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HomeMy WebLinkAbout0037 HUCKLEBERRY LANE - Health 37 Huckleberry Lane Marstons Mills P I ( 1 i COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS kl ip DEPART>D�IENT OP ENVIRONMENTAL PR CEIVED SEP 3 2002 TOWN OF BARNSTABLE HEALTH DEPT. TITLE S OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PARTA CERTIFICATION Property Address: 37 Huckleberry Lane Marstons Mills Ma.02649 Owner's Name: Karen Hayden Owner's Address: SAME Date of Inspection:August.22,2002 MAP I Name of Inspector. Patrick M O'Connell PARCEL Company Name: Septic Inspection Services Co. LOT 1 Mailing Address: 189 Cammett Road - Marstons Mills MA 02W Telephone Numba-. (503)428-1779 CERTIFICATION STATEMENT I certify that I have personalty 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 15.340 of Title 5(310 CMR 15.000). The system: _X_ Passes Conditionally Passes Needs Further Evaluation by the Local Approving,Authority Fails Inspector's Signature: Date: 8�Z 816 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 ofthe DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Motes 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. Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 37 Huckleberry Lane Marston Mills Ma.02648 Omer. Karen Hayden Date of Inspection: August 22,2002 Inspection Summary: Check A,>liyC D or E/ALWAYS complete all of Section D A. System Passes: X i have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CUR 15.304 exist_Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: 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. The septic tank is metal and over 20 years olds or the septic tail-(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfrktration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank-as approved by the Board of Health. 4A 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 back-up 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 or replaced ND explain: The system rewired 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: Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 37 Hueideberry Lane Marston Mills Ma.02648 Owner. Karen Hayden Date of Inspection:August 22,2002 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 public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CAIR 15.303(lxb)that the system is not functioning in a manner which will protect public health,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 any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ 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. _ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. _ 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 50 fxt or more from a private water supply welly*.Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory,for cotiform 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 Page 4 of I I OFFICIAL.INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 37 Huckleberry Lane Marston Mills Ma.02648 Owner: Karen Hayden Date of Inspection: August 22,2002 D. System Failure Criteria applicable to all systems: You must indicate`yes"or"no"to each of the following for an inspections: Yes No _X_ Back-up of sewage into facility or system component due to overloaded or clogged SAS or cesspool —X_ 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 %day flow X Requires]pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s)- Number of times pumped X Any portion of the SAS,cesspool or privy is below high ground water elevation. X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. _X_ Any portion of a cesspool or privy is within a Zone I of a public well. _X_ Any portion of a cesspool or privy is within 50 feet of a private water supply well. _X_ 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 conform 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 forma _No_(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 sera'e a facility with a design flow of 10,000 gpd to MOOO Imo• You must indicate either"yes"or"tx"to each of the following: (The following criteria apply to large systems in addition to the criteria 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 _ the system is located in a nitrogen sensitive area(Tnterim Wellhead Protection Area—IWPA)or a.mapped Zone H 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 15304_The system owner should contact the appropriate regional office of the Department_ Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SELVAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 37 Huckleberry Lane Marstons Mills Ma.02649 Owner: Karen Hayden Date of Inspection: August 22,2002 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? X _ 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? X_ _ Were as built plans of the system obtained and examined?