HomeMy WebLinkAbout0081 OST.-W.BARN. RD - Health A= 120 001 015
r
DATE 10/26/06
PROPERTY ADDRESS 81 ost-west Barnstable Road
MA 02655
D f00
On the above date, the septic system at the address above was
Inspected.
This system consists of the following:
1., 7- 1500 gaiion zept.ic tank
2.s I-Diat2.igut.ion Box
3. 2- 500 gaiion cham9ean
Based on inspection, I certify the following conditions:
4.- 7h-ij i,3 a 7.it.�e V zzpt-ic zyztem
5., Septic system .is .in 122opea Woak.ing gadea at the /22e,6ent
t-iMe.,
il
SIGNATURE
Name: Robert A. Paolini
Company: Joseph P. Macomber & Son Inc
Address: P. 0. Box 66 s ,
Centerville, Mass 02632
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Phone: 508-775-3338 or 508-7.75-6412
JOSEPH P. •.MACOMBER & SON, INC.
Tan ks-Cesspools-Leachfields
Pumped & Installed
Town Sewer Cbnnections
P.O. Box 66 Centerville, MA.02632-0066
775-3338 775-6412
•
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT-OF ENVIRONMENTAL PROTECTION
TITLE 5
OFFICIAL INSPECTION FORM-.NOT FORVOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PARTA
CERTIFICATION
Property Address: ..81 Ost—West Barnstable
Osterville MA 02655
Owner's Name: John Arthur
Owner's Address: Sam
Date of Inspection: 1 n j?G/n 6
Name of Inspectort (please print) Robert A _Pao.l"ini
Company Name: g_ 1)_Pacom elt S.o.n Inc.
Mailing Address:
Cent g ie le, a z.-02632
Telephone Number: 5 0 8-7 7 5=3 3 3 8
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 the inspection.The inspection was performed based on my
training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP
approved system inspector pursuant to-Section.13 340 of Title 5(310 CMR I. 000). The system:
XXX Passes -_
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
WFi
-r
0 Inspector's Signature: Date: o
The system inspector shall submit a copy of this inspection report to the.Approving Authority(Board of Health or
DEP)within 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
DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving
authority.
Notes and Comments
""This'report only describes conditions at the time of inspection and under the conditions of use at that
. time.This inspection does not address how the system will perform in the future under the same or different
conditions of use.
Title 5 Inspection Form 6/15/2000 page 1
Page 2 of 11
OFFICIAL INSPECTION-FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM r—
PART A
CERTIFICATION(continued)
Property Address: 81 Ost—West Barnstable Road
Osterville MA 02655
Owner: John Arthur
Date of Inspection: 1 o f 2 F n F
Inspection Summary: Check A,B,C,D or.E/ALWiAYSLcomplete•all of Section:D
A. System Passes: qe
Nr, I have not found any information which irfdicates`that•any of the failure criteria described in 3 10 CMR.
15.303.or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below.
Comments:
S2R 314,ilem, LA .n Anna non mn,7k nn n4CL,2 i Q (. t�Q� Q6Qnf fimQ y�
B. System Conditionally Passes:
AALa_ One or more system components as described in the"Conditional.Pass"section need to be.replaced.or
repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass.
Answer yes,no or not-determined(Y,N,ND)in the for the following statements.If"not determined"please
explain.
No The septic fault is metal.and.over 20 years old*or the septic tank(whether metal or:not)is:structuraIly
unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the
existing tank is replaced with a complying septic tank..js_gpproved.by the.Board of Health.
*A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
Observation of sewage backup'or break out or high static water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection..if(with
approval of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled bor replaced
ND explain:
Al The system requited pumping.more than 4 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
ND explain':
2
Page 3 of 11
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 81 Ost—West Barnstable Road
Osterville MA 02655
Owner: John Arthur
Date of Inspection: 1 0/2 6/0 6
C. Further Evaluation is Required by the Board of Health:
NO Conditions exist which.require further evaluation by the Board.of Health in order to determine if the.system
is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the
system is not functioning in a manner which will protect public health,safety and the environment:
No Cesspool or privy is within 50 feet of a surface water
/L 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 any)determines that the
system is functioning in a manner that protects the public health,safety and environment:
_LLD The system has a septic tank and soil absorption system(SAS).and the SAS is within 100 feet.of a
surface water supply or tributary to a.surface water supply.
x�e The system has a septic tank and SAS and the.SAS is within a Zone 1 of a public water supply.
A The system has a septic tank and.SAS and the SAS is within 50 feet of a private water supply well.
