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HomeMy WebLinkAbout0109 CARRIAGE LANE - Health A log Carriage Lane Barnstable P = 298 067 0 TOWN OF BARNS�T�ABLE LOCATION G a,S I0% (A 9;6,_6 Flo SEWAGE # VILLAGES ASSESSOR'S MAP & LOT D " INSTALLER'S NAME & PHONE NO. SEPTIC TANK CAPACITY /00,0 L 0 LEACHING FACILITY:(type) p (size) NO. OF BEDROOMS _PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER ' DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No i� L3 7179 si Izz PIZ COMMONWEALTH OF MASSACHUSETTS ExECUTIVE OFFI CE OF ENVIRONMENTAL AFFAIRS D1i:PART>![81iiT OF Drap� l��J�' OTECTION 2C5 ref Y 13 PM 3: 33 TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Prop"Addoess: e� C�r�'�a e G. i� t.�����. d L1; Oa 1rNj 6_?0r sivG��fx : Owner's Namur o e �o _ Owner's Address: o ���� G mot/ r✓J e OoZf,jv, Date of Inspection: � o �� it Name of Inspector•. print) Gt✓ /A�JPi��" Company Name: 'O-- 7--,=—:CXI MAMM Address: Q o9v y ,Z a vt� Telephone Number,a, �'_ CERTMCATION STATEMENT I certify►that I have personally inspected the sewage disposal system at this address and that the information reported below is bue,acxvrate and complete as of the time of the inspection The inspection was performed based on my VWning and experience in the proper function and maintenance ofon site sewage disposal System.Title S(310 CM1t 13.0ooN The I am a Dl approved system inspector pursuant to 15JO of Tit y � Passes Conditionally Passes Needs Further Eval nabon by the Local AXroving Authority Fails Inspector's Signature: Date:Q ® D � The system inspector shall submit copy of this inspection relM to the Approving Authonty(Board of Health or DEP)within 30 days of completing this inspection If the system is a shared spd or greater,the inspector and the system owner shall submit the �'�or has a design of 10the DEP.The original should be sent to the report to the appropriate regional l offs of the t ' system owner and copes sent to the buyer,if app he*k and the approving Notes and Comments i report only describes conditions at the time of inspection and ender the conditions of flame.This inspecdon does not address how the system will perform in the fu!tare under the ase at that same or different conditions of ow. N , • Page 2 of 11' OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A /CERTIFICATION( Property Addneas: ��`1 C�ap l-r a L�/ n r✓1 s � Owner. �6 /'o Date of Inspection: Inspectlon Summary: Check AAC,D or E/AL AY complete all of Section D' A. Sy Passes: I bave not found any information which indicates that t any of he failure caiteria 15.303 or in 310 CUR 15.304 post,Any failure criteria evah� below. in 310 OAR Comment- B. SWIM Conditionally Passes: —L;One or more system componer:ts as desabed in the"Conditional Pass"section need to be replaced or mP •lb system,upon completion of the M*C=2ft or Zq)*.as approved by the Board of Health,win pass• Answer yes,no or not determined(Y.N,ND)in the for the fWvlain. ollowing statement,If"not detmminecr please, 1U septic tsnk is omits substantial rmeta�t=m cr yew old*or the septic tank(whether metal or not)is struagaally adsting tank is r+apiaoed with a Complying septic�as aPp hilure� �p�man if the A metal septic talc will pass hupwdon if it is sh uchnnlly sound,not 1 rdofHaft indicating that the tank is less tbam 20 years old is available• �IIng a°d:f a Certifipte of Cow ND explain; o0bsWv8ftW of WWAV backM orbreak out or high static water level m the dstnbution box due to brokm or aPpraval of Board of Health). 