(If they were not available note as NIA) _X _ 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? X_ _ 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. X Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMFL 15.302(3kb)] Page 6 of I I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 37 Huckleberry Lane Marston Milts Ma,02648 Owner: Karen Hayden Date of Inspection:August 22,2002 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: 1 Ices residence have a garbage grinder(yes or no): YES Is laundry on a separate sewage system(yes or no):NO [if yes separate inspection required] Laundry system inspected(yes or no):_ Seasonal use:(yes or no): NO Water meter readings,if available(last 2 years usage(gpd)): 79 Sump pump(yes or no): NO Lastt date of occupancy_ CURRENTLY OCCUPIED COM1VIERCIALIINDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): 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/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: HOMEOWNER: (NEW SYSTEM, NOT PUMPED) Was system pumped as part of the inspection(yes or no): NO Ifyes,volume pumped:_gallons—How was quantity pumped determined? 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) NO 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: JUNE 30,2000 PERMIT #00-384 Were sewage odors detected when arriving at the site(yes or no): NO Page7of11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 37 Huckleberry Iran Marstons Mills Ma.02648 Owner. Karen Hayden Date of Ins pection:August 22,21b12 BUILDING SEWER X (locate on site plan) Depth below grade: 2' Materials of construction:—X-cast iron 40 PVC other(explain): Distance from private water supply well or auction line: 28' Comments(on condition of joints,venting,evidence of leakage,etc.): JOINTS AND VENTS IN GOOD CONDITION. NO LEAKS SEPTIC TANK: X (locate on site plan) Depth below grade: 6" Material of construction:—X—concrete_metal_fiberglass—polyethylene ather(eeplain) If tank is metal list age:— Is age confirmed by a Certificate of Compliance(yes or no):—(attach a copy of certificate) Dimensions:H-20 1500 GAL. 5'-8"X 10'-G" Sludge depth: I" Distance from top of sludge to bottom of outlet tee or battle: 23" Scum thickness: 2" Distance from top of scum to top of outlet tee or battle. T' Distance from bottom of scum to bottom of outlet tee or baffle: 24" How were dimensions determined: STICK WITH HINGE FLAP. Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leak-age,etc.): NO PUMPING NEEDED. BOTH TEES AND TANK IN GOOD CONDITION. LIQUID LEVELS WITHIN RANGE. 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 scion to top of outlet tee or baffle: Distance from bottom of scum to b ttom 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.): Page 8 of I I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 37 Huckleberry Lane Marston Mills Ma.02648 Owner. Karen Hayden Date of lnspectioa:August 22,2002 TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass_polyethylene other(explain): Dimensions: Opacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(con'diti(m of alarm and float switches,etc.): DISTRIBUTION BOX: X (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 page into or out of box,etc.): B-20 D BOX LEVEL AND OUTLETS EQUAL. NO SOLIDS CARRYOVER NO LEAKS IN OR OUT OF BOX. PUMP CHAMBER: (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.): • Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLLTNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 37 Huckleberry Lane Owner: Karen Hayden Date of Inspection:August 22,2002 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,earavation not required) If SAS not located explain why: Type leaching pits,number:_ _X_leaching chambers,number. 2 - 500 gal.CHAMBERS leaching galleries,number: leaching trenches,number,length: leaching fields number,dimensions: overflow cesspool,number: innovativelalternative system Typetname of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc_ SOIL DRY. NO PONDING OR BREAKOUT. CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and configaaeation: 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.): 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.): �L • Page 10 of 11 OFFICIAL.INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 37 Huckleberry Lane Marstons Mills Ma.02648 Owner: Karen Hayden Date of Inspection: August 22,2002 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch ofthe sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.locate all wells within 100 feet.locate where public water supply enters the building. 20 l�{ q � �q iZ z� 25 0 ll��S �Df l Vewc l �ou�e. T I Page I I of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 37 Hucldeber Lane p r'tY � Marstons Mills Ma.02648 Owner: Karen Hayden Date of inspection:August 22,2002 SM EDAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water: MORE THAN 12 FEET. Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting propcitylobservation hole within 150 feet of SAS) Checked with local Board ofHealth-explain: Checked with local excavators,installers-(attach documentation) X Accessed USGS database-explain: CHECKED USGS MAPS AND GIS GROUNDWATER CHARTS_ You must describe low you established the high ground water elevation: COMPARED GIS CHARTS TO USGS CONTOURS. PROPERTY tr,EL.56 GW. @ EL.42. CommoNwEALTH of MAssAmusETTs EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS a DEPARTxzNT OF L4NvjRONMENTAL PROTECTION TITLE 5 OFFICIAL INSTECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUTB'SXJRFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 37 Hucideberry Lane Marston Mills Ma.02648 Owner's Name: Karen Hayden Owner's Address: SAME Date of Inspection:August 22,2002 Name of Inspector. Patrick M O'Connell Company Name: Septic Inspection Services Co. Mailing Address: 189 Cammett Road Marston Mills MA 02648 Telephone Number. (508)428-1779 CERTIFICATION STATEMENT I certify that t have personalty 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 15.340 of Title 5(310 CMR 15.000). The system: X Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: Date; Z612 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. Page 2 of 1 l OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 37 Huckleberry Lane Marstous Miffs Ma.02648 Owner. Karen Hayden Date of Inspection: August 22,2002 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: X I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 C%1rR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: 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")in the for the following statements.If"not determined"please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or e4hration or tank failure is imminent. System will pass inspection ifthe existing tank is replaced with a complying septic tank as approved 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 pipes)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 lever or replaced ADD explain: The system required 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: f Page 3 of t 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 37 Hucldeberry Lane Marstons Mills Ma.02645 Owner. Karen Hayden Date of Inspection:August 22,2002 C. ftrther 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 public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(IXb)that the System is not functioning in a manner which will protect public health,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 any)determines that the System is functioning in a manner that protects the public health,safety and environment: _ 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. _ The system has a septic tank and SAS'and the SAS is within a Zone i of a public water supply. 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 50 feet or more from a private water supply well".Method used to determine distance "This system passes if the welt 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 triMered.A copy of the analysis must be attached to this form 3. Other: Page 4 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 37 Huckleberry Lane Marstons Mils Ma.0-7648 Owner: Karen Hayden Date of Inspection: August 22,2002 D. System Failure Criteria applicable to an systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No X_ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool -X 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 b"below invert or available volume is less than Y-day flow -X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). - Number of times pumped X Any portion of the SAS,cesspool or privy is below high ground water elevation. X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone I of a public well. X Any portion of a cesspool or privy is within 50 feet of a private water supply well. X 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 coliferm 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 foam.) (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: J To be considered a large system the system most serve a facility with a design flow of 10,000 gpd to 15,000 Ip- You must indicate either"yes"or"no7 to.each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no the system is within 400 feet of a surface drinking water supply _ 8re 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-TWPA)or a mapped Zone R 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 15304.The system owner should contact the appropriate regional office ofthe DepartmeaL r Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 37 Huchdeberry Lane Marston Mills Ma.02643 Owner. Karen Hayden Date dLaspeetion: August 22,20M Check if the following have been done.You most 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 ofthe system components pumped out in the previous two weeks? X _ 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? X_ _ Were as built plans of the system obtained and examined?