HomeMy WebLinkAbout0059 WILD WAY - Health 59 WILD WAY, MARSTONS MILLS
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Commonwealth of Massachusetts MqR 2
Executive office of Environmental airs 1996 �� }
Department of
o Environmental ��
Vfiftt F.Weld Wes. R. Harve & Sons-In Fully Insured
Y Trudury,tOEAy Co:e
Mve 508_548-2979 Licensed
Dav1d 8.$truhs
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0 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
Property Address: � Address of Owner:
j
Date of Inspection: 1 ►!/� 1� S `/ ( Of di Brent)
.Name of Inspector: �Lti�� lV�"�✓`t_' ` �L
Company Name, Address and Telephone Number:
Wm.R.Harvey 8:Sons, Inc:
210 Acapesket Road,East Falmouth, MA 02536•Tel. (508) 548-2979
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 sews sposal systems. The system:
P
_ Conditionally Passes
_ Needs Further Evaluation By the Local Approving Authority
Fails
Inspector's Signat rZsa
Date:
The Systr+Specto submit a'c y of t is.ins i n re rt to the ApprovingAuthi within thirty (30) day of completing this
inspection. If the system is a shared system or has a design o of 10,000 gpd or greater, the inspector and the stem owner shall submit
the report to the appropriate regional office of the Department of Environmental Protection.
The original shouid be sent to the system o,.+,ner and eopiet tent to the buyer, if applicable and the approving authority.
INSPECTION SUMMARY:
Check;PASSES-SYS :71
B, C D.
A have not found any information which indicates that the system violates any of the failure criteriaas defined in 310 CMR 15.303.
Any failure criteria not evaluated are indicated below.
BJ 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 8/15195)
One Winter Street 4 Boston,Massachusetts 02108 a FAX(611)556-1049 a Telephone(611)242-S500
A
V 1 Pnnred c�Retvded Pipe, -
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:
Owner:
Date of Inspection:
eJ SYSTEM CONDITIONALLY PASSES (continued)
_ Sewage backup or breakout or high static water level observed in the distribution box is due otro broken oPal obstructed e
pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspect'
if(wit
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 Wlll FAIL UNLESS THE BOARD OF HEALTH �ND7ECTBTHE PUBLIC HEALTH AND SAFETY AND WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT
THE SYSTEM IS FUNCTIONING IN A MANNER THAT PRO
ENVIRONMENT:
_ IhP wsiern nay a septic tanK and Soli absorption System dnd ib.withiU i00 (cel.iG a Su e�c wmci Su G uu:c
surface water supply. I well.
_ The s�•stPn� hay a septic tank and soil absorption system and.is within a Zone I of a public water supp ywelL
_ The system has a septic tank and soil absorption system and is within 50 feet of a private water supply
_ and soil absorption system and is less than 100 feet but 50 feet or more from a private water
The system has a septic tank
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
D) SYSTEM FAILS:
1 have determined that the system violates one or more of the following failure criteria as defined
in3131 LIAR 1r.303. The basis
is
ect
for this determination is identified below. The Board of Health should be cor>tacted to:determine
the failure..
_ Backup of sewage into facility or system component due to an overloaded or dogged 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.
2
trevised 9/15/95)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:
Owner:
Date of Inspection:
DJ 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 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.
El LARGE SYSTEM FAILS:
The following criteria apply to large systems in addition to the criteria above:
The resign 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 welli
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.
3
{revised 6/15/95)
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: ,
Owner:
Date of Inspection:
Check if the foil ing have been done:
Y Pumping information was requested of the owner, occupant, and Board of Health.
Zone 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.
-�' •e facility or dwelling was inspected for signs of sewage back-up.
Z- The system does not receive non-sanitary or industrial waste flow
_L i ne site was inspected for signs of breakout.
:/AII system components, excluding the Soil Absorption System, have been located on the site.
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.
6/The size and location of the Soil Absorption System on the site has been determined based on existing information or
app p 'mated by non-intrusive methods.
_The faci!::•; c+ ^ '!� 0c%.Pa^.ts, if d;;4 from ownpo were provided with information on the proper maintenance of Sub-
Surface Disposal System.
(revised. 8/15/95) 4
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address:
Owner:
Date of Inspection:
FLOW CONDITIONS '
RESIDENTIAL,:
Design flow:. �.. Ilons
Number of bedrooms:i:d_
Number of current residents:
Garbage grinder (yes or no)._�
Laundry connected to system (ye�tor no): �
Seasonal use(yes or no):_ 41'
Water meter readings, if available:
Last date of occupancy:
COMMERCIAVINDUSTRIAL:
Type of establishment:
Design flow:_gallons/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 RECOR and sGwcceWinfrmon:
System pumped as part of inspection: (y s or no)—L'V
If yes, volume pumped: ) `
Reason for pumping: /
TYPE OF STEM
Septic tank/distribution box/soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system (yes or no) (if yes, attach previous inspection records, if any)
Other (explain)
. information:
APPROXIMATMAGE of all components, date installed (if known) and source of
N
Sewage odors detected when arriving at the site: (yes or no) �'
S
(revised 8/15/95)
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
Owner:
Date of Inspection:
SEPTIC TANK:_
(locate on site plan)
Depth below gr
ade: 0 1
Material of construction: ncrete _metal _FRP other(explain)
Dimensions:
l
Sludge depth:
Distance from4pliudge to bottom of outlet tee or baffle:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or b
Comments:
tion of inlet and outlet tees or baffles, depth of liquid I el in relation t outlet invert; structural
(recommendation for pumping, condi
integrity, evidence of leakage, etc.)
