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HomeMy WebLinkAbout0010 BUNNY RUN - Health 10 Bunny Run House Barnstable A = 234 - 037 — BOO �, CONINIONN�EA.LTH OF '. ASSACHL'SETTS EXECUTIVE OFFICE OF ENNIRONNIENTAL A � d DEPARTMENT OF ENNIRONME\TAL P CTIO `+E 0- ONE Wl\TER STREET. BOSTON. N1A 02'108 61"•_9: ' �pTBg9N Igg� WILLIAV F WELD ,� ypFTlAe/F TAR 1 CO% Govemc Sere N ARGEO PALL CELLL'CCl I �Dw 'ID B STRL', Lt.Govemor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Commissioc PART A CERTIFICATION ,��rs.,K ter Property Address: \ t Address of Owner: V%Qp a Date of Inspection: 7 a� `�'1 (If different) G�O v.,V 1 'ems\ZS1 ro-x I ACfAS Name of Inspector: (,A% AZ:IA—L V-T zz I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 13.000) S . y P�t►'�`l� w4i1 A j Company Name: R , �--- e)Zb(.o / Mailing Address: -X Q-,y� Telephone Number. —I, , ZQ CERTIFICATION STATEMENT I cenir� that I have personaliy irsDected the sev`aee disposal system at this address and tha: the information reported below is true. accurate and comDlete as o;the time of inspeG 0' The inspect;on Kas penormed basec on m% training and experience in the proper function and maintenance of on-site sewage disposa systems The system Passes Conc,ho"�a. . gasses �eec ^ur^•e- -%a•.jaror E\ the Local 4ppro%:ne .Au:norir\ _ ha Inspector's Signature: Date: The Svse-r InsDecto• sha'' submit a copy or this inspection !eoort to the Approving Authority within thirtv (30) days of completing this inspecttor. It the system is a shared wstem o• has a Desien flow, of 10.000 gpd or ereater, the inspector and the system owner shall submit the repot to :tie appropriate reg,or.al onice of me Depar,ment of Environmental. Protection. The original should be sent to the system owne- and copes sent to the bu\-e,. o aoolicable. and the aDDrc-irg authorir\ INSPECTION SUMMARI: Check A, B, C, Or D: A] SYSTEM PASSES: I have not found anv information which indicates that the system violates any of the failure criteria as defined in 31.0 CMR 15.303 Any failure criteria not evaluated are indicatea below. COMMENTS: B] SYSTEM CONDITIONALLY PASSES: One or more system components as described to the "Conditional Pass" section need.to be replaced or repaired. The system, upc completion of the replacement or repair, as approved by the Board of Health, will pass. Indicate yes, no, or not determined (Y, N, or NDi. Describe basis of determination in all instances. If "not determined", explain why not. The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection; c the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltratton, or tar,. 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. (rev;.sed 04/25/97) Page 1 of 10 DEo o the Wona Wae Weo hrW lnvww magnet state ma usroec '. Pnntec on RecycieC Pace, SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Owner: Date of Inspection: ` e) SYSTEM CONDITIONALLY PASSES (continued Sewage backup or breakout or high static water level observed in the distri Lion box is due to broken or obstructed pipets) or due to a broken, settled or uneven distribution box. The system ill pass inspection if(with approval of the Board of Health;. Describe observations: broken pipets) are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four times a year due to br en or obstructed pipe(s). The system will pass insoection it. (with approval of the Board of Health) broken pipets) are replacec obstructior is removed C) FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which reauire further evaluation by the Board of H Ith in order to determine if the system is failing to protect th. public health, saner\ and the environment 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINE THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY D THE ENVIRONMENT: _ Cess000i or prig-. is within 50 feet of a surface water Cesspooi or pm, 15 %%jthin 50 feet of a bordering v getated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (A 'D PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THA- THE SYSTEM IS FUNCTIONING IN A MANNER THAT PliOTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: / The system has a septic tank and soil absorption system (SAS) and the SAS.is within 100 feet to a surface water supply or tnbutan, to a surface water supply The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supn'v well. The system has a septic tank and soil abso'rpnon system and the SAS is within 50 feet of a private water suppiy well The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, uniess a wel)/water analysis for coliform bacteria and volatile organic compounds indicates th< 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. Method used to determine distance (approximation not valid). 