_ The system has a septic.tank and SAS and the SAS is less than 100 feet-but 5Q-feet or more from a
private water supply well". Method used to determine distance viz ua e
"This system passes if the well water analysis,performed at a DEP certified laboratory,for colifonn
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,provided that no other
failure criteria are triggered.A copy of the analysis must be attached to this form.
3. Other:
3
Page.4 of 11
OFFICIAL INSPECTION FORM—NOT FOR:VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSs'EM INSPECTION:F.ORM .
PART A_.
CERTIFICATION(continued)
Property Address: 81 Ost-West' Barnstable Road
Osterville MA -02655
Owner: John Arthur
Date of Inspection: 1 n/2 ti/n
D. System Failure Criteria applicable to all systems:.
You must indicate"yes"or"no"to each of the following:for all inspections:
Yes No
_ . Backup of sewage into facility or system component due;to 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
X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
X Liquid depth in cesspool is less than 6"below invert or available,volume is less than'/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
y Any portion of the SAS,cesspool or privy is below high ground water elevation.
_ y Any portion of 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 al Zone 1 of a public well-
,y Any portion of a cesspool or privy is within.50 feet of a private water supply well. �.
,y 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..[This system:passes if the well water analysis,
performed at a DEP certified laboratory,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,provided that no other failure criteria
are triggered.A copy of the analysis must be attached to this form.]
10 (Yes/No)The system fails.I have determined that one or more'of the above failure.:criteria exist as
described in 310 CMR 15.303,therefore the system fails.The system owner.should contact the Board of
Health to determine what will.be necessary to correct the failure.
E. Large Systems:
To be considered a large system the system must serve.a.facility with a design flow of 1.01000 gpd.to 15,000.
gpd.
You must indicate either"yes"or"no"to.each of the following:
(The following criteria apply to large systems in addition to the driteria above)
yes no
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
_L_ 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
If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered
"yes"in Section D above the large system has failed.The owner or operator of any large system considered a
significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
15.304.The system owner should contact the appropriate regional.office of the Department.
4
Page 51of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACEISEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 81 Ost—West Barnstable Road
s ervi e MA 655
Owner: John Artnur
Date of Inspection: 6 0 6
Check if the following have been done.You must indicate"yes"or"no"as to each of the following:
Yes No
x Pumping information was provided by the owner,occupant,or Board of Health
X Were any of the system components pumped out in the previous two weeks?
. Has the system received normal flows in the previous two week period?
_ X Have large volumes of water been introduced to the system recently or as part of this inspection?
Were as built plans of the system obtained and examined?(If they were not available note as N/A)
_ Was the facility or dwelling inspected for signs of sewage.back up
X _ Was the site inspected for signs of break out
X _ Were all system components, excluding the SAS, located on site?
X _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition
of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum?
_ _ Was the facility owner(and occupants if different from owner)provided with information on the proper
maintenance of subsurface sewage disposal systems? _
The size and location of the Soil Absorption System(SAS)on the site has been determined based on:
Yes no
_X._ Existing information.For example,a plan at the Board of Health.
Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance
is unacceptable) [310 CMR 15.302(3)(b)J
5
Page 6 of l 1
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 81 Os.t-West Barnstable Road
s ervi e 655
Owner: JOhn Arthur
Date of.Inspection: 1 0/2 6/0 6
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): 3 Number of.bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203 (for example:110 gpd x#of bedrooms) 330
Number of current residents:L
Does residence have a garbage grinder(yes or no): rLeb
Is laundry on a separate sewage system(yes or no):Aa. [if yes separate inspection required]
Laundry system inspected(yes or no):_ _
Seasonal use-(yes or no):n.r, a 00q = 1 q gi opo-Ra))ons G R D 4S7,&q
Water meter readings,if available(last 2 years usage(gpd)):ap(25 09. D® g" ) cm_9 C, D= 57S' 9�
Sump pump(yes or no):�Q
Last date of occupancy: a 2 e-z e n
COMMERCIAL/I VbUSTRIAL