v
GREASE TRAP:_
(locate on site plan)
Depth below grade:
Material of construction: _concrete _metal _FRP _othe ex la )
Dimensions:
Scum thicknes_.
Distance from top of scum to top of outlet tee or baffle:
Ntance from bottc• - «iiT t^ tin— ot outlet tee or bame
Commerts:
(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. elc.i
6
(revised 8115/95;
II -
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
Owner.
Date of Inspection:
TIGHT OR HOLDING TANK:_ ,
(locate on site plan)
Depth below grader
Material of construction: _concrete_metal _FRP!othe explain)
Dimensions:
Capacity: gallons
Design flow: gallons/day
Alarm level:
Comments:
(condition of inlet tee, condition of alarm and float witches, etc.)
DISTRIBUTION BOX:_
(locate on si:e plan) t�"
Depth of liquid level above outlet invert:
Comments:
(note ii level and distrvbuuun s,eyuai, evidence of sujid, cairyv, er, evidence of leakage into or out o'box, etc.;
PUMP CHAMBER:_
(locate on site plan)
Pumps in wcrking order:(yes or no)
Comments:
(note condition of pump chamber, condition of pumps and appurt antes, etc.)
7
(revised 8/15/95)
\ SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
Owners
Date of Inspection:
ABSORPTION SYSTEM (SAS):
SOIL(locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods)
611 If not determined to be present, explain: ,—
Type: � - t,� 14
leaching pits, number.
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.)
CESSPOOLS: _
(locate on sit plan)
Number and con uration:
Depth top of liquid inlet invert:
Depth of solids layer:
Depth of scum layer.
Dimensions of cesspool: /
Materials of construction:
Indicanon of ground�•:alc
inflow (cesspool must pum as part of inspection)
Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
PRIVY:_ Ix
(locate on site plan)
Dimensions:
Materials of construction:
Depth of solids:
Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
8
(revised 8115/95)
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1
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SUBSURFACE SEWAGE_ DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
Owner.
Date of inspection:
SKETCH OF SEWAGE DISPOSAL SYSTEM:-
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100'
----------------
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C�>C)
C4,
DEPTH TO GROUNDWATER
Depth to oundwater.f�feet �
P 8r G.S�t
method of determination or approx matron: ( � I
cti O
14
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(revised 6/15/9S). 9
099TOWNOF LARNSTABLE l/
LOCATION ff,/ —_SEWAGE #__eLVILLAGE
_�
ASSESSOR'S HAP & LOT � � ��•
INSTALLSR'S NAME & PRONE No. 6zLA c ;� 1 o0
SEPTIC TANK CAPACITY
LEACHING FACILITY:(type) (size)_
NO. OF BEDROOMS_ PRIVATE WELL OR PUBLIC WATER
BUILDER OR OWNER ] /�
DATE PERMIT ISSUED:
DATE COUPLIANCE ISSUED:
VARIANCE GRANTED: Yes
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HE LTH
i' :
Appliration for Disposal Workii Tons rnrtion Prrntit
Application is hereby made for a Permit to Construct Q/f or Repair ( ) an Individual Sewage Disposal
System at: 1 y 11
Gt>�L� , �-� lAa-��,.� °---�5---• Lv T 8
L c ion;A� sar o. Lot No.
,.a ........ wn Address
...:...........O
Installer Address GG
Type of Building Size Lot..... .82.&-...Sq. feet
U Dwelling—No. of Bedrooms.....�................................Expansion Attic ( ) Garbage Grinder ( )
Other—Type e of Building No. of persons............................ Showers
a, YP g -••---•-•----••------------- P ( ) — Cafeteria ( )
P4 Other fixtures .........................--
- ---------------------------------------------------•-----------.... ---------.----..
W Design Flow......!?. ..................... ...gallons per person per day. Total dpjily flow..................•......_.._.........._....�lons.
WSeptic Tank—Liquid capacity/.__gallons Length....EL... Width.......&..... Diameter................ Depth.................
x Disposal Trench—No..................... Width.................... Total Length..........4........ Total leaching area....... ._....�._sq. ft.
3 Seepage Pit No........ ........... Diameter...../.7 ....... Depth below inlet.... ............ Total leaching area......,C ft
Z Other Distribution box ( ) Dosin tank ( )
'-' Percolation Test Rests -Performed b .. GsJ �T................. �' ._
Y * ..( /.. � �- Date r...
