HomeMy WebLinkAbout0017 LADY SLIPPER LANE - Health 17 Lady Slipper Lane
Marstons Mills P
A = 044 017003
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TOWN OF BARNSTABLE 1,
old 10 1 tna jA tq ,
L 'CATION (0SEWAGE #
VILLAGE k ASSESSOR'S MAP &QOV or)003
INSTALLER'S NAME&PHONE NO. �] (� �J
SEPTIC TANK CAPACITY Ulm -{ D ,
LEACHING FACILITY: (type) k O C h Ll j (size) I nnaw
NO.OF BEDROOMS (C f�—QQ r
BUILDER OR OWNER
PERMTTDATE: 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 y wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
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COMMONWEALTH OF MASSACHUSETTS RECEI�/ED
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
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DEPARTMENT OF ENVIRONMENTAL PROTECTION $Ep 2 3 2003
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a c (VIAP � TOWN OF BA NSTABLE
Q i HEALTH DEPT.
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5 LOT 1
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TITLE 5
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 17 LADYSLIPPER LANE MARSTONS MILLS,MA 02648 0
Owner's Name: MARTHA BRAMAN
�wner's Address: 17 LADYSLIPPER LANE MARSTONS MILLS,MA 02648 copy
)Date of Inspection: 9/2/03
ame of Inspector: (please print) JOHN GRACI,INC.
ompany Name: SEPTIC INSPECTIONS
ailing.Address: P.O.BOX 2119 TEATICKET,MA.02536
�elephone Number: 508-564-6813 FAX 508-564-7270
CERTIFICATION STATEMENT
certify that I have personally inspected the sewage disposal system at this address and that the information reported below is
rue,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
nspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system:
X Passes
_ Conditionally P sses
_ Needs Furth valuation by the Local Approving Authority
Fails
inspector's Signature: Date: 9/2/03
The system inspector shall submit a opy of this inspection report to the Approving Authority(Board of Health or DEP)within
30 days of completing this inspecti . If the system is a shared system or has a design flow of 10,000 gpd or greater,the
nspector 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.
Motes and Comments
SYSTEM PASSED TITLE V INSPECTION. RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE
YSTEM'S USEFUL LIFE.
"This report only describes conditions at the time of inspection and under the conditions of use at that time.This
nspection does not address how the system will perform in the future under the same or different conditions of use.
Titla. S Tncna.ntinn Fnrm A/]V1000 1
E
Page 2 of 1 I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
roperty Address: 17 LADYSLIPPER LANE MARSTONS MILLS,MA 02648
Oiwner: MARTHA BRAMAN
pate of Inspection: 9/2/03
nspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
4. System Passes:
I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310
FMR 15.304 exist. Any failure criteria not evaluated are indicated below.
I
(Comments:
YSTEM PASSED TITLE V INSPECTION.RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG TF E
YSTEM'S USEFUL LIFE.
B. System Conditionally Passes:
One or mores stem components as described in the"Conditional Pass"Y p section need to be replaced or repaired.The syste ,
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.
/a 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 exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced
ith 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.
D explain: n/a
n/a 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 or replaced
D explain: n/a
n/a 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: n/a
Page 3 of 11
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
P Property Address: 17 LADYSLIPPER LANE MARSTONS MILLS,MA 02648
wner: MART HA HA BRAMAN
ate of Inspection: 9/2/03
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 CMR 15.303(1)(b)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*ank 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 n/a
"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 cop,
of the analysis must be attached to this form.
3. Other:
n/a
Page 4 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
roperty Address: 17 LADYSLIPPER LANE MARSTONS MILLS,MA 02648
wrier: MARTHA BRAMAN
Date of Inspection: 9/2/03
D. System Failure Criteria applicable to all 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 6"below invert or available volume is less than %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 SYSTEM WAS PUMPED TWO YEARS AGO PER OWNER.
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 1 of a public well.
L 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 w th
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.]
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 serve a facility with a design flow of 10,000 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 criteria above)
yes no
X the system is within 400 feet of a surface drinking water supply
X the system is within 200 feet of a tributary to a surface drinking water supply
X 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 thrc at
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.
II Q
Page 5 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
�Pro;perty Address: 17 LADYSLIPPER LANE MARSTONS MILLS,MA 02648
caner: MARTHA BRAMAN
ate of inspection: 9/2/03
Check if the following have been done. You must indicate "yes" or"no" as to each of the following:
Yes. N.:
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?
