HomeMy WebLinkAbout0072 HAMBLIN'S HAYWAY - Health 72 HAMBLIN'S HAYWAY;
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Commonwealth of Massachusetts.
Executive Office of Environmental Affairs John Grad
D.E.P. Title V Septic Inspector
Deportment of P.O. Box 2119
ii.Environmental Protection Teaticket, MA G
WUllam F.weld (508) ��=�8
Trudy Coxe ►
sKr«ey,EOFA
SUBSURFACE SEWAGE DISPOSAL YSTEM INSPECTION FORM APR 3
ART A Q 1996
CERTIFICATION t
m,Its
Property Address: 11. `, \t�°}�G fAlSte�Adtl'ress of Owner:
Date of Inspection: (If different) '
Name of Inspector: Z.Li� CIIG F
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:
L,1%a�sses
_ Conditionally Passes.
Needs Fu her valuation By the local Approving Authority
Fails
Inspector's Signature: Date: [.� 12—L41 a(p
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 re-pon to the appropriate regional office of the Department of Environmental Protection.
The original should be sent to the s�stem,owner anu copies sera lu the bu)er, if applicable and the appro,ing authority.
INSPECTION SUMMARY:
ChecGA B, C, or D:
A) SYSTEM PASSES:
ave 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,
e) 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
One VAnter Strain a Boston,M+tssaahusetts 02108 FAX(611)W&1049 • Telephone(617)282.5=
Printed on Rwyded Pape
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM .
PART A
CERTIFICATION (continued) "
Property Address: ^ (�
Owner:
Date of Inspection:
81 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
CJ 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
ENVIRONNIE.NT:
_ i ne siem nd> a �eUUC lanik anus >uil dUDorption systen, al d is w4ll1' 100 fEet iG a Su10-:e •'void "Pt"y to Z
surface water supply.
_ The s�s!en- ha, 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-stem 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 w
D) 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.
_
an overloaded or do8ge d SAS or cesspool.
Backup_nfsewage into facility or sYstom component due to
_ Discharge or ponding of effluent to the surface of the.g►ound or surface waters due to an overloaded or clogged SAS or
cesspool. _. t
(revised .8/15/95)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
;erty Address: pp
►er:
of Inspection:
YSTEM 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.
,.RGE SYSTEM FAILS:
The following criteria apply to Barge 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 11 of a
public water supply welli
owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program
irements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.
iced 8/15/95) 3
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION, FORM
PART B
CHECKLIST
Property Add ess: a, M��n �tLZ�Wt
Owner: �,��� \`
Date of InspedRfri: y I Zy 1 C{t,p
Check if the following have been done:
_Ly.unping information was requested of the owner, occupant, and Board of Health.
J,yert2 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.
—h built plans have been obtained and examined. Note if they are not available with N/A.
L-T-N facility or dwelling was inspected for signs of sewage back-up.
!:fie system does not receive non-sanitary or industrial waste flow
The site was inspected for signs of breakout.
L_, system components, excluding the Soil Absorption System, have been located on the site.
_e e 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.
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
The !';Itn, ov n (a,f if diffarpnt frn n owner) were provided with information on the proper maintenance of Sub-
Surface Disposal System. .