,`4a Test Pit No. 1._ �..minutes per inch Depth of Test Pitt.......... Depth to ground wateryu.�......G....
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
----------------------------------------------------------------------------^--•-----------------.........................................................
0 Description of Soil................................. ,- ??
V -.r.C_ }'v_..I L.r!....K�...---------•--•---••--••--••... ..........•.....•..
. ......
UW ......--••••-----••----....-•-----------------------•--------•------------------------•-•---••----•-----------••-------------------•---•----•---•••---•---•-••----...-------•--•--•-----•----......-••--
Nature 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 Ti I'LL; 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. I
Date
Application Approved BY-•-••..0 %-Z- .. .... -----------------•----------- ........
Date
Application Disapproved for the following reasons:.................................................................................................................
.................-.......................................................................................................................................................................................
GA Date
Permit No........0..L:---�'-r..-(-n:..----•-----......•.. Issued........................................................
Date
Y '
THE COMMONWEALTH OF MASSACHUSETTS
- BOARD-OF HEALTH
)(5 ............OF.......
Application for Disposal Works Tonstrnrtion 'prrmit-
Application is hereby made for a Permit to Construct Q.4 or Repair ( ) an Individual Sewage Disposal
System at: 0-4�42
�A ,,. . C..I,.............. ...........wT......8--------- .... ---------------------------------
........
L caEion-Address or Lot No.
5.........................._... .....---------------_...-
Owner Address
Installer Address
Type of Building 2 Size Lot._)�R�.,�._..Sq. feet
Dwelling—No. of Bedrooms..... ................................Expansion Attic ( ) Garbage Grinder ( )
a`4 Other—T
ype of Buildin g ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
d Other fixtures . ..............................................
W Design Flow_....�?.�____________________________gallons per person per day. Total daily flow.___._._.____________......._.__....._.__..gallons.
WSeptic Tank—Liquid capacityJ _.gallons Length.... Width... Diameter................ Depth.5.:v_..._.
x Disposal Trench—No..................... Width...... Total Length.._......_f_____.__ Total leaching area.........w._...._._sq. ft.
3 Seepage /....._.__.. Diameter.......!..._.... Depth below inlet._..-_........•. Total leaching area.....ytr.aq:
See a-Pit No..____.. .
Z Other Distribution box (/) j Dosing tank ( )
aPercolation Test Results/ \ Performed by.... a_�`..___L_t�. _ =� Date_..7:: ..... _
Test Pit No. l...4-._Z .minutes per inch Depth of Test Pit..1.4 Depth to ground water. (1.GAZ.G
44 Test Pit No. 2................minutes per inch Depth of Test Pit............._...... Depth tiro—ground water........................
O Description of Soil.....................................•_----
..... ..................................................................
V ...-- •--•-•--•••••----•-••-•......---•-...--•-•-•--••-----_.....
W
VNature of Repairs or Alterations—Answer when applicable...............................................................................................
- ------------•---•-••-•--------•--•---••---------------------------------------------------......------------.....---.._..----•---
Agreernent:The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TIT?is 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..- -------- ke.................... / Zq/,
C Date
Application Approved By.......... •��--4sr - �.............................. .__-....1*-- -)'�r'-.6.!1..--
Date
Application Disapproved for the following reasons--------------------------•-----••----------------------•------•-------------•----------.........•-•-............
...........................•--•---•--...------------••-------•-•---------.....-------------••------•--....---•-•-------------------•---..:...-------------------•--•---•-------------....---•-••---..._..
Date
�.7a-
Permit No........ ..f�.L-.............••--•----......_.._..._.. Issued....................................................... -
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..........�.ram: a:t............OF.............. ..................................
Trrtifiratr of Tomplittnrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed (A) or Repaired ( )
by------•.--------•-.---•. ----------•-••-•-•--•-•--- -----------------------------------------•-----------------------•-••-•----•-----•------•-----------•-----•---------------------.-----
Iynsstaller
at................. ..[% ��f ._!�'- fi�t:....-•----- yl�d
has been installed in accordance with the provisions of TI'i'L: 5 of The State Sanitary Code as,described in the
application for Disposal Works Construction Permit No.___.��_._�.-2 n...... dated................................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATIS��A,CTORT.
DATE.......................��-. ` __I........................................
!----------------------- Inspector..................... ......---.._..-.....-----•-•----.............--
L�
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
�•rc, /+ t•;�1!1�:...........OF................ ............................. ,--�
No.... FEE....../-
Disposal Vorks Tonotrnrtiorc Wrmff
Permission is hereby granted... ......... .............................................................................
to Construct ( ) or Repair ( ) an Individual Sewage Disposal System
atNo. a__,- -- --------- ------=-------------------- ...............................
Street
as shown on the application for Disposal Works Construction Permit No--- _a7) Dated_...._._--__..f.1..�.�t-=T
r v.� '
DATE. / ! J Board of Health
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