X 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?
Was the site inspected for signs of break out`?
X Were all system components,excluding the SAS, located on site'?
_ 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 maintenan e
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 CMR 15.302(3)(b)]
5
Page 6 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 17 LADYSLIPPER LANE MARSTONS MILLS,MA 02648
Owner: MARTHA BRAMAN
Date of Inspection: 9/2/03
FLOW CONDITIONS
ESIDENTIAL
Number of bedrooms(design): 3 Number of bedrooms(actual): 3
DESIGI`flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms):330
Number of current residents: 5
Does residence have a garbage grinder(yes or no): YES
s laundry on a separate sewage system(yes or no): NO [if yes separate inspection required]
Laundry system inspected(yes or no): NO
Seasonal use: (yes or no): NO
Water meter readings, if available(last 2 years usage(gpd)): n/a
Sump pump(yes or no): NO
Last date of occupancy: n/a
COMMERCIAL/INDUSTRIAL
Type of establishment: n/a
Design flow(based on 310 CMR 15.203): n/agpd
Basis of design flow(seats/persons/sgft,etc.): n/a
Grease trap present(yes or no): NO
Industrial waste holding tank present(yes or no): NO
Non-sanitary waste discharged to the Title 5 system(yes or no): NO
Water meter readings, if available: n/a
Last date of occupancy/use: n/a
OTHER(describe): n/a
GENERAL INFORMATION
Pumping Records
Source of information: SYSTEM WAS PUMPED TWO YEARS AGO PER OWNER
Was system pumped as part of the inspection(yes or no):NO
If yes,volume pumped: n/agallons--How was quantity pumped determined? n/a
Reason for pumping: n/a
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): n/a
Approximate age of all components,date installed(if known)and source of information:
1981 BY OWNER
Were sewage odors detected when arriving at the site(yes or no): NO
Page 7 of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
PropertyAddress: 17 LADYSLIPPER LANE MARSTON S MILLS,MA 02648
Owner: MARTHA BRAMAN
Date of Inspection: 9/2/03
BUILDING SEWER(locate on site plan)
Depth below grade: 10"
Materials of construction:_cast iron =40 PVC other(explain): n/a
Distance from private water supply well or suction line: n/a
Comments(on condition of joints, venting,evidence of leakage,etc.):
WELL WATER- 100+FT. AWAY
SEPTIC TANK: X(locate on site plan)
Depth below grade: 4"
Material of construction: Xconcrete_metal_fiberglass_polyethylene other(explain)n/a
If tank is metal list age: n/a Is age confirmed by a Certificate of Compliance(yes or no): NO(attach a copy of certificate)
Dimensions: L 8' 6" H 5' 7" W 4' 10"
Sludge depth: 2"
Distance from top of sludge to bottom of outlet tee or baffle: 32"
Scum thickness: 2"
Distance from top of scum to top of outlet tee or baffle:6"
Distance from bottom of scum to bottom of outlet tee or baffle: n/a
How were dimensions determined: MEASURED
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as relate
to outlet invert,evidence of leakage,etc.):
SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY.
RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE.
GREASE TRAP:_(locate on site plan)
Depth below grade: n/a
Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a
Dimensions: n/a
Scum thickness: n/a
Distance from top of scum to top of outlet tee or baffle: n/a
Distance from bottom of scum to bottom of outlet tee or baffle: n/a
Date of last pumping: n/a
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as relate
to outlet invert,evidence of leakage,etc.):
n/a
7
?age 8of11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 17 LADYSLIPPER LANE MARSTONS MILLS,MA 02648
Owner: MARTHA BRAMAN
Date of Inspection: 9/2/03
TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade: n/a
Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a
Dimensions: n/a
Capacity: n/a gallons
Design Flow: n/a gallons/day
Alarm present(yes or no): N/A
Alarm level: N/A Alarm in working order(yes or no): NO
Date of last pumping: n/a
Comments(condition of alarm and float switches,etc.):
n/a.
DISTRIBUTION BOX:X(if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: LEVEL WITH BOTTOM OF PIPE
Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage i to
or out cf box,etc.):
D-BOX IS STRUCTURALLY SOUND.