(revised 8/15/95) 4
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property A dress:
Owner:
Date of Inspection:
LAlZL�`Cit,
FLOW CONDITIONS
RESIDENTIAL-
Design flow: ),_X)_gallR,ns
Number of bedrooms:
Number of current residents:
Garbage grinder (yes or no): �5
Laundry connected to systn(yes or no):_ S
Seasonal use (yes or no):_
Water meter readings, if available:
Last date of occupancy:
COMMERCIAUINDUSTRIAL• r'11
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 RtORDS and source of information:
SA has nc�t k in �4, a,
_ n+Y�Q_ \ QSs �_a CL V_
System pumped as pan of inspection: (yes or n�_
If yes, volume pumped gallons
Reason for pumping:
TYPE OF SYSTEM
t----5'eptic 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)
APPROXIMATE AGE of all components, date installed (if known) and source of information:
Sewage odors detected when arriving at the site: (yes or no)
(revised 8/15/95) 5
s
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property A ress: " �c o
Owner:
Date of Inspection:
11-Zti�ic�e
SEPTIC TANK:-6--�
(locate on site plan)
Depth below grade: �� t
Material of construction: _kt6ncrete _metal _,FRP—other(explain)
Dimensions: tt III
Sludge depth: tf
Distance from top of sludge to bottom of outlet tee or baffle:_ t
Scum thickness:_
Distance from top of scum to top of outlet tee or baffle: L t
Distance from bottom of scum to bottom of outlet tee or baffle: I I
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, epth of liquid level in relation to outlet invert, structural
integrity, evidence of leakage, etc.) c1
S
GREASE TRAP:
(locate on site plan)
Depth below grade:
Material of construction: _concrete _metal _FRP —other(explain)
Dimensions:
Scum thickne».
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom no crw m t- bottom of outle! tee or baffle
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.)
(revised 8/!5/95) 6
r
SUBSURFACE SEWAGE DISPOSAL SYSTEM.INSPECTION.FORM
PART C
SYSTEM;INFORMATION (continued)
Property Address: d Ylf\)CAV\ w
Owner: ,- �\LC�
Date of Insp 1
TIGHT OR HOLDING TANK:
(locate on site plan)
Depth below grade:
Material of construction: _concrete_,metal ,,,_FRP other(explain)
Dimensions:
Capacity: gallons
Design flow: ¢allons/day
Alarm level:
Comments:
(condition of inlet tee,.condition of alarm and float switches,.etc.)
DISTRIBUTION BOX:
(locate on site plan)
Depth of liquid level above outlet invert:
Comments: � '�\
(note if level and distribuliun 1� eyudl, e� deilCt of solid, carr)o,er, e%idence of leakage into or out of box, etc.) 1 J"" l
PUMP CHAMBER:L �..
(locate on site plan)
Pumps in working order.(yes or no)
Comments:
(note condition of pump chamber, condition of pumps and appurtenances, etc.) _
(revised 6/15/95) 7
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM -
PART C
r� SYSTEM INFORMATION (continued)
Property A",ess:. 1 V\ \�
Owner: ��G C�l
Date of Inspection`\ V
SOIL ABSORPTION SYSTEM (SAS):y,,-'
(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: l 1
leaching pits, number:� J� C5 \\(A_N 1��l� Vct'U_N .�l 1—•
leaching chambers, number:_Je,
leaching galleries, number:
leaching trenches, number,length:
leaching fields, number, dimensions:
overflow cesspool, number.
Commentsi (note�e condition of soil, signs of hydraulic failure, level of ponding, non n of vegetation,etcJ �Q C
Y,NG
(24(2iv
(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 ground•,,a:c-.
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: 4trnens.ions;
Depth of solids:
Comments: (note condition of soil, signs of hydraulic failure, level of ponding,condition of,xegetaton, eta.)
(revised 8/15/95) iS
J �
SUBSURFACE SEWAGE DISPOSAL SYSTEM.INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property ress: ��l,—
Owner: io�i c�
Date of Inspect L_1 a yt
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100'
e
Io�A
o I�
tA
DEPTH TO GROUNDWATER
Depth to groundwater: feet
method of determination or approximation:
9
(revised 8/15/95)
�C
LOCATION SEWAGE PERMIT
/ NO.
Lc�T 2z }1f} m (3c ,rV5 jlg7wr9 / X7' //f,
VILLAGE p//� pcl
Mfi2ST odv m i t c.S
INSTALLER'S NAME A ADDRESS
J01-1 N 4L TO
I U I L D E R OR OWNER
I
DATE PERMIT ISSUED
53 � j0 - 84-
DATE COMPLIANCE ISSUED
i
OF
1t4ow21
` m
C1
� M t
�1
'S 1
d�
1
1
w TOWN OF BARNSTABLE
LOCATION SEWAGE #
VILLAGE ASSESSOR'S MAP & LOT
INSTALLER'S NAME & PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY:(type) (size)'
NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER
BUILDER OR OWNER
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED:
,VARIANCE GRANTED: Yes No
11-7
POO �
1
boo (L s
Board of Health
Town of Barnstable
P.O. Box 534 F�$....5..................
