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HomeMy WebLinkAbout0169 WHITE MOSS DRIVE - Health 169 WHITE MOSS �y� �11�15 A = 031 004.006 j Commonweatth of Massachusetts Executive Office of Environmental Affairs Department of Environmental Protection Wllllam F.Weld Govemor Trudy Coxe Secretary,EO 6 David B.Struhs V ` Commissloner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM b O q•O 0"f0 PART A CERTIFICATION Property Address: 169 White Moss Road, Marstons Mil]Vdress of Owner: Date of Inspection: 12-3-96 (if different) Name of Inspector: Donald R. Klimm Company Name, Address and Telephone Number: Robert B. Our Co. , Inc. , 24• Great Western Road, N. Harwich, MA 02645 508-432-0530 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 Conditionally Passes Needs Further Evaluatiogi By the Local roving Authority _ Fail I 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: X 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. 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, 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 8/15/95) 1 t One Winter Street • Boston, Massachusetts 02108 • FAX(617)556-1049 • Telephone(617)292-SSW A SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM . PART A CERTIFICATION (continued) Property Address: Owner: 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): 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 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: _ inr > >ir��• ��d� d sUtiL id,in d, j suu .65urp,00n syiiem d�� a �ti�. „� v.. cc: :.. :. S:, aCC %':3;C: SUrr.i' •.•.'i ,. r surface water supply. _ The w ten) 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 sy stern 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 5 ppm DI 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. (revised 8/15/95) 2 t r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Owner: Date of Inspection: D] SYSTEM FAILS (continued): 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 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. E] 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) 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 8/15/95) 3 r e , SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 169 White Moss Road, Marstons Mills Owner: A. & J. Doherty Date of Inspection: 12-3-96 Check if the following have been done: _X 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. X 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. X The system does not receive non-sanitary or industrial waste flow X The site was inspected for signs of breakout. X All system components, eWluding 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 existing information or approximated by non-intrusive methods .X The facilir, o•.^.e !and nrr inaMc if rfiffprpnt frnm owner) were provided with information on the proper maintenance of Sub- Surface Disposal System. (revised 8/15/95) 4 r I SUBSURFACE SEWAGE DISPOSAL,SYSTEM INSPECTION FORM PART C ' SYSTEM INFORMATION Property Address: 169 White Moss Road, Marstons Mills Owner: A. & J. Doherty Date of Inspection: 12-3-96 FLOW CONDITIONS RESIDENTIAL: Design flow: eeu gallons Number of bedrooms: 2 Number of current residents: 2 Garbage grinder(yes or no):_jj� Laundry connected to system (yes or no): X S Seasonal use'(yes or no): n Water meter readings, if available: Last date or occupancy: now COMMERCIAUINDUSTRIAL: Type of establishment: Design flow: ¢allons/day Grease trap present: (yes or no)_ Industrial Waste Holding Tank present: (yes or no)_ Non-sanitary waste discharged to the Title 5 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: Not available