4 settled or uneven disrnbution box. System will pm inspec•tion if(with replaced is lion box is leveled or neplaoed l�mspectian if(with approval of the Board of Health)a yew due to broken or obstructed ppe(s).The system will br�aken pipes)one mplaow obstruction is removed ND explain: Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM IATSPECTYON FORM PART A CERTIFICATION(continued) Property Addr+em* 9 CGr�ii G�/ Owner. Date of Inspection:Q>' 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 rs fillmg to PWd Public health,safety or the went. 1. System will pass unless Board of Health determines 18 accordance with 310 Cat 1&303(i)(b)that the system Is not fincdoning In a manner wbicb will protect public health,safety and the environment: ._ Cesspool ar Privy is within SO feet of a Rufaoe water _ Cesspool or Privy is within SO feet of a bordering vegetated wedand or a salt marsh L System will fail unless the Board of Health(and Public Water Supplier,H any)determines that the system is fimcdOufmg In a manner that protects the public health,safety and environment: The system has a septic tank and sail absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tnbfty 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 SO feet of a private water The system has a septic tank and SAS and the SAS is less than 100 fleet but SO feet or more from a Fate water supply well's.Method used to determine dislanoe '*This system Passes if the well water analysis,Performed at a M certified bacteria and volatile ;f�ooliform organic eon indicates that the well is from fmmpolludon from that facility and ft furl Pmseuce of� and mtnte nitrogmn is equal to Of lei than S Plan,P�ded that no other triggered A copy of the analysis must be attached to this form. a Other Y i ,r Pa®e4of11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTMCATION(con inued) Property Addmm- �� 1,40 Owner: 1 ro Date of Inspection; �o 0 D. System Failure Crtterla applicable to an systems; You ma indicate`fires"or`bo"to each of the following for aAin ons; Yes No ofsewalpinto sty or systemdue to overloaded or clogged SAS or cesspool I>na~bar®e ponding of effiuent to the surface of the ground of sndaoe waters due to an overloaded of !TW SAS or cesspool Stadc liquid level m the distribution box above outlet invert due to an overloaded or clogged SAS or depth m cesspool is less than 6"below invert or available volume is less than K Ilow — —4ZRaTaffCd p�Png more than 4 times m the last yew ly,�T due to dogpd or obstructedpi s .N /dftimes pumped prpe() umber v portion of the SAS,cesspool or privy is below high ground war perms 0f cesspool or pmy is within 100 felt of a � � �Y surface water supply or tnbutary to a surface ��AnsY'p�mi of a cesspool or privy is within a Zone 1 of a public well. �L V portion of a cesspool Or�is within 50 feet of a cesspool or privy is less than 100$et�water 50fe well. supply well with no acceptable water t3r'�than SO feet from a private water I qm&Y analysis. Cris system passes if the well water analysis, performed at a DEP certified laboratory,for eMerm bacteria and volatile organk Compounds indicates that the well is fne f'lom pollution from that facility and the presence of ammonia WUVM and WbVe R&Ggen is equal to err less than S PPm,provided that no other faidrne criteria are triggemd.A ropy of the analysis mast be attached to this form.] (Yes/No)The system fill I bave determined that one of more of the above Muse c mterm exist as described in 310 CUR 15.303,therefore the system fails,The system owner should contact the Board of Health to determine what will be necessary to correct the failm+e. E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 14M You must indicate either"Yee or"no"to each of the following: (Tic Wong entena apply to WV systems is addition to the catena above) n the system a within 400 fat of a surface dnnlvng water sup* the system is within 200 fiat of a u utary to a surface ddnidng water supply _ the system is lacmted in a nitrogen sensitive aura(Interim Wellhead Protection Area_�pA)or a lI of a public water supply well mapped if you have answered"yes"to