI P""VE
Lt.Governor
SUBSURFACE SEWAGE DISPORT ASYSTEM INSPECTION FORM
u�' r� 3 �99�
CERTIFICATION D
n 1 HFBARNSTARtr
l.THDFPT
Property Address: 169 Timber Lane Marstons Mills a3 Address of Owner:
Date of Inspection: 7/27198 (If different) C
Name of Inspector: John Graci Mrs.Sgarlat �j ro
I am a DEP approved system inspector pursuant to Section 15.340 of Title%(310 CMR 15.000)
Company Name,Address and Telephone Number:
CERTIFICATION STATEMENT
I certify 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:
X Passes This Inspection Is based on criteria defined In Title V
code 310 CMR 16303.My findings are of how the system is
_ Conditionall asse performing atthe time of the inspection.My inspection does
Needs Fur er Ev ation By the Local Approving Authority not Imply any warranty or guarantee ofthe longevity ofthe
septic system and any of Its components useful life.
Fails
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Inspector's Signature: Date: 7127198
The System Inspector shall s bmit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this
inspections. 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:
x I have not found any information which indicates that the system violates any of the failure criteria
defined as in 310 CMR 15.303. Any failure criteria not evaluated are indicated below.
COMMENTS:
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, 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
CoTnpl)ance(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 04n7197)
One Winter Street a Boston,Massachusetts 02108 a FAX(617)556-1049 • Telephone(617)292-5500
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 169 Timber Lane Marstons Mills
Owner: Mrs.Sgarlat
Date of Inspection:7127198
_ Sew.acie backup or,hreakout or hioh.static water level observed.in.the distribution box is due to a broken.
or obstructed pipe(s)or due to 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 leveled 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
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 PROTECT THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
_ The system has a septic tank and soil absorption system and is within 100 feet to a
surface of water supply or tributary to a surface water supply.
The system has a septic tank and soil absorption system and is within a Zone 1 of a public watersupply 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 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 presense of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm. Method usedto determine distance (approximation not valid)
3)Other
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 in 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
cesspool.
SAS is in hydraulic failure.
(revised 04127197)
L
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 169 Timber Lane Marstons Mills
Owner: Mrs.Sgarlat
Date of Inspection:7127199
D]SYSTEM FAILS(continued)
Yes No
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).
Numbers 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 1 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.
E] 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:
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 i
_ 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)
The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program
requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.
(revised 0412M)
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECLIST
Property Address: 169 Timber Lane Marstons Mills
Owner: Mrs.Sgarlat
Date of Inspection:7/27198
Check if the following have been done:YOU must indicate either"Yes"or"No"as to each of the following:
,c_ — Pumping information was requested of the owner, occupant,and Board of Health.
x None of the system components have been pumped for at least two weeks and the 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.
x As built plans have been obtained and examined. Note if they are not available with NIA.
x The facility or dwelling was inspected for signs of sewage back-up.
x — The system does not receive non-sanitary or industrial waste flow.
_c_ — The site was inspected for signs of breakout.
x All system components, excluding the Soil Absorption System,have been located on the site.
x 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.
x 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 Systens.
x Existing information. Ex. Plan at B.O.H.
x Determined in the field(if any failure criteria related to Part C is at issue, approximation of distance is
— — unacceptable)[15.302(3)(b)]
{revised 04127)97)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
. PART C
SYSTEM INFORMATION
Property Address: 169 Timber Lane Marstons Mills
Owner: Mrs.Sgariat
Date of Inspection:7127199
FLOW CONDITIONS
RESIDENTIAL:
Design flow: 220 9•p•d./bedroom for S.A.S.
Number of bedrooms: 4
Number of current residents: 2
Garbage grinder(yes or no): No
Laundry connected to system(yes or no): Yes
Seasonal use(yes or no): No
Water meter readings, if available:(last two(2)year usage(gpd):
rda
Sump Pump(yes or no): No
Last date of occupancy: n1a
COMMERCIAL/INDUSTRIAL:
Type of establishment: n1a
li Design flow:0 gallons/day
Grease trap present: (yes or no) No
Industrial Waste Holding Tank present:(yes or no) No
Non-sanitary waste discharged to the Title 5 system:(yes or no) No
Water meter readings,if available: n1a
Last date of occupancy: n1a
OTHER:(Describe) rda
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
System was last pumped 3 years ago.
System pumped as part of inspection: (yes or no)No
If yes,volume pumped: 0 gallons
Reason for pumping: rya
TYPE OF SYSTEM
x Septic tank/distribution box/soil absorptions system
Single cesspool
Overflow cesspool
Privy
Shared system(yes or no) ( if yes, attach previous inspection records, if any)
ILA Technology etc. Copy of up to date contract?
Other:
APPROXIMATE AGE of all components, date installed(if known)and source information:
System Is 20 years old.