System pumped as part of inspection: (yes or no) n If yes, volume pumped. gallons Reason for pumping: TYPE OF SYSTEM X Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy no Shared system (yes or no) (if yes, attach previous inspection records, if any) Other (explain) APPROXIMATE AGE of all components, date installed (if known) and source of information: _ Built in 1987 9 years old Sewage odors detected when arriving at the site: (yes or no) (revised 8/15/95) 5 i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 169 White.Moss Road, Marstons Mills Owner: A. & J. Doherty Date of Inspection: 12_3_96 SEPTIC TANK: X (locate on site plan) Depth below grade: 611 Material of construction: X_concrete _metal _FRP —other(explain) Dimensions: 81611L X 4,lOttW--X 5'8t!D 1000 gallon Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: 6 n Scum thickness: 1411 Distance from top of scum to top of outlet tee or baffle: 11-2" Distance from bottom of scum to bottom of outlet tee or baffle: 181, Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet in 'structural it n vi ence of.le ka e, etc.) tld be maintenance pu pe e ore addition, no leakage found, tees good. GREASE TRAP:_ (locate on site plan) Depth belov, grade: Material of construction: _concrete _metal _FRP _other(explain) Dimensions: Scum titic�n� s Distance from top of scum to top of outlet tee or baffle: Llt<ranre I,nrr botto r. M <rtim t� hotior- Of OOtlet tee Or battle- 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.i (revised 8/i5/95) 6 t I 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 169 White Moss Road, Marstons Mills Owner: A. & J. Doherty Date of Inspection: 12-3-96 TIGHT OR HOLDING TANK:_ (locate on site plan) Depth below grade: Material of construction: _concrete _metal _FRP—other(explain) Dimensions: Capacity: Qallons Design flow: gallons/day Alarm level: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX:_X (locate on site plan) Depth of liquid level above outlet invert: equal Comments: (note ii le%e; and distributiui, �y4�`., e•;dence of solid; ca:-;�.c:, evidence of leakage into or out of box, etc.) No leakage found, no carry over. PUMP CHAMBER:_ (locate on site plan) Pumps in working order:(yes or no) Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) (revised 8/15/35) 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 169 White Moss Road, Marstons Mills Owner: A. & J. Doherty Date of Inspection: 12-3-96 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: Type. 1 •6 x 6 recast it with stone leaching pits, number:_ P pit found half full on 12-3-96 leaching chambers, number:_ leaching galleries, number: leaching trenches, number,length: leaching fields, number, dimensions: overflow cesspool, number: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,etc.) Soil clean, no signs of hydraulic failure. No vegetation. 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 8/15/95) B i ti SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (cot tinued) Property Address: 169 White Moss Road, Marstons Mills Owner: A. & J. Doherty Date of Inspection: 12-3-96 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' E(0) 0 0 G o oro CGO / 000 (� DEPTH TO GROUNDWATER Depth to groundwater: feet \ �\ method of determination or approximation:_ ��/)/c! y�j/-�x� (revised 8/15/95) 9 t t TOWN OF BARNS TABLE LOCATION L-o� Vk,V Muse Qi w SEWAGE # c67 12 �(; UO(p VILLAGE CM,�cy��v.s IM d�� ASSESSOR'S MAP & LOT &INSTALLER'S NAME & PHONE NO. -) S : p �Si 1� -77 1'3 6(b N SEPTIC TANK CAPACITY LEACHING FACILITYAtype) C-PcivL (size) 6c 4 NO. OF BEDROOMS _PRIVATE WELL 0 PUBLIC WATER BUILDER OR OWNER (�c ey► �' OP � C a�D DATE PERMIT ISSUED: 7 DATE .COMPLIANCE ISSUED: ` VARIANCE GRANTED: Yes No „,- L �� C`s- -t^. N W � I y � iA .r� J J THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ............--. . .t ± .........oF...-........ ? ................................ Appliration for Disposal Murk, Tonstrurtion ramit Application is hereby made for a Permit to Construct ( t 'or Repair ( ) an Individual Sewage Disposal System at p 412 �y ! or Lq No. ocatio Acres .................................. 1.... .... �. .» p .......... Address ...................................... . ......::: `Y. :........................----.........----•-•---------.................... Installer Address Type of Building Size Lot2��.6 :2Sq. feet �.. Dwelling—No. of Bedrooms....... .............................Expansion Attic (4) Garbage Grinder Other—Type of Building No, of persons............................ Showers � YP g -•-------------•-•------••-• P ( ) — Cafeteria ( ) Otherfixtures .--- ----•.......................... •--•-•--------------------------............... Design Flow......... .............. _gallons per person per day. Total daily flow......... 35 ...............gallons. tic iameter Disposal Trench Tank—LiquidNo capacity.-�' idthns.....LengthTotal Length Width................. . ... Total leaching area-..Depth._...s . ft. Seepage Pit No......... ...... Diameter.................... Depth. below inlet.................... Total leaching area.......-......... q. ft. Z Other Distribution box ( ) Dosing taeepth ( ) D �1./...r. t�..... a Percolation Test Results Performed b .. � ? '..w.. eAK ate...... �' a Test Pit No. 192:s ..minutes per inch of Test Pit _�/...1. Depth to ground water.-.�fJ.. G4 Test Pit No. �!�C minutes per inch Depth of Test Pit..._..-- ../. ...... Depth to ground water..`!... .. a .... -`5--.. 7............... ......... ....................-.-------------.-----------------•-----: O Description of Soil...., ` "=`• P.... .�`�-•--._.-....-` U Nature of Repairs or Alterations—Answer when applicable............................................................................................... ----•-----•-•---.......-•--•............................................•--.......---------••-•---.........-•---...--•------...-•••----•--------•--•-----..... ....-•--••--•-••-----•............... Agreement: i The undersigned agrees to install the aforedescribed Individual Sewage Disposal System,in accordance with the provisions of TITIS 5 of the State Sanitary Code—.The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of-health. _Signed_ ...: . :... ,t `.•. �3 �� .. Application Approved BY..... l I - - Dfite. ••.............. ,., ................. ate Application Disapproved for the following reasons:----•-......--••-••----•......•---•--------•••--......----••--•--•--------..............................:.»» --•-•-•--•-•-•..............•---------.......:..--•------------••----•-•-•----------.....---.....-•----•.---•••-••••---•--•--•--••-•----•-••••-••-•---•--...-•----•---..._--•----------•--•----._.....» 5_7 -- l'Z Date Permit No..... .,7--•------------------------•---»-----».._ Issued-.....................................................» Date THE COMMONWEALTH. OF MASSACHUSETTS BOARD OF HEALTH t ................. .. ......OF............ �, '� J. .................... f5rr#if irtttr of Toutplittnrr THIS IS TO CERTIFY That the I dividual Sewage Disposal System constructed ( r Repaired ( ) . by - J/49ry:- ....... _1 . .. ?. . .:........................•----•----.............:-•----•-••--•--•-•-•----.....................,..