TH A� r{a6Ai U SETTS
rHSOAR® OF HEALTH
............. ...................-.........OF........................................--------........----......_..__::........-
Appliration for Milfatial Morks Tonstrurtinn Vamit
Application is hereby made for a Permit to Construct ( 4or Repair ( ) an Individual Sewage Disposal
System t: T
G.f.!�1:3...... ...... �.v �.1 -------------��--`------................................
Location-Add ess `
or Lo .
.._ .... 1�11�.... ... =... ....._... fill :.. '�1 _.....}}..1���...... .........--
W �® // Address
._.../'�`' .:...........•---•-••-.•. ....... ....... ...--•------._....................------•-••--•....
Installer
Address
U Type of Building Size Lot_4Y, 22-----Sq. feet
Dwelling—No. of Bedrooms.__...___3.............................Expansion Attic ( ) Garbage Grinder ( )
Other—T e of Building ...._.. No. of persons............................ Showers
a YP g --------------------- P ( ) — Cafeteria ( )
dOther fixtures ..--•-••-•----•--------------••.....•-----------....•..•-•--•••--••••--•••-•--•------................__....
W Design Flow............_9P ......................gallons per person per day. Total daily flow................3.�5..�.......•..__..gallolis.
WSeptic Tank—Liquid capacity/QQi gallons Length___-t ..___. Width...... .__.. Diameter________________ Depth.....'111......
x Disposal Trench—No..................... Width............. Total Length.................... Total leaching area•-._.----.•_•------sq. ft.
� �Seepage Pit No______ __ ______ Diameter-. .. o
.___ �-�._. Depth below mlet___.:�a a..._. Total leaching a ea..._.._.�._sq. ft.
z Other Distribution box ( Dosing tank ( / �
'-' Percolation Test Results Performed by-__ -_. _WGcX• l - Date......
!�ter.�__
6
14 Test Pit No. 1.�>.7rminutes per inch Depth of Test Pit/,VV�.... Depth to ground
(i Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
�•,
W -- -- -- - - --
O Description of Soil..... f 77 /! C -- - -- - -- ..... --
V „ ... ---•---•................•••-••---.....----.------------------------•---------•-------------•-----•-•-•----•-- --------•-•---•-------•-------•--------------------•----------••------------
W
V Nature of Repairs or Alterations—Answer when applicable................................................................................................
••----••------•-----------••••••---••-•-------•.....................•-----......•---.....---••-----•-••-•-•-----••--••----••---------•---•----•-----•----------•-••-••------------......_•--•-----------
K
Agreement: '
e: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Sanitary Code—The undersig d further agrees not to place the system in _
operation until a Certificate of Compliance has b96rk issued by the a of health.
Sined ... ............................
Date
Application Approved B _..,// �'_
" Application Disapproved for the following reasons.•----•-•••-•--•--•---------••-•-••••----•-------••••-----------•••......------•--•---------•Date
••....._--•---
r..
................................................................................................................._.................•.---...................--.--............_.....---......._.M.........
Date
Permit No....................................
....................... ------•-••----•••---- Issued------.....--••----------------•-••-•----•-••••-•--=--
Date
yR
----------------------
N : "-------,� .......J...........'
�+ THE.COMMONWEALTH OF MASSACHUSETTS
"N BOA-RD OF HEALTH
....................................OF.-...........-..--....--.-...-......
Appliption for Dhipvii al Works Tonotrnr#ion runfit
li
Application is hereby`"made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
Zcation-Address
- -/
••or Lot No.
