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HomeMy WebLinkAbout0035 CAPE COD LANE - Health 35 Cape Cod Lane Barnstable P r A = 298 001 a p h o o � I 3 r COMMONWEALTH OF MASSACHUSETT 4- 1 S �• ExEcuTivE OFFICE OF ENVIRONMENTAL NME DEPARTMENT OF ENVIRONMENT PR E, TI I CEIVED JUL 2 9 TOWN 0,- �.; HEALT,-t TITL OFFICIAL INSPECTION FOR�tii NOTE 5 1-� SUBSURFACE SEWAGE DISPOSAL YSTENI FORINI ENIS PART A R1�I CEE'RTIFICATION \1��� Property Address: e Cod Z 41 / Owner's Name: MAP Owner's Address: 3 oSs PARCEL �- - ®K) l Date of Inspection: � ,o LOT Name of Inspector. (please print) Company Name: E !/ip — G rywling Address: 0 Telephone Number.' O CERTIFICATION STATEIINIENT 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 ins pectioa The inspection was po ed training and experience in the proper function and maintenance of on site sewn a performed based on my approved system inspector pursuant to Sect' 153•i0 of Title S 310 CMR c disposal systems. I am a DEP ( ) The System: Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fat Inspector's Signature: Date: (' �p b The system inspector shall submit a copy of this inspection re DEP)%ice 30 days of completing this inspection_ If the systemR s a shared system or has a to the pproving Authority(Board of Health or sign flow or lo,000 gpd or greater,the inspcctor 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 a authority. ppro�ing Notcs 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 t conditions of use he future under the same or differe nt 9-4rV i Vl 11 �} • OFFICIAL INSPECTION FORAt—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSZ'ErvI IN FORM ! PART A CERTIFICATION (continued) !t Property Address . 2• e Owner: a�n G e O 6�C7 Date of[nspectioa: ��O f Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section on D A. Sys Passes: —/ I have not found any information which indicates that an of the 15.303 or in 310 CN R 15.304 exist Any failure criteria not evaluated ed are indiicaure tedbbel�described in 310 Civilt Comments: B. System Conditionally Pauses: —Zk O e or more system components in the repaired.The system, upon compioetion of the replacement or conditional Pais-section need to be replaced or Pam,as approved.by the Board of Health,will pass. Answer yes, no or not determined(Y,N,ND)in the for the follovvin •• g statements. If not determined'please The septic tank is metal and over 20 years old*or the septic _unsound,exhibits substantial infiltration or exfiltration or tank P tank(whether metal or not)is structurally e cisting tank is replaced with a complying septic tank as a roved by lure is unrcuaent System will `A metal septic tank-wilt passcturally the Board of Health. pass inspection if the indicating that the tank is less than 2020 years old issueavailable.� d not leaking and if a Certificate of Compliance ND eXplain: Observation of sewage backup or break out or high static water level in the distribution bo. Obstructed pipe(s)or due to a broken,settled or uneven distribution box System will v due to broken or aPProval of Board of Health): pas ins inspection if(with broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND e.,cplain: The system required pumping more than 4 times a y Pass inspection if(with approval of the Board of Health): ear due to broken or obstructed pipes) The system will broken pipe(s)are replaced obstruction is removed ND explain: t - . OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORI-vt PART A CERTIFICATION (continued) Property Address: e Car--'- / Owner. �C?5rj Date of Inspection• C. Fu/rther Evaluation is Required by the Board of Health: G y Conditions evst which require further evaluation by the is failing Board of Health in order to determine if the system to protect public health,safer,or the environment. 1- SvStem will pass unless Board of Health determines in accordance with 310 CbfR 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 nay)determines that the system is functioning in a manner that protects the public health,safety and environment: The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply, _ The system has a septic tank and SAS and the SAS is'within a Zone 1 of a public water suppiv. _ The s<•stem has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. system Private water supply well**. M thod used to determine distance SAS and the SAS is less than 100 feet but 50 feet or more from a e "This system performed Passes if the well water analysis, 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 failure criteria are triggered. A copy of the analysis must be a�ctachedlto provided no other 3• Other. s OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORNI ' PART A CERTIFICATION(continued) Property Address: r ��i e cc Owner. R,03- Date of Inspection: o O D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the follo«ing for