HomeMy WebLinkAbout0023 SPRUCE STREET - Health Po
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LOCATION°a3 S �U( Sl- SEWAGE #
VILLAGE h1. A/.1 ASSESSOR'S MAP & LOTC9 ('Z OSb
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) C¢SS�2 W ) (size)
NO. OF BEDROOMS
BUILDER OR OWNER (— 4
PERMIT DATE: 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 feaching facility) L Feet
Furnished by S� c� '.�✓1SOct.T7dn
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COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
TITLE 5
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 23 Spruce Street
West Barnstable, AM 02668 i
Owner's Name: Dorothy Rice RECEIVED
Owner's Address: Same
Date of Inspection: August 21, 2001 J U L 2 9 2001
Name of Inspector:(Please Print) James M. Ford TOWN OF BARNSTABLE
HEALTH DEPT.
Company Name: James M.'Ford Ma
Mailing Address: P.O. Box 49" `.< f Parcel:050 -
OW"f[le,MA 02655-0049
Telephone Number: (508)862-9400
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is true,accurate and complete as_of the time of the inspection. The inspection was performed based on my
training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system:
✓ Passes
Conditionally Passes
NeWs Further Evaluation by the Local Approving Authority
F is
Inspector's Signature: Date: August 22, 2001
The system inspector shall sub a copy of this inspection report to the Approving Authority(Board of Health or
DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000
gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the
DEP. The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving
authority.`
Notes and Comments
****This report only describes conditions at the time of inspection and under the conditions.of use at that
time. This inspection does not address how the system will perform in the future under the same or different
conditions of use.
Title 5 Inspection Form 6/15/2000 page 1
Page 2 of 1 I •
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 23 Spruce Street
West Barnstable, AM
Owner: Dorothy Rice
Date of Inspection: August 21, 2001
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. 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 CMR 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 riot determined(Y,N;ND):in the ..for the following statements. If"not determined",please
explain.
r:
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 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 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 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:
2
I _-
Page 3 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 23 Spruce Street ------ -- ---�—-- -- • -- -- - - --- ,-
West Barnstable, MA
Owner: Dorothy Rice
Date of Inspection: August 21, 2001
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 sysiem(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 feet or more from a
private water supply well**. Method used to determine distance
**Tiffs sj+ster:gasses if the well Euater a*:alysis;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.
3. Other:
3
Page 4 of'11 -
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
F PART A
;CERTIFICATION (continued)
Property Address: 23 Spruce Street
West Barnstable, MA ,:,, r s• �, ,
Owner: Dorothy Rice
Date of Inspection: August 21, 2001 - .S
D. System Failure Criteria applicable to all systems:
You must indicate either"yes"or"no"to each of the following for all inspections:
Yes No
✓ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
✓ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
✓ 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 '/z 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 SAS,cesspool or privy is below high ground water elevation.
✓. Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
✓; Any portion'of a'cesspool or privy is within.a.Zone 1 of a.public well.
✓ Any portion of a cesspool or privy is within 50 feet of a private water supply well.
✓ Any portion of a cesspool or privy pis less than.100'feet but greater than.50.feet from a private water
supply well with no acceptable water quality analysis. [This system passes if the well water analysis,
performed at-a°DEP*certified laboratory,for:coliform bacteria.and.volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
- nitrogen and nitrate.nitrogen is equal to or less than 5 ppm,provided.that no other failure criteria
are triggered. A copy of the analysis must be attached to this form.]
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 System:
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
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped
Zone II of a public water supply well
If you have answered`yes"to any question in Section E the system is considered a significant threat,or answered
"yes"in Section D above the large system has failed. The owner or operator of any large system considered a
significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
15.304. The system owner should contact the appropriate regional office of the Department.
4
Page 5 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
'-CHECKLIST
Property Address: 23 Spruce Street
West Barnstable, MA
Owner: Dorothy Rice
Date of Inspection: August 21, 2001 `' y
Check if the following have been done: You must indicate"yes"or"no"as to each of the following:
Yes No
✓ Pumping information was provided by the owner,occupant,or Board of Health
✓ 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?
✓ Have large volumes of water been introduced to the system recently or as part of this inspection?
n/a 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,? (House not inspected)
✓ i" + Was.the site-inspected for signs of break out
v'. Were all system'components,excluding the SAS;located on site..?. �.r
_ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition
of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum?
✓ Was the facility owner(and occupants if different from owner)provided with information on the proper
maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has been determined based on:
Yes No
✓ Existing information. For example,a plan at the Board of Health.
✓ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance
is unacceptable)[310 CMR 15.302(3)(b)].
•_ ,".::3 i 3;t 4 r P., ,,at �JL.✓ V� . ... .i . •. '3. -r... t''r:-.'1' .. i. '
5
Page 6 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
'SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
4 PART C
,> !SYST-EM;INFORMATION
Property Address: 23 Spruce Street
West Barnstable, MA
r, a
Owner: Dorothy Rice
Date of Inspection: ' August 21, 2001 w
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): n/a Number of bedrooms(actual): 2
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 220
Number of current residents: 1
Does residence have a garbage grinder(yes or no): No
Is p p (y gsystem) (y ) [if yes separate inspection required] , ,
Laud stem separate
ns ected es or n No orQno : No
Seasonal use(yes or no): No
Water meter readings,if available(last 2 years usage(gpd)): well water
Sump Pump(yes or no): No
Last date of occupancy: Currently occupied
COMMERCIAL/INDUSTRIAL
Type of establishment: " .. .._ ... .