PUMP CHAMBER:_(locate on site plan)
Pumps in working order(yes or no): NO
Alarms in working order(yes or no):NO
Comments note condition of um chamber,condition of pumps and appurtenances,
( ces etc.
pump P P PP )
n/a
R
Page 9 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 17 LADYSLIPPER LANE MARSTONS MILLS,MA 02648
Owner: MARTHA BRAMAN
Date of Inspection: 9/2/03
SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required)
If SAS not located explain why:
n/a
Type
PIT leaching pits, number:
n/a leaching chambers, number: n/a
n/a leaching galleries, number: n/a
n/a leaching trenches, number, length: n/a
n/a leaching fields, number: n/a
n/a overflow cesspool, number: n/a
n/a innovative/alternative system
Type/name of technology: n/a
Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.):
DID NOT EXPOSE LEACH PIT,APPEARS TO BE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY.
SYSTEM SHOWS NO SIGNS OF FAILURE.
CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration: n/a
Depth—top of liquid to inlet invert: n/a
Depth of solids Layer: n/a
Depth of scum layer: n/a
Dimensions of cesspool: n/a
Materials of construction: n/a
Indication of groundwater inflow(yes or no): NO
Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
n/a
PRIVY: (locate on site plan)
Materials of construction: n/a
Dimensions: n/a
Depth of solids: n/a
Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
n/a
4
(Page 10 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
roperty Address: 17 LADYSLIPPER LANE MARSTONS MILLS, MA 02648
pwner: MARTHA BRAMAN
Pate of Inspection: 9/2/03
KETCH OF SEWAGE DISPOSAL SYSTEM
rovide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.
ocate all wells within 100 feet.Locate where public water supply enters the building.
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�rPage 11 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 17 LADYSLIPPER LANE MARSTONS MILLS,MA 02648
Owner: MARTHA BRAMAN
Date of Inspection: 9/2/03
SITE EXAM
_Slope
_Surface water
_Check cellar
Shallow wells
Estimated depth to ground water 12+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: n/a
YES Observed site(abutting property/observation hole within 150 feet of SAS)
NO Checked with local Board of Health-explain: n/a
NO Checked with local excavators, installers-(attach documentation)
NO Accessed USGS database-explain: n/a
You must describe how you established the high ground water elevation:
GROUNDWATER WAS DETERMINED BY HAND AUGER- 12+FEET
I
U Commonwealth of Massachusetts
Executive Office of Environmental Affairs
Department of
• Environmental Protection
William F.Weld Trudy Coxe
Governor 11-r+arY
Arpeo Paul Cellucci David B.Struhs
tL Gowm« comm"lo wr
•
ee
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
y
Property Address: 1 Lady Slipper Lang Address of Owner.
6 (If dltforent)
Date of Inspeotlon:3 19/9 � ,j
Name or lnapeotor.Joseph P. Macomber Jr. v� %� 996'
Company Name,Address and Telephone Number. s
J.P.Macomber & Solt-Inc. Box 66 Centeryille,Mass.02632 ���,��
`
CERTIFICATION STATEMENT 508-775-3338 � �
+
I certify that I have personally inspected the sewage disposal system at this address and that the information reported belowis-titie,accurate
and complete as of the time of inspection. The'inspection was performed bayed on my training and experience in the proper function and
maintenance of on-sits sewage disposal systems. The system:
ZPasses
_ Conditionally Passes
_ Needs Further Evaluation By the Local Approving Authority
— FaiL
✓� a l�o
Inspector's 9ignat Date.
The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this
inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the
report to the appropriate regional office of the Department of Environmental Protection.
The original should be sent to the system owner and copies sent to the buyer,it applicable and the approving authority.
INSPECTION SUMMARY:
Check A,B, C,or D:
AJ SYSTEM PASSES:
ZI have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303.
Any failure criteria not evaluated are indicated below.
Bj SYSTEM CONDITIONAUY•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)
X2Ths septic tank is metal,cracked,structurally unsound,shows substantial infiltration or exilltration,.or tank failure is
Imminent. The system will pass inspection if the existing septic tank is replaced with a 9ouforming septic tank as approved
by the Board of Health.
(revised 11/03/95) 1
One 1Mlntor Street a Boston,Masaa:husetts 02108 a FAX(617)556-1049 a Telephone(617)M-SS00
Printed on Recycled Paper ,
-- _ _ _ li
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
P"r"o'��rtyAd 19 Lady Slipper Lane; Osterville,Mass.