3) OTHER J (revimed 04/25/97) Page 2 of 10 SUBSURFACE SEWAGE DISPOSAL S?'STEM INSPECTION, FORM PART A CERTIFICATION (continued) Property Address: Owner: Date of Inspection: D) SYSTEM FAILS: You must indicate either "Yes" or '*No' as to each of the following: t have determined that the system violates one or more of the following fail re criteria a< defined in 310 CMR 15.303. The bans for this determination is identified below. The Board of Health should be ontacted to determine what will be necessary to cornea the failure. Yes No Backup of sewage into facility• or system component due to n overloaded or clogged SAS or cesspool. Discharge or pondrng of effluent to the surface of the gro, d or surface waters due to an overloaded or clogged SAS or cesspool. Stanc !squid level in the distribition boa above outlet nvert due to an overloaded or clogged SAS or cesspool. Liouid depth in cesspool is less than 6" below inve or available volume is less than 1/2 day floe. Recurred pumping more than 4 times in the last ear NOT due to clogged or obstructea prpe!s . Numoer or times pumped _ — — Am poon oi the 5 ,I Absor 'i n Svstem. cesspool or privy is below thehi h groundwater elevation i An% port,on o*. a cess000l or priv ,s withi 100 feet of a surface water supbiv or tributan to a surface water supple. � r — — And portion of a cesspoo' or pri%) is �.%itNIr a Zone I of a public well. Am po^.o-_ o* a cesspoo! or privv is within 50 feet of a private water supply wet! An por:.or o;a cesspool or pri„• is/less than 100 feet but greater than 50 feet from a private eater supply well with no acceo:abie water qualm anak-, 14 the well has been anahzed to be acceptabie. attach cope or well water analysis for coliforr- bacteria volatile organic.compounds, ammonia nitrogen and nitrate nitrogen. E] LARGE SYSTEM FAILS: You must indicate either "Yes' or "',o•• as to each of the following. The ioliow,ng c�iterna aop,% to large systems in addition to the criteria above: The system serves a facilin 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: i` 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 i 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 iniormation. (revaaed 04/75/97) Page 3 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 10 &4*U Owner: V,ShNX- . Date of Inspection: Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Yes 'vo No Pumping information was provided by the owner, occupant, or Board of Health. None of the system components have been pumped for at least two weeks and the system has been receiving normal r-- i r uced into the system recenti% or v not been nt od Y flow rates during that period. Large volumes of water have as part of this inspection As built plans have been ootained and examined, Note if they are not available with N/A. The tac:lin or 6velim-e �%as inspected fo, signs o`sewage back-up. The system does not recei\e non-sanitary or industrial waste flow. The site �\as inspected for signs of breakout All s\steT cornoonenis. excludine the Soil Aosorpuon System, have been located on the site. The septic tank manhoies were uncovered. openecl. and the interior of the septic tank was inspected for condition of baf ies or tees. materta! o• construction. dimensions. ceptn of liquid, depth of sludge, depth of scum. The size and location of the Soil .Absorption Svstern on the site has been determined based on The fac.im, owne• ano occuoants. if diReren: trorn owner) were provided with information on the proper maintenance of Sub-Surface Disposal System Exist!ne information. Ex Plan at B.O H _ Determined in the field r an, of the failure cetera reiated to Part C is at issue, approximation of distance is unacceptan�e (>3.302 3::b'J (revised 04/25/47: Page 4 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Propertm Address: (O GLXQtJj Owner: Date of Inspection: I FLOW CONDITIONS RESIDENTIAL: - Design floK 330 i).d./bedroom for S.A.S Number of bedrooms. Number o`current residents: D Garbage g,; der (yes or nol: Laundry co-•^ected to system ('es or no? es Seasonal use (yes or no,:�� � Water meter readings, if available (last two ;2i year usage tgpd): Nib Sump Pump (ves or no): 1J( ) Last dale of occupancy QQ\p,2 j,f` I�GnO1J, COMMERCIAL'INDL'STRIAL: Type of establishment. Design fio%+ ealions day Grease trap present. (Yes or no_ Industria! \taste Holding Tank present. ves or no_ Non-sanitan v,aste discharged to the T!toe 5 sysem ;ves or no_ eater meter readings. if avadabie Las,.pate o: o OTHER: .De:cribe Last date of occuoanc-. GENERAL INFORMATION PUMPING RECORDS and source or rnformatior System umped as par, of inspection: ;ves or no_ If Yes, volume pumped eallons Reason for pumping ' TYPE OF SYSTEM _ Septic tank/distr but'on box/soil absorption system Single cesspool weleRdVi Cesspoo ( I Overflow cessp of P rn�, Shared system (yes or no) (if yes, attach previous inspection records, if any) I/A Technologv etc. Copy of up to date contract? Other ' APPROXIMATE AGE of all components, date installed (if known) and source of information: Sewage odors detected when arriving at the site. (yes or no)J—jL7 (revised 04/25/91) Pago 5 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM -PART C SYSTEM INFORMATION (continued) Property Address: Owner: Date of Inspection: BUILDING SEWER: (Locate on site plan) Depth below grade: Material of construction: _cast iron _40 P%,C _other (explain! :. Distance from private water supply well or suction li-t Diameter Comments: (condition of joints, venting, evidence of leakage, etc.) SEPTIC TANK:_ (locate on site plan Depth below grade Material of construction: _concre*,e _meta _Fiberglass _Polyethvlene _other(explain! If tank is metal, list age _ Is age confirmec b\ Cert,i)cate of Compliance _(YesNo Dimensions Sludge depth Dtsiance from top of sludge to bottom of outie. tee or ba^'e Scum thickness: Distance from top of scum to top of outlet tee or ba^ie Distance from bonom of scum to bot o-n of outlet tee or bare. How dimensions were determined 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.) 