(If they were not available note as NIA) _X _ 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 scram? X _ 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. - X_ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)1310 CMR 15.302(3)(b)] F Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM.INFORMATION Properly Address: 37 Huckleberry Lane Marston Mffls Ma.02649 Owner: Karen Hayden Date of Inspection:August 22,2002 FLOW CONDITIONS REMENTIAL Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CUR 15.203(for example: 110 gpd x#of bedrooms):330 Number of current residents: I Does residence have a garbage grinder(yes or no): YES Is laundry on a separate sewage system(yes or no):NO [if yes separate inspection required] Laundry system inspected(yes or no).— Seasonal use:(yes or no): NO Water meter readings,-if available(last 2 years usage(gpd)): 79 Sump pump(yes or no): NO Last date of occupancy: CURRENTLY OCCUPIED COMMERCIAIJIND USTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seatslpersonsJsgl},etc.): 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/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: HOMEOWNER: (NEW SYSTEM, NOT PUMPED) Was system pumped as part of the inspection(yes or no): NO If yes,volume pumped:_gallons—How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM ?S_Septic tanl,distribution box,soil absorption system Single cesspool _Overflow cesspool —Privy _Shared system(yes or no)(if yes,attach previous inspection records,,if any) NO _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(descxilm): Approximate age of all components,date installed(if known)and source of information: JUNE 30,2000 PERMIT 900-384 Were sewage odors detected ag when arrivingat the site es or no :( NO y ) I Page 7 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 37 Huckleberry Lane Marston Mills Ma. 02648 Owner: Karen Hayden Date of Inspection:August 22,2002 BU.ELDING SEWER X (locate on site plan) Depth below grade: 2' Materials of construction:—X-cast iron 40 PVC other(explain): Distance from private water supply well or suction line: 28' Comments(on condition of joints,venting,evidence of leakage,etc.): JOINTS AND VENTS IN GOOD CONDITION. NO LEAKS SEPTIC TANK: X (locate on site plan) Depth below grade. 6" Material of construction: X 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:H-20 1500 GAL,. 5'-8"X 10'-6" Sludge depth: t" Distance from top of sludge to bottom of outlet tee or baffle: 23" Scum thickness: 2" Distance from top of scum to top of outlet tee or baffle: 7" Distance from bottom of scum to bottom of outlet tee or baffle: 24" How were dimensions determined: STICK WITH HINGE FLAP. Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): NO PUMPING NEEDED. BOTH TEES AND TANK IN GOOD CONDITION. LIQUID LEVELS WITHIN RANGE.. GREASE TRAP:—(locate on site plan) Depth below grade:T Matenal 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 bale: 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.). ' Page S of I I OFFICIAL INSPECTION FORAM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 37 Huckleberry Lane Mmstow Mills Ma.02648 Owner. Karen Hayden Date of Inspection:August 22,2002 TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass_polyethylene other(explain): Dimensions: capacity: gallons Design Flow: ons/day Alarm present(yes or no): Alarm level: Alarm m working order(yes or no): Date of last pumping: Comments(condition of alarm and#lw switches,etc.): DISTRIBUTION BOX: X (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.): H-20 D BOX LEVEL AND OUTLETS EQUAL, NO SOLIDS CARRYOVER IO LEAKS IN OR OUT OF BOX. PUMP CHAMBER: (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_): Page 9 of l l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 37 Huckleberry Lane Owner. Karen Hayden Date of Inspection:August 22,2002 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number:_ X leaching chambers,number: 2 - 500 gal.CHAMBERS leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number. innovativetalternative system Typelname of technology. Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc. SOIL DRY. NO PONDING OR BREAKOUT. CESSPOOLS: (cesspool must be pumped as part of inspection)(loc ate on site plan) Dumber 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.): 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.): Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 37 Hucideberry Lane Marstons MillsMa.02643 Owner: Karen Hayden Date of inspection: August 22,2002 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building. zo ly at .a iq I �s o 1`7Riv�v✓A� W IS ��cl2�err�/ Ur e Page i 1 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address 37 Huckleberry Lane Marstons Mills Ma.02648 Owner. Karen Hayden Date of inspection;August 22,2002 SM EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water: MORE THAN 12 FEET. Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-if checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board ofHealth-explain: Checked with local excavators,installers-(attach documentation) X Accessed USGS database-explain: CHECKED USGS MAPS AND GIS GROUNDWATER CHARTS. You must describe}row you established the high ground water elevation: COMPARED GIS CHARTS TO USGS CONTOURS. PROPERTY @ EL.56 GW. @ EL.42. 1 TOWN OF BARNSTABLE LOCATION � /, ,� / SEWAGE # ©a- y 3 VILLAGE �ors%»s /"1 ' �� ASSESSOR'S MAP & LOT 122- If-7 INSTALLER'S NAME&PHONE NO. 4!77- k. SEPTIC TANK CAPACITY /SOU• :-: LEACHING FACILITY: (type) 2 (o oZ 12" U/i=:!S (size) -2S NO.OF BEDROOMS 3 E BUILDER OR OWNER PERMITDATE: L, - a o COMPLIANCE DATE: - o x Separation Distance Between the: Maximum Adjusted Groundwater Table to the 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 i •ty) Feet Furnished by �� �L��' • _ .. _ _ .yam - i A z o o I TOWN OF BARNSTABLE E e 1, LOCATION SEWAGE # _ 00- 3 VILLAGE w,—<Tyhs ) ? /� ASSESSOR'S MAP & LOT I dl-/27 INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) 2 ,5'00 �ol, //w witil1 (size) 0 NO.OF BEDROOMS BUILDER OR OWNER PERMITDATE: G- 2 - Q d COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the 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 faci 'ty) Feet Furnished by r b f�, Fr®raT j orw�,w�y r No. / ' , Fee e�'7U THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS / ZIPPYication for Migozai 6peaem Conotruction Permit V Application for a Permit to Construct(t/�Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. f, �{fiC ��bGr�' 44OWee Owner's Name,Address pd Tel.No. Assessor's Map/Parcel ear AV Installer's Nj�e,Add ,and Tel.No. 4 f f—v?el` Designer's Name, ddresss?and el.No. ,/.,tpN a� 14/?�OS JGSG j�d► Inc /31�df S Type of Building: Dwelling No.of Bedrooms _ Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank / Type of S.A.S. Description of Soil Nature of Repai or Alterations(Answer when applicable) ` 1V610 ^ ° I Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been i ued by this and o Health. Signed Date p, Application Approved Date " ` �J Application Disapproved for the following reasons Permit No. Date Issued r �� VV,,f4 .' ' I �y . i3ri No. " ! Fee THE COMMONWEALTH OF'MASSACHUSETTS Entered in computer: s PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS / 0[ppricatfon, for ]Dfopooaf *pgtem Construction Permit V i Application for a Permit to Construct(4-TRepair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. f 7 NUS����bGf'/' Alee. Owner's Name,Address 4nd Tel.No. n,,,T.�,i/s Assessor's Map/Parcel D Ld /,' Z 2 -eez V Installer's Name,Address,and Tel.No. CK77—o jr elf Designer's Name,Address and ifel.No. ✓o� e��i ,a CSC+ , d 5 ✓a5 c doer I7•c /.3���'GS,� Type of Building: Dwelling No.of Bedrooms 5 Lot Size sq. ft;. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan' Date Number of sheets Revision Date Title Size of Septic Tank / Type of S.A.S. Description of Soil, S�rol Nature of Repairs or Alterations(Answer when applicable) ^. lsr11 lova 'L d0 l S �1; y' �r vis UjAdV ZH.�r�/�,� H—2 o a,�•j p�h��rs Date last inspected: 9 Agreement: s The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system `in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliapce has been is ued by this B and of Health. Signed Date / Application Apiroved , Date 47" ` ��S Application DITapproved for the following reasons Permit/No. r Date Issued ' --------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-sj'?e wage Disposal System Constructed( �Ifepaired ( )Upgraded( ) t Abandoned( )by 1113,f,04 at = U L had been constructed in accordance with the provisions of Title 5 and the or Disposal System Construction PermiXsT� - ' d l:► " �Tj, jj Installer es /'r"D. co� ��ly,0 _5 Designer . ���� 4'_ The issuance this perms shall not be construed as a guarantee that the sysWn will functio as -ne Date Inspector + --�y----,—�--- --------------'------------ No. t i / �'` 2 7 Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS 1. mf 6poal *pgtem Conztructfon.YPermft Permission is hereby granted to Construct( 44-Repair( )Upgrade( )Abandon( ) System located at 3 7 and as described in the above Application for Disposal System Construction Permit. The-applicantrecognizes his/her duty to comply with Title 5 and the following local provisions or special.conditions. Provided:Construction must be completed within three years of the date of t. Date: Z& '°"._ f `!� Approved y. �� ' i 1/6/" NOTICE: 'This Form Is To Be Used For the Repair Of Failed Septic Systems Only. CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CM'STRUCITON PERMIT (WITHOUT DESIGNED PLANS) I, s1-1-V �IZ 164,en5 , hereby certify that the application for disposal works construction permit signed by me dated G — 2�'-�D , concerning the property located at 37 &kl4e.