M question in Section E the system is Considered a "Yes"in Section D above the large system has furled.The owner or operator of � �LVV consideredof answered significant threat under Section E of failedunder SecdoaD shall e the system macoowith 31a 15.304.The system owner should contact the lu office CUR regional mice of the DepattmeM Pars ofll OFFICIAL INSPEC TION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM '. PART B CIIECIKLIST PnWrty Adar �✓r p� Owner. Data of Inspection: Check if the following bm been done.You mast imdicate`Yes"or"no"as to each Of the following: Yes Mg harmacm was 1mvi&d by ft owner,occupant,or Board of Health V were any of the system c omponefts Pumped oot in the p micas two weeks Hu system received normal Saws in the previous two week period lame volmnes of water been irmoduood to the system=mdy of as part of this hopmem, ere as built puns of the system obtained and examined?(If they were not rime note as N/A) the hcft a dweflingmspeced for of sewage bads up _ Was the site mspocted for sigma of lmrak oat wane an system con4mcnK=fuding the SAS,located on site w the septic tank manholes sad ft�,opened, mtennr of the teak mspoctod far the aonditiion of the ar tem mft"of construction,&=Mdans,ft&of>iA ft&of dodge and dap&of scum 'e the 606W ownef(and=upam if dffer ft fim'ovmm)pwided with iaformadon on the proper meo�e�oe afe sewage diaPosal . 'The se11 e and locx&m.of the&Q Absorption System(S"on the site has been deteamiued based on:' Yes no/ El Wft,&ftmafm Fcw cmm#t a plan at the Bowd of Ikalth. . . Determiaod in the field(if any of the fay m criteria related to Part C is at issue approximation of is uaaooeptable)I310 C11�D1,1S.303(3A)J y r. { i Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSA,IENTS SUBSURFACE,SEWAGE DISPOSAL SYSTEM INSPECITON FORM PART C SYSTEM INFORMATIQN PrqpertyAddrew Owner. �ro Date of Iaspectios tm 0ry 2 S s RESEDENTLt3. CO fMNS ► s �l� Numberofbedroorns(dedp) Number ofbeamr s(acxnalr o v DESIGN flowbased aa:310 k5103(for.cxampk 110 gpd x 0 of bodrooeus)r /Y Number of caraw nsidems: ol— IQeC o wt M t r.N Does residence ha<►e a garbeg�e grinder(yam no): S — ✓�VIP T f le S Is laundry an.a separate sewage system or no)._ [ifyes separate inspecdicel�-req 1had] . Laundly sy� at no): S Seasonal use:(yea or no): Water mewreadgA f ava0able(last 2 yews usage(gpd)): Sump or no): CX S�►�'� Last date of wcgnncy: COMMERC1fALTOUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203). ,'"(4 Basis of design flaw(seatsfpersous/sgketc.): GmmbVj w (yw�):_ Gr fee s<?�— IndusbW waste holding presen i(yes or no): Non-sanitary waste discluugod to the 71&S system(yes or no):_ Water meter readings,if avaffabie: Last date of oavpancy/use. OTHER(describe): GENERAL INFORMATION Pumping Records Source of iabrmatim /l e�- Hf- Wa s sY�pMod as pelt of the inspection(yea or nn): 0 c✓�-/� 3 ►volume —How was quantity pumped determm e r F SYSTEM _Septic tact,distrrbutton box,sal absorption system _Single cesved Omftw ceswod _Shared system(Yes or no)(rf yea,attach Previous mspection roo ,*Ma") —InDOMWSystem ) obtame from Alta ownwclmolo&y. Attach a copy of the cumeot operatiaa and Cana COMW(to be _Tight tack Attach a copy of the DEP approval AXwAmaw age of all components,dde inRalted(if known)and source of information: Were sewage odors detected when arriving at the site(yes or no): Pame 7 of l I OFFICIAL INSPECTION FORM—NOT.FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(comiau4 Property Addnsc 0 9 Car,,., _ Z-41 Owner. 