Sewage odors detected when arriving at the site: (yes or no) No
(reylsed 04117)97)
f
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 109 Timber Lane Marstons Mills
Owner: Mrs.Sgarlat
Date of Inspection:7127198
SEPTIC TANK: x
(locate on site plan)
Depth below grade: 4"
Material of construction:x concreate metal FRP Polyethylene_other(explain)
If tank is metal, list age nra . Is age confirmed by Certificate of Compliance No (Yes/No)
Dimensions: L8'6"h5'7"w4'10"
Sludge depth:V
Distance from top of sludge to bottom of outlet tee or baffle: 25"
Scum thickness:6"
Distance from top of scum to top of outlet tee or baffle:S"
Distance form bottom of scum to bottom of outlet tee or baffle: 12"
How dimensions were determined: measured
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.)
septic tank and all components are structurally sound and functioning properly.Recommend pumping every one to two years.
GREASE TRAP:
(locate on site plan)
Depth below grade: rda
Material of construction: concrete metal FRP Polyethylene_other(explain)
Dimensions: rya
Scum thickness:rda
Distance from top of scum to top of outlet tee or baffle:rda
Distance from bottom of scum to bottom of outlet tee or baffle: rda
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.)
nfa
BUILDING SEWER:
(Locate on site plan)
Depth below grade: 1-
Material of construction:_cast iron_40 PVC_other(explain)
Distance from private water supply well or suction line—
Diameter: nfa
gr�mments: (conditions of joints,venting,evidence of leakage, etc.)
(revised 0427197)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
169 Timber Lane Marstons Mills
Mrs.Sgarlat
7127198
Depth of groundwater 12.
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 4
Check pumping records
Check local excavators, installers
Use USGS Data
Describe in your own words how you established the High Groundwater Elevation.(MUST be completed)
USGS Maps and Charts
(revised0427197) Year 10 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
969 Timber Lane Odl"ens Mils
Mrs.squdgt
7Jil7J98
SKETCH OF SEWAGE DISPOSAL SYSTEM:
Include ties to at least two permanent references.landmarks or benchmarks
locate all wells within 1W(Locate where public water supply comes into house)
aR
AC �4
Page O! $0
{revfaedOMTRn S
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 169 Timber Lane Marstons Mills
Owner: Mrs.Sgariat
Date of Inspection:7127f98
SOIL ABSORPTION SYSTEM (SAS):x
(locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) .
If not determined to be present,explain:
rda
Type:
1000 gallon leach It
leaching pits, number. g p
leaching chambers, number:nla
leaching galleries, number: rda
leaching trenches, number,length: rda
leaching fields, number,dimensions:nla
overflow cesspool,number:nla
Alternate system:-rda Name of Technology:_nra
Comments: (note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.)
The leach pit was structurally sound and functioning properly.The leach pit had T ofwater In it at the time of the Inspection.
CESSPOOLS:
(locate on site plan)
Number and configuration: ola
Depth-top of liquid to inlet invert: rda
Depth of solids layer: rVa
Depth of scum layer: rda
Dimensions of cesspool: nla
Materials of construction: nla
Indication of groundwater: rda
inflow(cesspool must be pumped as part of inspection)
rda
Comments: (note condition of soil, signs of hydraulic failure,level of ponding,condition of vegetation, etc.)
nla
PRIVY:
(locate on site plan)
Materials of construction. Na Dimensions: nra
Depth of solids: rda
Comments: (note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.)
nis
(revised 04127197)
I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 169 Timber Lane Marstons Mills
Owner: Mrs.Sgarlat
Date of Inspection:7/27198
TIGHT OR HOLDING TANK:
(locate on site plan)
Depth below grade: nra
Material of construction:_concrete_metal_FRP_Polyethylene_other(explain)
Dimensions: nra
Capacity: nla gallons
Design flow: n1a gallons/day
Alarm level:_nra Alarm in working order?_Yes_No
Date of previous pumping:
Comments:
(condition of inlet tee, condition of alarm and float switches,etc.)
nra
DISTRIBUTION BOX:
(locate on site plan)
Depth of liquid level above outlet invert: nra
Comments:
(note if level and distribution is equal, evidence of solids carryover,evidence of leakage into or out of box etc.)
nra
PUMP CHAMBER:.
(locate on site plan)
Pumps in working order:(yes or no)t o
Alarms in working order(yes or no)_Yes
Comments:
(note condition of pump chamber, condition of pumps and appurtenances, etc.)
nra
(revised 04127197)
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VILLAGE _
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INSTA LLE 'S A M E & ADDRESS
B UtLDE R OR OWNER
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DATE PERMIT ISSUED
DATE COMPLIANCE ISSUED
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INSTA LLE 'S NAME & ADDRESS
BUILDER OR OWNER
DATE PERMIT ISSUED
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