*, °y L4,4,-, 1-k *1/5, meets all of the following criteria: • The failed system is connected to a residential dwelling only. There are no commercial or business uses associated with the dwelling. The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch. There are no wetlands within 100 feet of the proposed septic system k*"Thcre are no private wells within 150 feet of the proposed septic system There is no increase in flow and/or change in use proposed There are no variances requested or needed The bottom of'the proposed leaching facility will not located less than five feet above the maximum adp ted groundwater table elevation. (Adjust the groundwater table using the Frimptor method when applicable) �Pleachln the S.A.S. will be located with 250 feet of any vegetated wetlands, the bottom of the proposed Jg facil,:7 will nit be located less than fourteen(14)feet above the maximum adjtuted groundwater table elevation, Please complete the following: A) Top of Ground Surface EIevation(using GIS J . �12 information) B) G.W. l?Ievation- + the'MAX' High G.W. Adjustment DU7FER'D10E BETWEEN A and 13 ' SIGNED (Sketch proposec�plan of DATE' 8— oa q:�u foide, System on back). q rq f - -500 I r I ( I I II Q ` Kanen 6. #ayden 37 #ucklebenny Lane Mansions Mills, MA. 02648 August 8, /998 Thomas A. McKean, R.S. ,C.11.0 Town o� Barnstable Public Health division 367 Main Stneet Hyannis, M4. 0260/ RC: 37 llucklebe.nny. Lane Mansions Mills ancel .#/02//27 bean Mn. McKean; To conlinm our telephone conversation and yours letter ne- ceived by me on 4ugust 4, /998 prompted by assentations made by one Yohn %eetnopoulos in your o//ice Z have the �ollowing comments: The septic system at 37 flucklebennc Lane, ManatonA Mills was installed by the previous owneas, / obent and Donnue L.onsalvL, Z believe in the early /960 's. At the time of passing papers there was no mention o� the septic system, however we were told, both by Mns. ConsalvL and hen attorney, Mn. Konkuch, that the abutting .Lot/06 would never be built on, it is wetlands. Since that time Lot /06 was 6acklilled by N. Stathopoulos and is now somehow Beamed buildable. 4: building permit was issued to Peggy Ruth Brown. 4 numbers o� years ago my exhusband had upgrade work done to my septic system with no a�/ect to its placement on the lot. Z am no more privy to information neganding that upgrade now than Z was then. Z have no contact with my exhus6and who might betters provide you with inlvnmation in that negand. Some two on move years ago Z sought inOrmation/neconds /nom %own fall on my pnopenty �on an upcoming hearing on Mns. Bnowna ' building permit. At that time Z was LnOrmed that the neconds o� my septic system could not be located. While Z am �amilian with the .Locations v/ the covens to my septic system and there ane no cement bounds on the pnopenty, Z eel no qualifications to present you with a scetch. At no point and time has my septic system presented any health problems whatsoever, thene�ore there is no health issue-, tome-solve as we agreed. In closing may Z thank you Ion bringing this matters to my attention. Any Iunthen assentations will be considered harassment and will be handled accordingly. Sin rely. ., i 1 - pTME Town of Barnstable snRrtsrnsUZ, MASS. ,. Board of Health P.O.Box 534,Hyannis MA 02601 Office: 508-790-6265 Susan G.Rask,R.S. FAX: 508-790-6304 Ralph A.Murphy,M.D. Sumner Kaufman,M.S.P.H. Ms.Karen E.Hayden 37 Huckleberry Lane Marstons Mills, ?AA 02648 RE: 37 Huck-eberry Lane,Marstons Mills Parcel#102/127 Dear Ms.Hayden: Please submit a sketch showing the location of the septic system at 37 Huckleberry Lane,Marstons Mills. The Health Deparrment does not have any record of the location of the septic system. However,we were recently informed that your system was upgraded approximately eight(8)years ago and may be located on the adjacent property. I would appreciate your cooperation in resolving this issue. Our mailing address is: P.O.Box 534, Hyannis,MA 02601 and our FAX number is 790-6304. Sincerely yours, - Ao� Thomas A.McKean,R.S.,C.H. . Agent of the Board of Health cc: John Petropoulos 717 .';;�,0J7U1r=1I/-f6Jr06)N /'W.,1111#1k49 0 c/j I HM ] 01 H E A L T H M A S T E R ] HELP [ ] R E C O R D ] ACTION A] For Parcel N er 102] ] ] Rental Property(Y/N) [ ] Owner Nam HAYDEN, KAREN E ]' Zone of Contrib (Y/N) [ ] Locati n 37 HUCKLEBERRY LN ] Contaminant Rel (Y/N) [ ] 611�er5J nl t (S Mfg Business ame [ OZ6Y�3 ] Area Number Contact PC ern [ ] Phone [ ] [ ] Fuel Storage Tank Permi Card on File [ ] _ Perc Test Well Septn]I le PermitN9-� [ ] [ ] [cb, Issuance Date Completion Date [ ] [ l Last Communications [ ] (MMDDYY) Comments [ ] Cancel [ ] NEXT SCREEN [HM ] ACTION [A] PARCEL NBR [ ] [ ] [ ] TANK NBR [ ] ] [ l C Lj ro rv�a-"- 6�'- l S Ie-r I 0� C_ Utl .� )n ceSJ�v /n3 ,1 C)Ut KAC, �'"� a v m s lG -f-✓'a�f G'�oa r a ;vi�l a U&-c( Nok 't loot p- ? cIle- �e-v y i rUL2 i S rob rl ela L,L) (> �r