all inspections: Yes No/ -!;,-,,--Backup of sewage into facility or system component due to overloaded or clog — I/ Discharge or ponding of effluent to the surface of the ground wed SAS o cesspoolbade Clogged SAS or cesspool ! or surface waters due to an overloaded or - cesspool squid depth in cesspool is less than 6 below invert or available volume is less than _. Required pumping more than 4 times in the last year NOT due to clogged a day flow /of times pumped geed or obstructed pipe(s)• Number �/"y portion of the SAS,cesspool or privy is below high ground water elevation. -V Any portion of cesspool or privy is within 100 feet of a surface�Vhter supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone 1 of a public welva l. Any portion of a cesspool or privy is within 50 feet of a — . y portion of a cesspool or privy is less than 100 feet but greatwater r tthan SOpfcc from a rival Supply well with no acceptable water quality analysis. P e water F=indicates DEP certified laboratory,for coliform(This Passes v rile o orga water nic COmpouodys, indicates c:::, ;ne well is tree from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than S ppm,provided that no other failure criteria Wry are triggered.A copy of the analysis must be attached to this form.] es/No)The system fails. I have determined that one or more of the above failure criteria exist as described e e 10 new 1t will 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 la s:.tem gpd. the system must serti•e a facility with a design now of 10,001l gpd to 15,000 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 11 of a public water supply well If you have answered"yes" to an " Y question in Section E the system is considered a signi Yes"in Section D above the la_- ficant threat,or answered ,,e system has faded•The owner or operator of any large system considered a stgrt�cant threat under Section E or failed under Section D shall u 15.304.The System owner should contact the a lade the System m accordance with 310 Clot ppropriate regional ofce of the Department. x Page 5ofll .{ OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY A SUBSURFACE SEWAGE DISPOSAL SYSTEr j INSPECTION FORMS s , PART B CHECKLIST Property Address: r Owner: Dste or inspection; 6 �o Chcck if the following have been done. You must indicate"ce " s or"no"as to each of the followin Yew No mpmo ii1foratation was provided by the owner, occupant,or Board of Health Were any of the system components pumped out in the previous two weeks 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 Were as built plans of the system obtained and examined?(!f they.were not available note as N/A) Was the facility or dwelling inspected for signs of sC%age back up Was the site inspected for signs of break out Were/ all system components,excluding udtng the SAS, located on site Were the septic tank manholes uncovered,opened,and the interior of the tank ins of th es or tees,material of construction,dimensions depth of li petted for the condition v P Quid,depth of sludge and depth of scum Was the facility owner(and occupants if different from owner)provided%ith information on the proper maintenance of subsurface sewage disposal systems The size and location of the Soil Absorption System Ye no (SAS)on the site has been determin ed based on: E.=ting information. For e.`cample,a plan at the Board of Health- Determined in the field if is unacce any of the failure criteria related to Part C is at issue approximation of distance ptable) [3I0 CrCiVIFt 15.302(3)(b)] rage o of &I - }r OFFICIAL. INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTENI IlYSPECTION FORM PART SYSTEM INFO%NL4,-I0N Property Address: ` C_ a. e Owner: Date of Inspection: RESIDENTIAL FLOW CONDITIONS Number of bedrooms(design): 3 Number of bedrooms(actual): DESIGN flow based on 310 C1*1Il2 15.203 (for example: 110 Number of current residents; OU x#of bedrooms): -0 Does residence have a garbage grinder(yes or no): � Is laundry on a separate sewage system(yes or no)'je�2[if yes separate in q l ): Laundry system uispected(yes or no /0uon re sired Seasonal use: (yes or no):Lfjo Water meter readings,if available(last 2 years usage(gpd)): Sump Pump(yes or no): "L-o Last date of occupancy: L COMMERCIALT0USTRIAL Type of establishment: Design flow(based on 310 CUR 15.203): �d Basis of design flow(seats/persons/sgft etc.): Grease trap Present(yes or no): Industrial waste holding tank present(,yes or no):_ Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings,if available: Last date of occupancy/use: OTHER Pumping Records GENERAL INFOILNUTION Source of information: Was system pumped as part of the i if yes,volumepumped: 0 �"p uminspection(yes or no): P Ped:----gallons—How was quantity ?Reason for pumping: Pumped determined OF SYSTEM Septic tank distribution box,soil absorption system _Single cesspool Overflow cesspool r Privy ._Shared system(yes or no)(if Yes,attach previous ins pection spection records. if ant) _Innovative(Alternative technology.Attach a copy of the obtained from system owner) current operation and maintenance contract(to be _Tight tank _Attach a copy of the DEP approval _Other(describe): APPrO-'d=e age of all componenM date installed(if known and sou rce of h rnformzdon: Were sewage odors detected when arriving at:he site(yes or no): /%� Page 7 of l 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORAIATION(continued) Property Address: Owner. 