Pro
& Vergena
Date of Inspection:3/19/9 6
B)SYSTEM CONDITIONALLY PASSES(continued)
e
AW Sewage backup or breakout or hA static water level observed in the distribution boat 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
dW The system required pumping more than four tinja a year due to broken or obstructed pipe(s). The system will pass
inspection if(with approval of the Board of Heal ):
broken pipe(s)are replaced
obstruction is removed
Cl 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:
d'g Cesspool or privy is within 50 feet of a surface water
A' Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
Z) SYSTEM.WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER,IF APPROPRIATE)
DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND
SAFETY AND THE ENVIRONMENT:
Q� The system has a septic tank and soil absorption system and is within 100 feet to a surface water supply or tributary to a
surface water supply.
The system has a septic tank and soil absorption system and is within a Zone I of a public water supply well.
�lQ The system has a septic tank and soil absorption system and is within 60 feet of a private water supply well.
dX) The system has a septic tank and soil absorption system and is less than 100 feet but 60 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 Erse
from pollution from that fagility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or lass than 6 ppm.
3) OTHER
(revised 11/03/95; 2
r
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 19 Lady Slipper Lane Osterville,Mass .
Owner. William & Vergwaa•
Date of Inspeotion:3/19/9 6 •
•
Di SYSTEM FAILSS •
•
AVI have determined that the system violates one or more of the following failure criteria as defined in 310 CDdR 16.50$. The bsuii for
this:dsterminatlon is identified below. The Board of Health should be contacted to determine what will be necessary to correct the .
Wait.
?' Backup of"wage into facility or system component due to an overloaded or clogged SAS or cesspooL
w
DUcb."p or ponding of stauent to the surface of the ground or surface waters due to an overloaded or clogged SAS or
cesspool
�171 Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or CasspooL
"PO issl AP Liquid depth in ooaspoei• loss than V below invert or available volume is less than 1/2 day flow.
40 Required pumping more than 4 times in the last year NOT due to clogged or obstructed pips(s)-
Number of times pumped..__
�j Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation.
,1 AMportion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
AO 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 60 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
' aptable water quality analysis. If the well has been analyzed to be acceptable,attach Copy o f well water analyst for
cce '
coliform bacteria,volatile organic compounds,ammonia nitrogen and nitrate aitrogen.
El LARGE SYSTEM FAILS:
The following criteria apply to large systems in addition to the criteria above:
The system serves a facility with a design Dow of 10,000 MA 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:
19 the system is within 400 foot of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
1 the system is located in a aitrogen sensitive area(Interim Wellhead Protection Area(IWPA)or a mapped Zone II of a public
water supply well)
The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program
requirements of 314 CMR 5.00 and 6.00. Please oonsult the local regional office of the Department for farther information.,
$
(revised 11/93/95)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
ProperVAddrem 19 Lady Slipper Lane Osterville,Mass . ,
Owner. William & Verg4ria
Date of Inspection: 3/19/9 6
Check.if'the following have been done:
,+Pumping information was requested of the owner,occpant,and Board of Health.
2NOns of the system components have been pumped for at least two weeks and the systam bas been receiving normal flow rates
d ' that period. Large volumes of water have not been introduced into the system recently or as part of this inspection.
As built plans have been obtained and examined. Note if they are not available with N/A.
„f/The facility or dwelling was inspected for signs of sewage back-up.
„2The system does not receive non4anitary or industrial waste flow
., e4s site was inspected for signs of breakout.
System components,ficluding the Soil Absorption System,have been located on the site.
, The septic tank manholes were uncovered,opened,and the interior of the septic tank was inspected for condition otbafdes or
tees,material of construction,dimensions,depth of liquid,depth of sludge,depth of scum.
YThe size and location of the Soil Absorption System on the site has been determined based on edsting information or
approximated by non-intrusive methods.
/The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of Sub.
.Surface Disposal System.
(revised 11103/95) 4
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 1.9 Lady Slipper Lane 0sterville,Mass.
Owner. William & Vergena
Date of Inspection:3/19/9 6
• FLOW CONDITIONS
RESIDENTUL-
Design •
flow: ns •
Number of bsdro ums
Number of current reaidents:M-1,
Garbage grinder(yes or no):Ajo.
