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HomeMy WebLinkAbout0195 WILLOW STREET - Health 195 WILLOW STREET, o _ oA 155 009 o p a TROY WILLIAMS a. ' 0 '00*1 SEPTIC INSPECTIONS J U N i 4 1996 � Cc-tified by MA Department of Environmental ProtectionY. fttiiDEpt (508) 60-1819 40 Old Bass River Road South Dennis,MA 02660 Jan - commonwealth of Massachusetts(,4.z L Executive Office of Environmental Affairs D°� Department of Environmental Protection William F.Weld Trudy Coxe Argoo Paul Cellucci David B.Struhs LL Go emor Qxr.TAwiorwr SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A - 1 CERTIFICATION Property Address: 19 w �l a cN Sf. W e-1�- &_rh s f z �c-• Address of Owner. f U S z�f j /"(o IS �+ Date of Inspection: (If different) Name of Inspector. �/�n („f i r.µ, > S.1p t. Company Name,Address and Telephone Number. S� Ck 6.✓ CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: -Z Passes Conditionally Passes Needs Further Evaluation By the Local Approving Authority Fails Inspector's Signature A _P Date The System Inspector shall submit a coy 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,if applicable and the approving authority. INSPECTION SUMMARY: Check A, B. C,or D: A) SYSTEM PASSES: �1 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. B) SYSTEM CONDITIONALLY PASSES: M114 One or more system components need to be replaced or repaired. The system,upon completion of the replacement or repair,passes inspection. Indicate yea, no,or not determined(Y. N,or ND). Describe basis of determination in all instances. If"not determined",explain why not) The septic tank is metal, cracked,structurally unsound, shows substantial infiltration or exfiltration,or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a Conforming septic tank as approved by the Board of Health. (revised 11/03/95) 1 f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A / CERTIFICATION(continued) Property Address: Owner. Mars Date of Inspection: 5117 B) SYSTEM CONDITIONALLY PASSES (continued) Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed C1 FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: 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. The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for ooliform 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. 3) OTHER (revised 11/03/95) 2 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Addresa: Owner. a vs 11 c. 1 Date of Inspection: C 117 0(- D) SYSTEM FAILS: A///9 I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. — Backup of sewage into facility or system component due to an 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 1/2 day flow. — Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped — Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. — Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. — Any portion of a cesspool or privy is within a Zone I of a public well. — Any portion of a cesspool or privy is within 50 feet of a private water supply well. — Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. El LARGE SYSTEM FAILS: ^114 The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: — the system is within 400 feet of a surface drinking water supply — the system is within 200 feet of a tributary to a surface drinking water supply — the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area (IWPA)or a mapped Zone 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 consult the local regional office of the Department for further information. (revised 11/03/95) 3 f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: Owner. Date of Inspection: Check if the following have been done: Pumping information was requested of the owner, occupant, and Board of Health. None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. / V As built plans have been obtained and examined. Note if they are not available with N/A ZThe facility or dwelling was inspected for signs of sewage back-up. V The system does not receive non-sanitary or industrial waste flow Y The site was inspected for signs of breakout. All system components, excluding the Soil Absorption System, have been located on the site. JL/The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. ZThe size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods. ZThe facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of Sub- Surface Disposal System. (revised 11/03/95) q I� SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address; Owner. A' Date of Inspection: RESIDENTL&L FLOW CONDITIONS Design now:- Q�allona Number of bedrooms:�.