10 Date of Inspection- a BUILDLNG SEWER(locate 0 ite plan) Depth below gam: Materials of constru!'tion:_ Distance from private water cast iron PVC other(explain): Comments(on condition of jo�l veniting,evidence of leakage, etc.): SEPTIC TANK:_(locate on -te plan) Depth below gam; '7 Material of consnvctio'n: — concrete_meta! fiber _other(explaia) _fiberglass._polyethylene If tank is metal list age:— Is age confirmed by a Certificate of Com liance ce:tificate) P (yes or no): (attach a copy of Dimensions: CX (.Q Sludge depth: Distance from top of sludge to bottom of outlet or baffl Scum thickness: e: ��� Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom o outlet tee or baffle:How were dimensions determined: o Comments(on pumping commendations,inlet and oud tee or .. `e co as atcd to outlet invert,��n of leakage,etc. : baffle condition.structural irate cf ,� griry, liquid levels ec c �74- 07 GREASE TRAP; (locate on site plan) Depth below gam:_ Material of construction:_concrete_metal_fiberglass_polyethylene (explain): other Dimensions: Scum thiclrness; Distance from to of sc�urtt to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or bctfile: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or as related to outlet invert.evidence of leaks baffle condition,structural irate leakage,etc.): integrity, liquid levels Page aofII OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address• �oc_j Owner. 0-5- Date of inspection: 6 TIGHT or HOLDING TANKtank must be pumped at time of'uLspection)(iocate on site plan) Depth below!'lade: Material of construction: concrete metal fiberglass_polyethylene other(cxplain): Dimensions: Capacity: g�ous Design Flow: ealIons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of Iasi pumping: Comments(condition of alarm and float switches,etc.): DISTRLBG i iv`:�0.%:1XV went must be o a Pr pe ed)(locate on site plan) Depth of liquid level abov_ .. invert �D��/`�Gi Comments(note if box is Ic%el 2.;:d distribution to outlets leakage into or ut of box,etc. : any evidence of solids GUTyover,any evidence of s PUMP CHAMER��ocate 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 appunenanccs.etc.): { ( Page 9 of l l — OFFICIAL, INSPECTION FORM—NOT FOR VOL `€ SUBSURFACE SEWAGE DISPOSAL SY `I'E�I INsp RY ASSESSMENTS PART C ECTION FORIvi SYSTEM INFORMATION(continued) Property Address: �J <f:;F e �o Owner. Date of Inspection: SOEL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located e:cplain why: i TYPe _ leaching pits,number. leaching chambers,number. r leaching galleries,number: S leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool, number innovative/altemative system Typeiname of technology: Comments(note condition of soil,signs of hydraulic failure, level of pondin ......dam etc')' / / g. p soil,condition of vegetation, CESSPOOLS:/—t/(cesspool must be pumped ped as part of inspection)(1«ate on site plan) Number and configuration: Depth—top of liquid to inlet invert: Leptia of solids layer. Depth of scum layer Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetatiorL etc.): PRIVY'x0ocate 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.g on.etc.): --------------- i i t 1 - rjgc lV Vl ll ! j OFFICIAL INSPECTION FORM—NOT FOR V ' LUNTY SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORMS PART C SYSTEM INFORMATION(continued) Property Address: �'�� Owner. _OS r Ltr7 ,J� �P�� Date of Inspection: 9 p SKETCH OF SEWAGE DISPOSAL SYSTE1Vi Provide a sketch of the sewage disposal system including tics to at least two permanent reference landmarks or benchmarks.Locate all wells within 100 feet. Locate where public water supply enters the building. 3; a, /4-3 / ® (2) a.-)' 1 �r 11. 