•�_, " , r .._R...............
a ----•--- � ,*�WX ____________________ -•----•--••-•- ....... �` ...........................___........._.____...
taller ,Address
K •- �..r
d Type of Building Size Lot_ff"!'. ------Sq. feet
U Dwelling—No. of Bedrooms__.______________________________________Expansion Attic ( ) Garbage Grinder ( )
a� Other—T e of Building No. of ersons____________________________ Showers —
YP g ------------------------•-•• P ( ) Cafeteria ( )
ti Other fixtures --! gallons per person per day. Total daily y flow____________ _____ _.______.__._• to
w Design Flow 5^S ._ Widthc
WSe tic Tank—Liquid capacity_,X:ac gallons p L ngth____�__.___. _.._ /.__._ Diameter_______________ Depth_..� ns:
x Disposal Trench No_____________________ Width.................... Total Length...._._:__........... Total leaching area....................sq. ft.
Seepage Pit No....../........... Diameter..Z?.. Depth below inlet___: ...... .Total leaching area__: '_ ...sq. ft.
Z Other Distribution box ( ,.) Dosing tank
aPercolation Test Results Performed by-__� .__._ __.r _.-!4_, ..........._..,- ------ Date------� '�#�` ?..........
4 -4
Test Pit No. 1 __Z—:minutes per inch Depth of 'Vest Pit �'`�__.__.___ Depth to ground water'
_A-----�
fZ4 � Test Pit No. 2................minutes per inch Depth of Test Pit.,___._._._________. Depth to ground water.______..._____.___._._.
Descri tion,of Soil----• �•'- .-• "
r
P ..
- - _ - --• -• ---- �;. - ----------•-------•---•--------------•--------•--•-----------
c,
w
x -------------------------------------------------•-------•--•••-•••-------•---•--•---•----••----•---•-•--------•-•••-------------------•=--=-----•-••--------------•---•••••-------------......._---•--
U Nature of Repairs or Alterations—Answer when n applicable...............................................................................................
------------------------------------------------------------•-----•••--------•••----'-......------------••------•-•---•-••••-----•-•----•---------•---•-•----_•---------------••--•-----.....--•--_...--
Agreement: ..,:
-The undersigned agrees to install the aforedescribed Individual Sewage}Disposal System in accordance"with
the provisions,of II.I1 5 of the State Sanitary Code— The undersigned further agrees not to place the system in ..
�u operation until a Certificate of Compliance has been issued by the board f health
,.
Signed -...._•-- •-- + ..
._�a�
Application Approved BY . ..
g'.; I&N -----
Application Disapproved for the following reasons: -----:•_____________________________________________________________________•---•__•.__-_--•••--_
--...._..-•-----------••--••--------------------------------------------------------------- `
--------------------------------- (-•----•----
Date
PermitNo......................................................... Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
...........................................OF.....................................................................................
Urrtifiratr of Tontplinnrr
u
THIS IS TO CERTIFY, ThaPthe Individual Sewage Disposal System constructed ( ) or Repaired ( )
bY--------•----------------- ......................................................................................................-............................'.............
Installer
at........................... „ . -----
%
has been installe m accordance with th p ns of _1F -- 2h'eg toe ani ary Code as described in the
application for Disposal Works Construction Permit No---------J04Y_„_ _ __'��`` ____ dated.....................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE ®NSTRtlE® AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY. 'y
DATE...................... L � f..---•--_._. Inspector -•---.............................................................
.f
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..........................................OF.........----.._..._.__....... _.-.
00,
No.. L�„r�. `« FEE j� -
_t�
Movall al Works Tonotrnrtttion prrntit
Permission is hereby granted.................... • --•• ---- -----------•••-•••---•-• •••----• .......... ------
to Construct ( ) or„Repair ( ) an Indivi ewage Disposal System
atNo.........................
_ -------------------------------------•--
as shown on the application for Disposal Works Construction%Permit No.............. Dat0d..........................................
----------------•----....---------------•------._
DATE ----•- �
------•-•----------••---•----- ---------------- ' Board of Health
FORM 1255 A. M. SULKIN, INC., BOSTON
4i
N