� Number of current residents: y Garbage grinder(yes or no):_,6/4) L&nnd=Y connected to system(yes or no):—�f S Seasonal use(yes or no): /ld Water meter reading, if available: r'. c/t, c - (/.) I ll J / H H K Nam. O .L U l/� L v K o inJ to C:C-- Laat date of occupancy: COMMERCIA LAND USTRiAi•/�I/� Type of establishment: Design fl0w:_—gal1ons/day Grease trap present: (yea or no)_ Industrial Waste Holding Tank present: (yes or no)_ Non-sanitary waste discharged to the Title 5 system: (yes or no) Water meter readings, if available: Last date of occupancy: OTHER (Describe) Last date of occupancy: GENERAL INFORMATION PUMP RECORDS d source of information: System pumped as part of inspection: (yes or no) /YQ . If yes,volume pumped: gallons Reason for pumping: TYPE SYSTEM �- Septic tank/ cn ba soil absorption system Single oesspool Overflow cesspool Privy Shared system(yes or no) (if yea, attach previous inspection records, if any) Other(explain) APPROXIMATE AGE of components, date installed(if known) and source of information: a -ems - s,. '• Sewage odors detected when arriving at the site: (yes or no) /VO (revised 11/03/95) 5 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (oontinued) Property Address: I q S V v l/U GJ Owner. / of Inspection: Mai- Date S w ' SEPTIC TANK:_ (locate on site plan) Depth below gra&: Material of construction: ✓concrete_metal_FRP—other(explain) Dimensions: Sludge depth: " Distance from top of sludge to bottom of outlet tee or baffle: a Scum thickness: NOW Distance from top of scum to top of outlet tee or baffle: /Vc) Distance from bottom of scum to bottom of outlet tee or baffle: /y10 S c- vh Comments: (recommendation for pumping, condition of inlet and tlet tees or baffles, depth of liquid level in relation to outlet invert, stru integrity, evidence of leakage, etc.) U C- GL S t o v f' { 7- 5 r.�c.� .s c� i h W o✓ o✓c�c.iAl- GL t o i/ ✓ �LJro�" GREASE TRAP: (locate on site plan) Depth below grade: Material of construction: _concrete_metal_FRP—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: Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert,structural integrity, evidence of leakage, etc.) (revised 11/03/95) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Addrem Owner. /l/(4✓5 Date of Inspection: s/ /7 /�6 TIGHT OR HOLDING TANK IVI/I (locate on site plan) Depth below grade: Material of constriction:_concrete_metal_FRP—other(explain) Dimensions: Capacity:_ moons Design flow: gallons/day Alarm level: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX:/V1/� (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.) PUMP CHAMBER Z�4 (locate on site plan) Pumps in working order:(yes or no) Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) (revised 11/03/95) 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C 4 SYSTEM INFORMATION(continued) Property Address: / / w !(o-J Owner. Date of Inspection: //7 / 6 / SOIL ABSORPTION SYSTEM(SAS): L (locate on site plan, if posabk;excavation not required,but may be approximated by non-intrusive methods) If not determined to be present,explain: Type: leaching pits, number:_ leaching chambers,number:- -1 . leaching galleries, number. leaching trenches, number,length: leaching fields, number,dimensions: overflow cesspool, number: Comments: (note condition of soil, signs of hydraulic failure, level ofpond}ng, condition of vegetatio ) �,, k. ` c brut ✓�' CESSPOOL: it/l/9 (locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer. Depth of scum layer: Dimensions of cesspool: Materials of constriction: Indication of groundwater: inflow(cesspool must be pumped as part of inspection) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY: /1119 (locate on site plan) Material of construction: Dimensions: Depth of solids: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) (revised 11/03/95) 8 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C 11 Li c SYSTEM INFORMATION (continued) Property Address! /�/ J �J fNo(,) 5�. Owner: ✓"�a`r 5�a 11 Date of Inspection; S'/l 7 04 SKETCH OF SEWAGE DISPOSAL SYSTEM: indude ties to at least two permanent references landmarks or benchmarks locate all wells within 100' U� io 0 0 0 / a W,J DEPTH TO GROUNDWATER Depth to groundwater: S• 02 feet y y adjusted high groundwater level method- of determination or approximation: �( 9 Permit Number: Date:-s/ l 7 �y6 Completed by: �wi � u�vas HIGH GROUND-WATER LEVEL COMPUTATION Site Location: y S �� 1/v W �f Lot No. Owner: ��✓S l�� j� Address: Contractor: Address: Notes: STEP 1 Measure depth to water table tonearest 1/10 ft. .............................................................................. .Date month/day/year STEP 2 Using Water-Level Range Zone and Index Well Map locate site and determine: a Dv� OAppropriate index well.................................................... Q OB Water-level range zone ..................................................... STEP 