Design flow(based on 310 CMR 15.203) _ pd
.,Basis.of desii'gn`,flow_ (seats/persoris/sgft,etc). r�. .,.�._
Grease trap present(yes or no):
�..
in tank resent es or no :r •waste hold _.Industrial as
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: Pumped 2 months ago-per owner
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
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):
- •,r. --. Approximate age of all components,date.installed.(if.known)and source of information:
f Unknown
Were sewage odors detected when arriving at the site(yes or no): No
6
Page 7 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
•SYSTEM INFORMATION (continued)
Property Address: 23 Spruce Street
West Barnstable, MA_
Owner: Dorothy Rice
Date of Inspection: August 21, 2001
BUILDING SEWER(locate on site plan)
Depth below grade:
Materials of construction: _cast iron 40 PVC ✓ other(explain): Orangeburg pipe
Distance from private water supply well or suction line:
Comments(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK: None (locate on site plan)
Depth below grade:
Material of construction: _concrete _metal _fiberglass _polyethylene
_other(explain) + _
If tank is metal list age: is age confirmed by a Certificate of Compliance(yes or no):• i(attach a copy.of
certificate) .
Dimensions:
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
How were dimensions determined:
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.):
t
GREASE TRAP: None (locate on site plan)
Depth below grade:
Material of construction: _concrete _metal _fiberglass polyethylene _other
(explain):
Dimensions:
Scum thickness:
-Distance from:top of scum to top of outlet tee or.baffle:
Distance from bottom of scum to!bottom of outlet tee or baffle:
Date of last pumping: +• , ;T
Comments(on pumping recommendations inlet and outlet tee or baffle condition structural integrity, liquidaeYels
as related to outlet invert,evidence of leakage,etc.):
7
Page.8 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM IN'FORMATION (continued)
,
Property Address: 23 Spruce Street
West Barnstable. AM
Owner: Dorothy Rice
Date of Inspection: August 21, 2001 y
TIGHT or HOLDING TANK: None (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: gallons/day
Alarm present(yes or no):
Alarm level: Alarm in working order(yes or no):
Date of last pumping:
Comments(condition of alarm and float switches,etc.):
f rT� f ..? �. ..., Viz:.. � .r. _ �.i Ai P,i�;ri• R %'i �.:r �a Vie,. r ..
`.::,._.DIS'TRIBUTIONrBOXc ':1Vone (if pesent:must be pp
ened).(locate on site'plan)'
Depth of liquid level above outlet invert:
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.):
PUMP CHAMBER: None.(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.):
si��
8
Page 9 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
' SYSTEM:INFORM.ATION (continued)
Property Address: 23 Spruce Street .
West Barnstable, AM
Owner: Dorothy Rice _. _
Date of Inspection: August 21, 2001
SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required)
If SAS not located explain why:
Type
leaching pits,number:
leaching chambers,number:
leaching galleries,number:
leaching trenches,number,length:
leaching fields,number,dimensions:
✓ overflow cesspool,number: . 1 _
Innovative/alternative system -Type/name of technology_
Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,y
etc.):
ne overflow cesspool was S'W x.6'T x 8' bottom to-grade, and had 3'of water-on the bottom.,The scum line was at the same
level. There were no suns of failure. The cover was 16"below-grade.
CESSPOOLS: ✓ (cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration: I with overflow
Depth-top of liquid to inlet invert: —
Depth of solids layer: 6"
Depth of scum layer: 1"
Dimensions of cesspool: S'Wx S'T x 8' bottom to-grade
Materials of construction: Block
Indication of groundwater inflow(yes or no): No
Comments (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
The liquid in the cesspool was up to the outlet pipe. The outlet tee was present. The cover was 12"below-grade.
PRIVY: None (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.):
9
4
Page 10 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
�. . ;� :. SYSTEM.INFORMATION(continued)
Property Address: 23 Spruce Street
West Barnstable, MA 4+'. -•,t _.
Owner: Dorothy Rice
Date of Inspection: August 21, 2001
Map:216
Parcel:OSO
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.
ids
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10
Page 11 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM.INFORMATION�(continued)
Property Address: 23 Spruce Street y"m ="• �`: ,.:j-47
West Barnstable, AM
Owner: Dorothy Rice
Date of Inspection: August 21, 2001
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth 0 ground water 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 of Health-explain: topographic&water contours maps
Checked with local excavators,installers-(attach documentation)
Accessed USGS database-explain:,
You must describe how you established the high ground water elevation:
The bottom of the cesspool to grade was approximately 8. Using the Barnstable topographic map and the Cape Cod Commission
water contours map the maps were showing approximately 57'+/ to groundwater at this site.
This report has been prepared and the system inspected and passed as of the date of inspection. This report is not a
warranty or guarantee that the system will junction properly in the future. There have been no warranties or guarantees,
either expressed,written or implied, relating to the system, the inspection and/or this report.
11
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