'L b 6 ^b i u� r i . Page It of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORNI PART C SYSTEM INFORMATION (continued) Property Address: Owner. Date of Inspection: SITE EXAM Slope Surface water Check cellar Shallow wells / Estimated depth to groundwater 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: Checked with local excavators,installers-(attach documentation) Accessed USGS databa -explain: You mu describe w yo established the Pigh ground water elevation: o o f r-, e o 4 ro a off. 1-9 v, I 1 -�r 45:'4 to 4 6�(—(9(4 LA � � TOWN OF BARNSTABLE a LOCATION ,5r— SEWAGE # VILLAGE` ��� � � �� /ASSESSOR'S MAP & LOTZ INSTALLER'S NAME&PHONE NO. ��i�Lo�`� GD�cS�` �7��•��� SEPTIC TANK CAPACITY 15`O� 6c, L- LEACHING FACILITY: (type) Ika-dk4 J (size) 16'X 3 0 "A42 ' NO.OF BEDROOMS BUILDER OR(6 PERMTTDATE: h 2 9� COMPLIANCE DATE: Separation Distance Between the: _ Maximum Adjusted Groundwater Table and Bottom of Leaching Facility t 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 / V within 300 feet of leaching facility) ,(� Feet Furnished by + 0 it � � �� g£ � �� ., SE �$ _._ _ - ,1 �S �7 �C ,�� t � 1 -30 No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 01ppfication for Migpont bpgtem Congtruction Vermit Application for a Permit to Construct( )Repair( )Upgrade(Abandon( ) El Complete System ❑Individual Components Location Address or Lot No. S Owner's ame,Address d Tel.No.`Ca�oe Co la, � Assessor's Map/Parcel Installer's Name,Address,and Tel.No. / Designer's Name,Address and Tel.No. / 7 7/-�,3 Type of Building: Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Grinder F'r)e Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow //41;> gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. �� / 7�✓�' ®�� Description of Soil Nature of Repairs or Alterations(Answer when applicable) le 2Z Le Y Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issue th' f Signed a Date 46 Application Approved by Date Application Disapproved for the following reasons Permit No. Date Issued I 1 _,.. 24, No. - y 1 Fee (`-�// V THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLES MASSACHUSETTS ZIpprication for Migpogal *proem Conotruction Permit Application for a Permit to Construct'( )Repair( )Upgrade( Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. ��, Own_tom er's ame.,Address d Tel.No. �45 5 Assessor's Map/Parcel i.{ Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. AefXo 7 7/-93 Type of Building: Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Grinder Other Type,of Building . No. of Persons Showers( ) Cafeteria( ) Other Fixtures } Design Flow M&O gallons per day. Calculated daily flow 3 30 gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. t Description of Soil 10 X 30 :f'Z Nature of Repairs or Alterations(Answer when applicable) 72 Y Date last inspected: Agreement: The undersigned agrees to.ensure the construction and maintenance of the afore described on-site sewage disposal-system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issue, y hi .a d,-f — Signed Date 61,119 01 Application Approved.by Date Application Disapproved for the following reasons Permit No. Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CEg TIFY, that the On,site Sewage Disposal System Constructed( ) Repaired ( )Upgraded Abandoned(_ )by leel"le % Ce�s17` at cesf Al, ,!f'`4//�S qj�_ has be=constructed in accordance with.the provisions of Title 5 and the for Disposal System Construction Permit No ated Installer Designer The issuance of this permit shall not be construed as a guarantee that the system will function as designed. Date Inspector ------ ------- -- -- No. Fee R THE�COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS Mi5po5ar *potem Con!5truction Permit - - Permission is hereby granted to Construct ) eair( )Up rade( ►KAbando/n( ) System located at and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided: Con mu structio st completed within three years of the date oft Date: al ) / r Approved by eZ - l � J, 4 a - Y: t _ 7$ S�YPea-j_ - S r,�,,,'p4ff�ASr NOTICE:.This Form Igo Be Used For the Repair�Of Failed A xg Septic Systems Only. CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLAINS) I. �a���� J hereby c at b, certify that the application for disposal works construction permit signed by me dated �44'/_7 concerning the property located at a 7c, C® meets all or the following criteria: ere are no wetlands within 300 feet of the or000sed septic system here are no prvate wells within 150 :yet of the proposed septic system _ne observed=oundwater table is eel or=eater below the bottom or the :caching _cc .i^ There s zo increase n tiow and/or caarse in a.e DroDosed V/71.here :�::o var:arces "eouestec Or"eez: ed. SIGNED : DATE: LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER , [Attach a sketch pplan of the proposed system.Also if the licensed installer posesses,a certified plot plan, this plan s)ioud_ie submitted]. k TOWN OF BARNSTABLE LOCATION J�;rC4 SEWAGE # VILLAGE ��� ��/� /ASSESSOR'S MAP & LOTZ INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY 152115' AC, C LEACHING FACILITY: (type) z`� 'C Ika�d- (size) ld'X 3 0 �241 NO. OF BEDROOMS BUILDER OR� / PERMITDATE: ! �7 COMPLIANCE DATE: -a 90" 9 � Separation Distance Between the: _ Maximum Adjusted Groundwater Table and Bottom of Leaching Facility f 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 N J� within 300 feet-of leaching facility) / Feet Furnished by �L S J< 33 33