3 Using monthly report"Current Water`Resources Conditions" determine current depth to water level for index well ........................... month/year STEP 4 Using Table of Water-level Adjustments for index well (STEP 2A),current depth to water level for index well (STEP 3), and water-level zone (STEP 26) G determine water-level adjustment ' o.......................................................................................... STEP 5 Estimate depth to high water by subtracting the water- level adjustment (STEP 4) from measured depth to water <l ' levelat site (STEP 1) ............................................................................................................. / TOWN COF BA.RNSTABLE g s/ LOCArfo --1 �� 1 'a J SEWAGE VILLAGE w . ✓ " 5 ASSESSOR'S MAP& LOT 2 .60 INSTALLER'S NAME&PHONE NO. w S COS C6 ti 5 �- SEPTIC TANK CAPACITY l Co U v LEACHING FACILITY: (type) (size) NO.OF BEDROOMS 3 BUILDER OR OWNER PERMTTDATE: 12 4 /?3-COMPLIANCE DATE: 12- 122 Separation Distance Between the: Maximum Adjusted Groundwater Table and 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 feet99eaching fayiiivo Feet Furnished by a f 7 b r TOWN OF BARNSTABLE LOCATION�� / SEWAGE # � ✓' VILLAGE ASSESSOR'S MAP 6z LOT INSTALLER'S"NAME PHONE NO. , SEPTIC TANK CAPACITY LEACHING FACILITY:(type) (size) 4 NO. OF BEDROOMS_ 3 PRIVATE WELL OR PUBLIC WATER.tyeIi BUILDER OR OWNER /f DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: ► I VARIANCE GRANTED: Yes No R ' a5 66-3 34o.......... No.................A OV50 8rn8ta6lo CWjSCrvot 0n QCXAgg.44 COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH /4AP /S� 8i TOWN OF BARNSTABLE Appliration for Div ntittl Works Cnoustrnr#iun rumit Application is hereby made for a Permit to Coristruct ( ) or Repair (V) an Individual Sewage Disposal System at: Loc t'oii-Addressown r or Lot No. / �A. -- f � --- �© -------------------------------------------------------------------------- c. ...{ .. C ,.�fti......�_5�........................... 9 1i Address c pq q,5 Type of Building t� Size Lot............................Sq. feet Dwelling—No. of Bedrooms.---..-'.V----------------------------------Expansion Attic ( ) Garbage Grinder ( ) a`4 Other—Type of Building No. of ersons---_--. g -------------------•----.... P ------------------- Showers ( ) — Cafeteria ( ) d Other fixtures ------------------------------------------------------ W Design Flow............................................gallons per person per day. Total daily flow--------------------------------------------gallons. WW Septic Tank—Liquid capa6tytft.16--gallons Length---------------- Width---------------- Diameter_............. Depth................ Disposal Trench—No. .................... Width-------------------- Total Length.................... Total leaching area....................sq. ft. 3 Seepage Pit No...................... Diameter-----.--.-.-..-----. Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) P., Percolation Test Results Performed by---------- -------•---•-------•---•-----------•---•-•-------••----•----•-- Date........................................ 1.4 1.4 Test Pit No. I................minutes per inch Depth of Test Pit---.--------..-----. Depth to ground water........................ 40 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water...---.................. R. ---- --------------------- ---------------------------------------------------•-•---------.....---........................................................ ODescription of Soil........................................................................................................................................................................ x V .------------------••...------•-----•---------•-------------....------------------•••------------••---------•--•-•-•----•-------------••-------------••--•----•-----•------------.......----............. W x ----•---- - - ----- U Nature of Repairs or Alterations—Answer when applicable. - - --- ---- -- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The det igned further agrees not to place the system in operation until a Certificate of Compli4ivice has been is e o alth. Signed .......... kldo .............................. Dace Application Approved B --- -----............................................... ...................... .. •;w- ..� _3---3.... PP PP Y ...... - °v � Date Application Disapproved for the following rea.rons: .....---------------------------------------------------------------------------------------------------............................... -- .... ........ ..... ........................................................ ....... ......................................................................... ........................................ Dace Permit No. ------Fl_,.....t'0. .3................... D Issued ---------------------..................------------..--- ......... Dace _---.___--.---.------�--- —J 2 {{ f I 9'3- � � ; ram• � No........................... THE LTH MASSACHUSE BOARDAOF FH EALTH TS /�a /Ste' OU 9 TOWN OF BARNSTABLE . Appliration for Dim ujttl Wnrkii Towitrur#lun ramit Application is hereby made for a Permit to Construct ( ) or Repair (\/) an Individual Sewage Disposal System at: Loc t'o I-Address or Lot No. ....................... �--------------------------- --- =1 . ...................... ... re,.s........................................... etrd.. M Ownfr l/\J A dress ----•--- ......... v ��hist„'aller)/y Y11 S�i/� �y''��� Address Type of Building F Ifj r / Size Lot............................Sq. feet Dwelling—No. of Bedrooms--------------------------------------------Expansion Attic ( ) Garbage Grinder ( ) a`4 Other—T e of Building No. of ersons_--___. YP g ---------------------------- P �.----.....---------- Showers ( ) — Cafeteria ( ) dOther fixtures --------------------------------------------------------------•----------------------- ---•-----•-•......----•-•----•-- W Design Flow....._.............._.......________________gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacitylO!)U---gallons Length---------------- Width---------------- Diameter---------------- Depth................ x Disposal Trench—No. .................... Width....:............... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) �-' Percolation Test Results Performed by-----......................................................................_ Date........................................ Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water___:................... (i Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 04 •--••-••••---•...............•--•-•••-•---•••---•-•••-••••••--••--•-•......-••---------•-••-•--•---.......................................................... 0 Description of Soil........................................................................................................................................................................ x V .............................................. •------••-••••--•-•••---••-•--•----•-•••-•---•••----•••-•-••--•--------•-------•••-••••---•---•••••••••--•••••---•••••••••-•••-•-...--•---•-•............. W V Nature of Repairs(or Alterations—Answer�/when �yapplica{ble............................. � .�5.�_���___^�L��,��L�,u(•1- (.r lR � �.......... 5....��.1� SC_�...._._\.......Lt •_..�.� `���.............. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code —The ders"igned further agrees not to place the system in operation until a Certificate of Compliance has beenis bed-yy the boa -h'ealth. q�tSigned " ..........`-............_........_............... ...... .................................------ Dace Application Approved By .... ...... 3 `� -..- � -..9.... ...._Date Application Disapproved for the following reasons- ----------------------- ------------------------------------------------------------------------------------------------------------ ........................ ... ........... ............................. . . Dare Permit No. .7j_-..._�2. ..... .... Issued ................. ... - . ..................... Dace --——————_.——--- ————,—————---——--—--—'--————— THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Ge r#tfira e of Complian e THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired by ------- ---------C.- '- .'S.^ ( - ------------ ------------ ---------------------------------------------------------- at --------- r^�....... -`------v-l----- - -- ---------- z'- -C"1 r`� - ^ ........... � ------------- ------------------------------------ has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in the application for Disposal Works Construction Permit No. ... _':�-------.. dated .............__------------------------------ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. Inspector .�-f..:<.'.' � ..����e � �(r e DATE.. t.,.- . 1 Iq ��' - �T l.' Ir i{ f�' "L i . ; p '( --- ----- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH pp TOWN OF BARNSTABLE y FEE.._�.!9_.......... Diupulittl urk �u�t #rs#iunrrmi� Permission is hereby granted........... -_-.. ''S,c to Construct ( ) or Repair (\/) an Individual Sewage Disposal System at No....1,e`�. �..�_\. .Z�.----•---•-S_ C3...r n- {-�---.....2 Street e� as shown on the application for Disposal Works Construction Permit No._/..3_-47 3 Dated______�� DATE.................. - _._-.��-:_ .�.................•---•------- oars of Health FORM 36508 HOBBS 6 WARREN.INC.,PUBLISHERS