1v s -31 Date of hmpeedw. WELDING SEWER(locate on�e ptaa) Depth below Slade: // Materials of construed=®: iron otlarr(expiaia) �( Distanoe from private water suppiy weE ar sa�ctioa dqe: Comments(an condition.ofAlK v�eufg;�,�ee o f ): SEPTIC TANK: c/ _(local=.on,site plea) Depth below grade: Id huterial of on: -- _polyethylene H tack is metal listage:— Is ague by expL a CatifsCate of � ) Compiiaoce'(Yes ar no):_(attach a copy of Dimeos3ens: X Wes: Disrenoe top cf si I to bottom of outlet twca�bdk. S�Oddcoess: / 7 Distance from top of scam.to top of outlet tee or bdk. 7 Distance firm bottom of ecnm.to bottom of ttoo or� How were dimeoniaos dew p _ Q o%v ice_ Commerfs(an Pumping recommendaiook inlet and outlet or baffle co as to outlet invest evidence of l gkW��c•�c ctival integrity;liquid levels ,pjp I fRH lea GREASE TRAP; (locate ca site plan) Depth b&w grade:_ Aburial of eonstmcbion: Comets metal ft"glaw_.PoIY Y _other O: Dime: Scum Distaaoe from top scram tO WP of outlet tee or bade: ' Distaaoe from bottom of scam to bottom of outlet tee of baffle.Date of last paaV&X_ C MMM(00 PUPnS pansy inlet and outlet.tee or baffle condition,strocx�ual. as related to ouflet invert,evidence of l a QW etc.): h',liquid levels Page 8 of 11 OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE S19WAGE'DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Addnm ,e ownea: io &. �-� Date of Inspeedw: 4OV' TIGHT or HOLDING TANK:J_,(tank must be poked at time of inspection)(locate on we Plan) Depth below grade: Material of coast<tsrtion: concrete metal fiberglass lens Dimensions: �llons Design Flow: ~day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and fled switches,etc.): DISTRIBUTION BOX G y(if present must be opened)(locate on site plan) Depth of hgwd kved above outkt invert: Comments(note if box is level and asutWon to ontkts equal,any evidence of solids leakage into a�of box,etc,): /�/ 'O 'any evidence°f kle /1oC �,b PUMP C'HA1MBE8;/l�(locate on site per) Pumps in woddng order(yes or no): Alarms in working order(yes air no): Comments(note condition of pump chaber,condition of pumps and appurte naooes,etc.): • Phge 9 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE-OISPOSAL SYSTEM PmECnoN,FORM SYS/TEM E%RM MA'PION Property (ooeti�etaiy Addm /0 9 Owner. /o Date of Inspectir.c .30 0-5 SOa•AMRrriOX SVSTng s �sV plan.ercavad=scat regWroo If SAS no kcatni w+�ty: Type l mom:• 0 ,km: EW* , : overflow cesspool, system .TypW%mine of tecf nolow C°mt� ° ion of Mk signs of hy�c{��level of etas c J dmmP soil,conditiion cif vegetion, 14 / hf O. /a.. •'G �G,, yr+ CFSS?OOL&ZZOM lfod mm be pwnped as pert of inspmb(mvocate o a sft plan) Numberandm Depth-topaf�idto iakt iavert: Depth of salter jq= ofumI*= Dimeadow of oesspo* Matte atcousbuccom Indication of gamiftaff inftw on a nod Commou fnate; of soil;signs of h Ind afpmkftg 000dWon aft;etc. Mataisls a[mostroctoorx Dimeodor� Depth of solider ConnWW*ftmxlomofsak of by is faodarr,level ofpaw ms&k a ofvgpmdM ft); Page 10 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION&audm4 Property Addrem Owner: Date d Inspectioa; �� SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a doctor of tits sewage disposal system iwluftg ties to at least two permanent reference lmdm aft or benchnob Locate all wells within I00 feet,I where pdit wales sup*enters the bttil"& Io / SN n R••t7 �o r` v © � i r' _ Pap 11 of i l OFFICIAL INSPE CTION FORM—NOT FOR VOLUNTARY ASSESSMEM SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C p SYSTEMINFORMATION(continued) arty Address* coC�/0 / ti" G - Owner. Date of hopecdon; .?o p5 SITE EXAM Slaps Check cellar ��- Shallow wells D 0 ?o Estimated depth to pound water q0 feet Please mch (check)all methods used to determine the high pound war elevation: Obtained fmm system design Plans on reQaad-ff date sift( Aos mtyl�rvation hole °f dedgm plan dewed: afSAS) L�=with hxal Board of v`1 G�� 5 with local mccavators,installeas-(attach documentation Accessed USGS ? You mast dmcn'be b9wYog established the higb w��'�: /O w� ei vti tS LOG�►���J /J` 70� QO O� �s B i N 17 Wn. A co Q (� Do .(0co, C9 Co 0