Type of establishment: n/a
Design flow(Based on 310 CMR 15.203): „1n gpd
Basis of design;fow(seats/persons/sgft,etc.): „/n
Grease trap-present(yes or no):-a[a
Industrial waste holding tank present(yes or no):—a/a
Non-sanitary waste discharged to the Title 5 system(yes or no):-n/a
Water-meter readings, if available: n/a
Last date of occupancy/use: . n/a
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information: n/a
Was system pumped as part of the inspection(yes or no): h
If yes,volume pumped:15 0 0 gallons--How was quantity pumped determined? me a�3' u"zecl
Reason for pumping:
TYPE OF SYSTEM
x 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)
_Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be
obtained from system owner)
_Tight tank _Attach a copy of the DEP approval
_Other(describe):
Approximate age of all components,date installed(if known)and source of information:
8 Ueaitz a,39uiit
Were sewage odors detected when arriving ai the site(yes or no):—moo
6
f
Page 7 of 11
OFFICIAL INSPECTION FORM—NOT FOR.VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM"INFORMATION(continued)
Property Address: 81 Ost-West Barnstable Road
Ostervillb MA 0265.5
Owner: John Arthur
Date of Inspection: 1 0/2 6/0 6
BUILDING SEWER(locate on site plan)
Depth below grade: 2 6"
Materials of construction:_cast iron x_40 PVC_other(explain):
Distance from private water supply well or suction line: ZOf,ee et
Comments(on condition of joints,venting,evidence of leakage,etc.):
20 n1.6 r/,1?1?onn fight no Caaka Jig, 1/gra4,ar 4,%9 &94 4em'3 gent
SEPTIC TANK: locate on site plan) 1500 ga e i o n z
Depth below grade: I »
Material of construction: concrete_metal_fiberglass polyethylene
other(explain)
If_tank is metal list age:_ 'Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of
certificate)
Dimensions:10.' 6" L, 5 ' R"H, 5 ' R" Gl
Sludge depth:_n n n o
Distance from top of sludge to bonvm of outlet tee or baffle:rz o n o
Scum thickness: rz o n p
Distance from top of scum to top of outlet tee or baffle: non e
Distance from bottom of scum to bottom of outlet tee or baffle:
How were dimensions determined: ,n o n A/1"ad
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of.leakage,etc.): _-
Pump .tank eveay yea2., Gaagage dizpozae .i,6 Raezent. lank .iz
,3t2uctuaaiiU zounrl , Tnpot nnr/ n,if Oot. tgg4 Q Zo E;; 7449ele-'
GREASE TRAP: (locate on site plan)
Depth below grade:_
Material of construction:_concrete_metal_fiberglass__polyethylene_other
(explain):
Dimensions:
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 baffle:
Date of last pumping:
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.):
gaeabe - /ItaI2 i.6 nal pao. enf
7
Page 8 of 11
OFFICIAL INSPECTION FORM.—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 81 Ost—West Barnstable Road
Osteryille MA 02655
Owner: John Arthur
Date of Inspection: 10.19 6.10 6
TIGHT or HOLDING TANK: n o (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:
Material of construction: concrete metal fiberglass polyethylene, othei(explain): .
Dimensions:
Capacity: gallons
Design Flow: gallons/day
Alarm present(yes or no):
Alarm level: Alarm in working order(yes.or no):
Date of last pumping:
Comments(condition of alarm and float switches,etc.):
Tight oa ho-ed.ing .tank ate not ?2ezen.t
DISTRIBUTION BOX: y e z(if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: 0
Comments(note if box is level and distribution to outlets equal,any evidence.of solids carryover,any evidence of
leakage into or out of box,etc.):
[3ox .i,3 2eve eo Box has I iate za eo No .6.i na .6 oZ zo eid ca22y ove2
oa Peakage .in o2 out off' Pox
PUMP CHAMBER: no (locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no):
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
1 uin2 champ Pa i,t nol ,�nv.snn
' � I
8
Page.9 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION.FORM
PART.C
SYSTEM INFORMATION(continued):
Property Address: 81 Ost—West Barnstable Road
Osterville MA 02655
Owner: Jnhn Arthur
Date of Inspection: 10.12 6.10 6
SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required)
If SAS not located explain why:
/_oozier .too 'payo 90
Type
leaching pits,number:_
z leaching chambers,number-25 D 0, ga-e.,eo n,;.
leaching galleries,number:
leaching trenches,number,length:
leaching fields,number,dimensions:
overflow cesspool,number:
innovative/alternative system Type/name of technology:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,
etc.):
Loamu .to medium .sand no z igAz oZ 4al ea ze o2 12ond.inq , .to.i P�
ate d2y vepeta�_ion .i.6 no2ma o
CESSPOOLS: no (cesspool must be pumped as part of inspection)(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(yes or no):
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
E 6 4 474 e e 3 68% fit a 4 79,ge,3efi6
PRIVY: no (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.):
nl))4i ;A nnf �2no.tonf
9
Page 10 of I 1 _
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBS-17ACE SEWAGE-DISPOSAL SYSTEM INSPECTION FORM
PART C .