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 scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments: (recommendation for pumping, condition of islet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.; (rev:aad 04/25:97) Page 6 of 10 SUBSURF,kCE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: Date of Inspection: BUILDING SEWER: (Locate on site plan) Depth below grade. Material of construction: _cast iron _40 PVC _other (explains Distance from private water supply well or suction Ir-, Diameter Comments: (condition of joints, venting, evidence of leakage. etc.) SEPTIC TANK: (locate on site pian Depth below grade material of construction _concrete _meta _Floe glass _Pol ethvlene _othertexplam If tank is metal, lis: age _ Is age con-, rmec o, Ce^:ficate of C mpitance _(Yes,-.No Dimensions Sludge depth Disiance from top c: s:uege to boron of outle: tee o, ba�:e Scum thickness Distance from top of scum to top o! outle: tee or bake Distance from bottom of scum to bo-o-n o�ouue: tee e• o ..e Mow dimensions mere determines Comments trecommendation for pumping. condition or iniet and c4dei tees or baffles. depth of liquid level in reiation to outlet invert, structural integrity, evidence of leakage. etc.i GREASE TRAP: (locate on site plan! Depth below grade Material of construction: _concrete _metal F�bergiass _Polyethylene _other(explain) Dimensions: Scum thickness: Distance from top of scum to top of outlet/lee or baffle. Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments: (recommendation for pumping, condition of olet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural ,ntegrity, evidence of leakage, etc.; r (rev-med 01/I5.'97) Page 6 of 10 f SUSSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOR.ti1 PART C SYSTEM INFORMATION (continued) Property Address: Owner: Date of Inspection: TIGHT OR HOLDING TANK: lank must be pumped prior to, or at time, of ins ctioni (locate on site plan, Depth below grade. Material of construction _concrete _metal _Fiberglass _Polyethylene _oth (explain) Dimensions: Capacity gaiions Design flow gahors,da, Alarm level Alarm in v%orking order _ Yes. _ No Date of previous pumping Comments (condition of inlet tee. condition o- alarm and float switches. etc.) i l DISTRIBUTION BOX:_ locate on site p:ari De.-t^ of Mould level aoove outle: in%e Comments (note if level and disrriou;ior is eaua' evidence of solids carryover, evidence of leakage into or out of box, etc.( I 1 PUMP CHAMBER:_ / (locate on site plan. Pumps in working order: (Yes or No' Alarms in working order (l es or No- f i Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) 1 I 1 (revised 04/25/97) Page 7 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) PropertN Address: Ins 1�•�1 &VU Owner: T �,� l5 Date of Inspection:lbq q SOIL ABSORPTION SYSTEM (SAS):_UL? (locate on site plan, if possible, excaT uon not required. but may be approximated by non-intrusive methods) If not determined to be present, explain. Type_ leaching pits. number._ leaching chambers, number_ leaching galleries, number. leaching trenches, number.length leaching foeids, number, dilnens s overflowcesspool, number i.A'l Alternative system Name of Tecmnoiog\ Comments i ote ondrtion of sod sigrs of hydraulic failure, level of pondQg. condit� of vegetation, etc.' O * CESSPOOLS: (locate on site p ar. Number and con6gura:-or. `UN Depth-top of liquid to inlet Inver, Depth of solids lave, # °" Depth of scum laver it Dimensions of cesspool f.x U7 ' Materials of constructior CCC r_Ct,-_4_ r.C_ Indication of groundwate• inflow (cesspool must oe pumper as par, of inspectoon, 4J(� Comments: (note condition of soil, signs of hydraulic failure, level of pongfing, condition of vegetation, etc.) t f = L l �C t,.i o+ L.t Pow w.IE, sua.MnA mi PRIVY: _ (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments: (note condition of soil, signs of hvdrauhc-failure, level of ponding, condition of vegetation, etc.) (revised 04/25/91) page 8 of 10 r • SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) pp W`v Propert} Address: jV O%ner: Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) . (revised O4i25/57) Page 9 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Pro ertv Address: 'N Owner: S Date of Inspection: I(A,) 1C) . 1Z3 Depth to Groundwater _ 4e%% Please indicate all the methods used to determine High Groundwater Elevation: Obtained irom Design Plans on record Observation of Site (Abutting prope observation hole basement sump etc.) Determine it from local conditions ChecK %%ith loca! Board o! neattr. Check FE.. MA Maps Check pumping records Check local eaca\ators, installers t_se I-SCS Da:2 Describe in %o,,, own %-.orci no%\ \ou estab!qhed the tiigh Groundwater Elevation. (Must be completed, 1-�,3 +� q 4 o3�c�� ©-- Cass P� lzev:a*d :4,'25'9-. Page 10 of 10