Laundry connected to system(yes or no)l�s
Seasonal use(yes'or no):Jo
Water mster•readings,if available: l ✓' Q S
Jf
Last date of occupancy: ,
COMMERCIAL NDUSTRIAI:
Type of establishment: Olt
Design now• 4A pllons/day
Grease trap present:(yes or-ao)&/4
Industrial Waste Holding Tank present: (yes or no)_0
Non-sanitary waste discharged to the Title b system: (yes or no)"
Water meter readings,.if available: 104
Last date of occupancy:
OTHER(Describe)
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and so ormation:
U I '{1
System pumped as part of inspection: (yes or no) S
If yes,volume pumped dons Q
Reason for pumping: scusti
TYPE 0 SYSTEM
Septic tank/distr1ution box/soil absorption system
Single cesspool
Overilow cesspool
Privy
Shared system(yes or uo) (if yes,attach previous inspection records,if any)
Other(explain)
APP 0)aMA AGE of all components,da installed(if known)and source of information
Sewage odors detected when arriving at the site:(yea or no)
(revised 11/03/95) 6
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
propartyAddress:l9 Lady Slipper Lane Osterville,Mass .
Owner. William & Vergena
Date of Inspeotlon: 3 9/9 6
SEPTIC TANli{:,L-,AW
(locate.on site plan)
Depth below grade: 1S
Material of construction ncsete metal FItP--other(explain)
Dimeasioasi ' ' ,0 6'7" ' t u
Sludge depth:_
Distance from top of sludge to bottom of outlet tee or baffler_ 6
Scum thiclmesa: C
Distance from top of scum to top of outlet tee or baffler
Distance from bottom of scum to bottom of outlet tee or baffle:—a_
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.)' PUm tank 9 YerY 2— tee
a are 1 r
lace and sti ofleakage the septic
e septic tank i4 Qtr,int„ra113�sa)Ad Neep
GREASE TRAP-4,_)&41C,
(locate on site plan)
Depth below grade:AX
Material of constsuction:+gooncrete_metal_FRP_other(explain)
NR
Dimensions: N 11
Scum thickness:- A714
Distance from top of scum to top of outlet tee or baffle:A
Distance from bottom of scum to bottom of oatlet 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.) -'Pd rs�PilJrs
(revised 11/03/95) 6
1
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Propertymares 1-9 Lady Shipper Lane Osterville,Mass.
Owner. William Vergena
Date of Inspection: 3/19/9 6
TIGHT OR HOLDING TAN&A7fJ.p—
(locate on site plan) a
Depth below grade:,ja
Material of constructiowe&ncrete_metal_FRP_other(explain)
AIR
Dimensions:_
Capadty: ns s .
Design flovwr-__& Wday
Alarm level
Comments:
(condition of inlet tee;condition of alarm and float switches,ate.)
DISTRIBUTION BO%:Z
(locate on site plan)
Depth of liquid level above outlet invert:
Comments:
(note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.)
Box is level:no . evidence of solids carry over: No evidence of leakage in
or out of the distribution box- No rPnairs, are nPPdPd at this time
PUMP CHAMBERAj!/f,
(locate on site plan)
Pumps in working order.(yes or no),&ld
Comments:
(note n of pump chamber;condition of pumps and appurtenances,etc.)
(revised 11/03;95) q
;t�
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
C
(oontinuod)
PvpartyAddrasss 19 Lady Slipper 'Lane Osterville,Mass ., ,
owaars William & Vergena
Data of Inspootions 3/19/9 6
SOIL ABSORPTION SYSTEM CUSS—z e
Coate on Alta plan,ilpo!sus;mcavation not rsquixi�,but may be approximated by non-intrusive methods);
If not determined to be present,explain: •
Type;
kschtng Pib,number:1 . ..
somber: 66 �.,. .;.;.
leaching trenches,number,length:�_ :,
leaching fields,number,dime ions: T7 "
overflow cesspool,number
Comments:(note condition of soil,signs of hydraulic failure, 1-vf'! of condition of veptatlon,eto.)
_ See rage 8C No signs of hydrauli,c_ failure or -poriding.-All vegetation
tthis time.