SYSTEM INFORMATI.ON(continued)
Property Address: 81 Ost—West Barnstable Road
Osterville MA 02655
Owner: John Arthur
Date of Inspection: 1 0/2 6/0 6
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at Ieast two permanent reference'landmarks or
benchmarks.Locate all wells within 100 feet. Locate where public water supply enters.the building.-
0
' I
10
Page 11,ef 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART.0
SYSTEM INFORMATION,(continued)
Property Address: 81 Ost=West Barnstable Road
Ostervillb MA 02655
Owner: John Arthur
Date of Inspection: 1 n.12 ti/n 6
SITE EXAM .
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water., feet
Please indicate(check)all methods used to determine the high ground water elevation:
NO Obtained from system design plans on record-If checked,date of design plan reviewed:
u e,s Observed site(abutting property/observation hole within 150 feet of SAS)
y e 6 Checked with local Board of Health-explaima zs a l P.t e a 2r]
no Checked'with local excavators,installers-(attach documentation)
e�Accessed LlSGS database-explainA l-;6 ./2: O wrz.'9 a 1t n s.t a&i e.,m a.,u,3
/- You must describe how you established the high ground water elevation:
11,6ed • Ca/2e Cod Commizion 1datea 7agie CoAtouaz And %ugeic lVatea SuI212Qy
Oe2� head paotection aaea,3 mal2o Sent 1995
�ate2 aezousiceh oJP.ice cape cod commzzzorz
Top of Grouna
Leaching
feet
C
Groundwater: Feet Below Bottom of Pit High Groundwater Adjustment 1.8 ft per Frimpter Method
Therefore,the vertical separation distance between the bottom
of the leaching pit and the adjusted groundwater table is
feet.
11
'DOWN OF BARNSTAB•LE' 130AAD QF IIEAITH �
-49UIISURP'ACE SEWAGE I)ISPOSAI, AYSTFM INSPECTION FORM - pART D.•- CEti�`F1Pit.AT.ION
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-TYPE 01 PAINT 01,$ARbY-
PRO.PERTY r"PI*CTIs11
STREET ADDkZSe 81 .Ost-West Barnstable Road `Osterville . 02655
ASSESSORS MAP, BLOCK''AND 'PARCE'L _
OWNER's NAME John Arthur'
PART' D 081?TIFSCAT30N
NAME 'OF INSPECTOR _ 'Rob:eirt::A:Tao3i'n
COMPANY NAHE �7o'S'�t�21• P:: .Mai�csmha+.r. . �:. S`On T'i�c
COMPANY ADD,RFSS f t'O : ox>::66'.C'�r .0_rViI * MA- 0 0-2-006�
Town.or ty..
.BtaL�• L P
COMPANY TELEPHONE ( 5 08 7.5 .- 3338 FAX (' 508',$I90 f 578
CURT'I'FICATION. STATEMENT
I certify that; I 'heive persoriailiy •ins'peoted ..the Q@wage 'digpo�a . system at
this address and that' ;tbe' information reported .is true . 4000ra•te•, grid
omplete aq of the time a,�P'�inspection,• The in0pe¢tl0rn waa performed and any
recommen�lattons l�egard.ing .upgrade•, .Ma•inten4nce �'. and r' 04.ir •are• eongis'tent
with my trainipg and exP.erience in the proper fun'eti.'on' acid maintenanoe of on-
site sewage disposal. systems,
Check one;
System PASD _
The inspection which •.I. have .eondugte� has ,,n'v't' found any ,nformation .
which indicates that' the system' fails to ' ade j.:uate,ly pVotect .publi•o
health or the envi•ro �ment as defined in. .3l'0 CMR. l'g- 3�0.3•, My fAiiu•re
cri•ter.ia nbt ••ev&1unZ0' are as staffed in the FAILURV CRI' ERIA .seatiofl o•f
this, form.
System FAILED* `
The inspection which I have aaiidM,ted 'has '-found that •the oyste.m fails to
Protect the public heal th Rnd the enV4ronm' en•t ' in acoo'rdanee with Title
5 , 310 CMR 16 . 3051 and as • specificalIY noted 'on -PA C .- . FAILURE
CRITERIA of this inspection .form,
Inspector Signature- '
ignature Dade
nd• copy of this certl f iogtl4-,n must •he �7rovide'd ,to the .QWN tt, t BUYER'
where appli'.oable) -and th1� 33QARD or HEALTII$
* If the inspection FAIL'Lb., 'thb •6wnej,',Ox�"opepator s.hei],� , upgx?ade�•tihe eyetem•
within one year of the da't•e of the inapection, unless. al'loweed Qr' requi.,red
n t.harw{se. as urovided in' �;i40 CMR 16 , 305 ,, '
I