--••--.....:_..._..... �-••�, Installer �� 1� 3. ��'f 11�. all ,1 '�'-� �) 4J has been installed in accordance with the provisions of''ITS 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No..... _ '' i �...... "' '`� ----•----t.�._. dated........ ............ THE THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE............... -2 ... ma's.. .......................-» Inspector--C� ,�.�-,r_x.T-.-- _------•---•- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH � r1....... ...........................` ...... .......No .... , Fn..........._........... Disposal Works (14. t�urtion rrrntit Permission�is'hereby granted.....--- . ` �....-•--.. •••-'� .4 .............. ......._»»»to Constr ctoepair ( ) an Individual Sewage Disposal System at No....-.1 -.rt% ..... f�. ...• '�� - 'f=�'- =fr+ � .............f l L ................................... Street as shown on the application for Disposal Works Construction Permit No..�.: ........... Dated.._y�PP P ` .............. AA -- - Board of Health DATE. ..............................� : FORM 1255 A. M. SULKIN, INC.. BOSTON 3 /45 .JET 9AC L D 1 L. - r ��f�f s.tl, r LoT 98 t` t cis 9 l✓ 30 \ \ ,67. 9v W t - Lo T t 1 v` t k AO 2 `/03 aZ' �N r� c�ss IU�ei .EGEND :XISTING SPOT ELEVATION w� �; . ' OF ROPOSED SPOT ELEVATION :XISTING CONTOUR ---0--- ;/?`� DAV:n P. '10�\ ROSIN c 'ROPOSED CONTOUR 0 M(A.RIA1'JO zl^,; 'OTE: THE LOCATION OF ANY UNDERGROUNDy. CIVIL `i VVI y EWERAGE,WELLS, OR OTHER UTILITIES SHOWN ON .�No.31115`� a 31 1 Q HIS PLAN IS APPROXIMATE ONLY AS DETERMINED �;,f�� �' , / F01STER���QJ ,ROM RECORDS AND/OR VERBAL INFORMATION. :> �sS/ - oNQi �nwo5 HE CONTRACTOR IS RESPONSIBLE .FOR THE �' Il - ERIFICATION OF THE EXISTING LOCATIONS IN ✓ -HE FIELD. s: R I NGINEfPrw I T A .EVY 8, ELDREDGE ASSOCIATES, INC. CLIENTI7PF F PROPOSED SOT ".AN ENGINEERS - LANDSCAPE ARCHITECTS JOB NQ..�� R A RV Y R PLANNE S - L ND SU E 0 S DR..BY,* IN 889 WEST "IN STREET CHKD. BYs � S CENTERVILLE, MA. 02632 SHEET OF SCALES � DATE, �n % 20 FT. M/N. NOTE /F E/TNER THE SEPT/G TANK OR ', s .... ZZrAC/�//n/G P/T ARE /YORE TNA/V /2"ffrLOAi i '" - GRADE Aa ?4 �O/AMETEK CO�yG'.P.ET� COiiO ` 1O M/N SCHEpc/Lff+0 SJ/ALL B.E BROUGHT TO GIgAOE.6AN EXTR/4 11�- P v C. 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SEWAGE O/SP0%5A L .Sy.57'EM /INL.ET' LEACHING PIT FT TA1Blll.ATION LEACH//VG AV7' D/MENSION A DE5/6,V CRITERIAST- 1 DIMENS/ON G --FT. =_- ,� /NUMBER OF 6EDR00/NS 3 G�ReA6.F v/SPOSAL u�rl:r� AI,9- SOIL LOG SD/L. TFST TOTAL 30 GAL.1,0AV Sol L TEST ^*41 $O/L 7---S7-02 4 NUMBER QF' LEACNIJVl p/7.S�� ELEY. 9 -2 PATE aF SO/L TEST �/ x SIDELCACH/NG PER P/T' ice'—�i >:T. �, , RESULTS h//TNESSED 8 p -2 TaP ff . BOTTOM L.69CN/NG P6R P!T 54. RT gvl35o�L PE�l'CaLAT/ON RATIO j*/ — "Ml. rIIVCH TOTAL lEAC•N//YG AREA SAP. FT. PfhCOLAT/ON RATE 2 MIN1IN RESFMV�E LB4CN/NG ARE. SQ. FT. s of1R5t- $; � `Vc�" M �. Gi'!I! ti No.31115l'� <; LEVY&ELDREDGE ASSOCL T� S 0. 91 889 WEST MAIN STREET CENTERVECI� NOGl�OUND YYi4TCR gNCDUNTEREO GL _ C7 M0 U/NO.W-47 PAT ELEV JOB No . :..FG . r, Iry 'El El SCALE: ) APPROVED BY: DRAWN BY AA i z DATE: ' .t? REVISED d Q y a N s DRAWING NUMBER W 0 �2Dro5C7 E-x,ev r, vSrr Oki S +NIf 1 J � � ZGivo►e-- -Fivnz-- vd,Noflv� � c� � w►,in, � pPENdNt� SCALE: ( APPROVED BY: DRAWN BY rAe, i z DATE: © REVISED W .. N Q aU u W DRAWING NUMBER 0 41/rl'I'rF Gil SCALE: j APPROVED BY: DRAWN BY DATE: 2� DRAWING NUMBER vpr n N ._... J�►�I t 2i��' �6 a4 • �r'Z'I GDP �.Y . o i6 n Q Y�0 N llY-i ke )% lbvc P °q r2�� AN4410L fv Gapes 3N�,,��� � �►�rrzzr� �� ��°� v���� �1.� �2.oJ�`, N��S'�o�'�K Vlll�u�, SCALE: ( 5 APPROVED BY: DRAWN BY DATE: d 31�z Go oJ >E fi G rL o'er 1— _ rLoo� -t—o,��lDA-r•i o1.� DRAWING NUMBER