CESSPOOLSt •' r
(locate on site plan)
Number and wall =tion 1
Depth-top of liquid to islet invert: /
Depth of solids latyei:
Depth of scum 1;yei:
Dimanrioas of oesspools
Materials of construction:
Indication of gro:tndwater.
• inflow(oesapool must be pumped as part of
Commants•(pots condition o soil,suns of hydraulic failrra, condition of vegetation,etc.)
PRms
Qocaie on site plan)
Materials;of Dimon sious: /y
Depth of solids.,_
Comments is ooMato"of soil,signs of bydraulic faiiurc, :cn of vegetation,itc.)
1 Ct "' 2 •
(revised 11/03195) 8
r
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(oontinued)
pmpertYAddrog . 19' Lady Slipper Lane Osterville,Mass .
owner. bn William & Vergena
Date of Inspootton:3/19/9 6
e
•SIIMH OF SEWAGE DISPOSAL SYSTEM: e
iacIA ties to at least two permanent references landmarks or benchmarks
locate all wells within 100'
Centerville Osterville
Marstons Mills Water
Company. 428-�6691 �( �
147
DEPTH To GROUNDWATER
Depth to grmadwater 1 6' +teat
method ofdeterminatioa or approximation: See page 80. No water encountered at 12"
(revised 11/03/95). 9
Il
�n•r.nnr..-nrvtr'-•r't- nrmr•nmr�rn n+•rrnn:vr*+:+srrt+r(rti**n'++nrnW rra-rrrs+r NECI.... tr-nr'•.+na.t-••�
TOWN OF ; Barnstable UOARD OF HEALTH
S1111SURFACR SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART D •- CERTIFICATION
•••4IN T•:•:!r—*.1,,.•••TTT\Tir.+n•nmr."mArv4rArRn•r—vr+•-t.rrRra'lrRmr�•TT+rrR+.1+r +7 rim nTrrrnnss•.7rrr►rn a•..-.rr.—•rr•1r•••••�
-TYPL OR PRINT CI.EARLY-
PROPERTY INSPECTED
STREET ADDRESS 19 Lady Slipper Lane Ostervillj,Mass,
e .
ASSESSORS. MAP , BLOCK AND PARCEL #
OWNER' s NAME William &' Verbena
PART D - CER7'IFICA7'I0N f
NAME OF INSPECTOR Joseph P. Macomber Jr. .
+
CONRANY NAME J•P•Macomber & Son Inc. +
COMPANY ADDRESS Box 66 Centerville Mass . 02632
Street Town or City State LIP
COMPANY TELEPI4ONE ( 508 ) 775 - 3338 FAX ( 508 ) 790 - 1578
ri niTl ra
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposEi7 system at
this address and that the information reported is true , accurate, and
complete as of the ti.rne of :inspection . The inspection was performed and any
recommendations regarding upgrade , maintenance , and repair are consistent
with my training and experience in the proper function and maintenance of on-
site sewage disposal systems .
Check one: ;
XXXXCXXSYsteoi PASSED-
fie inspection 1ihich I have conducted has not found any information
which indicates that the system fails to adequately protect public
health or Lhe environment as defined in 310 CMR 15. 303 . Any failure
criteria not evaluated are as stated in the FAILURE CRITERIA section of
this form, ,+
System FAILED*
The Inspection which I have conducted has found that the system fails to
protect the public health and the environment in accordance with Title
5 , 310 CMR 1.5 . 303 , and as specifically noted on PART C - FAILURE
CRITERIA of this inspection form .
e , ,
Inspector Signature Date 3/30/96
One copy of this certification must be provided to the OWNER, the BUYER
( where applicable ) and the BOARD OF 112ALz'11,
If the inspection FAILED, thZ: owner pr operator shall upgrado ' the eyntem
wiChin one :year of the date of the inspection , unless allowed nr Tnr„r4r4
� b
-
All
= s�yY 3r�1
THE COMMONWEALTH OF MASSACHUSETTS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
BE IT KNOWN THAT i
a'*
Joseph P. Macomber, Jr.
Has satisfied the Department's qualifications as required and is hereby
authorized to use the title
CERTIFIED TITLE 5 SYSTEM INSPECTOR
as provided in 310 CMR 15.340 and Section 13 of Chapter 21A of the
General Laws. Issued by The Department of Environmental Protection.
June 8. 1995
Acting Director�of the ion of Water Pollution Control
p