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Home My WebLink About0166 INDIAN HILL ROAD - Health 166 INDIAN HILL ROAD, CUMMAQUID A= A � �. :.. is t � - � � _ ^ -. •:. D. � - � , '" ` .. RECEIVE® TROY WILLIAMS MAY 7 1996 TH DEPT. SEPTIC INSPECTIONS TO WNo BARN STArJLE A�' i i Certified by MA Department of Environmental Protection (508) 760-1819, 40 Old Bass River Road South Dennis,MA 02660 D o Commonwealth of Massachusetts Executive Office of Environmental Affairs Department of Environmental Protection William F.Weld Trudy Coxe Go an°r .80oMary Argeo Paul Celluccl David B.Struhs LL GNortgr CormJrbner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A - [ CERTIFICATION Property Address 1 4�! Address of Owner. Pia /.A Date of Inspection: .S"I.?/`I 6 (If different) LL Name of Inspectors—ro7 fn/: (I; o�.•,S a2 V S7u�r u h /9dc_. Company Name,Address and Telephone Number. 5. Yw✓ ,you f(` / K S.-(. CA.60,t. oa c c y 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: Conditionally Passes Needs Further Evaluation By the Local Approving Authority Fails Inspector's Signature;�- 5 n l /��I- Date S /3 /q6 The System Inspector shall submit a copy 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: I 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 evahmted are indicated below. III SYSTEM CONDITIONALLY PASSES:111119 One or more system components need to be replaced or repaired. The system,upon completion of the replacement or repair,passes inspection. Indicate yes, 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,chows substantial infiltration or exfiltration,.or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a ponforming septic tank as approved by the Board of Health. (revised 11/03/95) 1 4 r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: !6 6 Owner. c✓� Date of Inspection: 5 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 C) FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: N4/J 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 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. 9) OTHER (revised 11/03/95) 2 f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(oontinued) Property Addreas: 1 Owner. Date of Inspeotion l tt.S �•"'� DI SYSTEM FAIL: N�i9 I have determined that the system violate*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 oorreet the failure. — Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. — Discharge or poading 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 leas 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 ooliform bacteria, volatile organic compounds,ammonia nitrogen and nitrate nitrogen. --- El LARGE SYSTEM FAILS: The following criteria apply to large systems in addition to the criteria above: d or greater(Large System) and the system is a significant threat to public The system serves a facility with a design flow of 10,000 gp 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) ill 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 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECMST Property Address: !G 6 1 H d( Owner. 1-i-1 z' ova �ai 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. ✓ As built plans have been obtained and examined. Note if they are not available with N/A V The facility or dwelling was inspected for signs of sewage back-up. _L'The system does not receive non-sanitary or industrial waste flow —JZ'The site was inspected for signs of breakout. , All system components, excluding the Soil Absorption System, have been located on the site. ✓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. TThe size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods. /The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance-of Sub- Surface Disposal System. 1 (revised 11/03/95) 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Addresx c� _ rn. Owner. �� f`Z, c v.- f Date of Inspection: RF9roEtvTwL- FLOW CONDITIONS Design flow:_�bona Number of bedrooms: ;L Number of awrent residents: O Garbage grinder(yes or no): /V o Laundry connected to system(yes or no): No Seasonal use(yes or no):_G S Water meter readings, if available: p V O 914 - 5 cX - (p Odd Last date of occupancy: S, COMMERCIAL/INDUSTRiAI• /,[/-I Type of establishment: Design flow:�gallons/day Grease trap present: (yea or no) Industrial Waste Holding Tank present: (yea or no) Non-aanitary 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 PUMPING RECORDS and sourcg of information: P✓h c_yt / /� h✓ rO � s✓J CJ n System pumped as part of inspection: (yes or no) IVO . If Yes.volume pumped: --------gallons Ball Reason for pumping: TYPE F SYSTEM Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system(yea or no) (if yea, attach previous inspection records, if any) Other(explain) APPROXIMATE AGE of all components, date installed-(if known)and source of information: -.L,.s J,/I c.ACA Sewage odors detected when arriving at the site: (yes or no) nod (revised 11/03/95) 5 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: /G C .:Gas;w h "To,,. Owner. Date of Inspection: SEPTIC TANK:_V (locate on site plan) Depth below grade: �S �k f r; 51, Material of construction:,/concrete_metal_FRP_other(ezplain) Dimensions:_ S X 9 ' X G ' /o v o Sludge depth: Distance from top of sludge to bottom of outlet tee or baMe:—? '3 Scum thickness: ^10,^4 Distance from top of scum to top of outlet tee or baffle: e�y S C-mod`. Distance from bottom of scum to bottom of outlet tee or baffle: S Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet� invert,structural.inteV*, evidence of leakage, etc.) �oti�� -f c� S �o r i /e u s..k o-� f ra�r TZ�.i o.J, t.. I w y✓ i A.4 o T/a c'c.�+ S c w�.s, c y1 d i f .. r../a S t u 4— t lq y>J ih d. N G GREASE TRAP_L//,j (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 r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C. SYSTEM INFORMATION(oontinued) Property Address b b �"j . �. •- Owner. �� Date of Inspeotlon: c d s / TIGHT OR HOLDING •W TANK i9 (locate on site plan) Depth below grade: Material of construction:_concrete_metal_F"_other(explain) Dimensions: Capacity:- gallons Design flow: gallons/day Alarm level: Comments: (condition of inlet tee,condition of alarm and float switches, etc.) DISTRIBUTION BOX: V/ (locate on site plan) Depth of liquid level above outlet invert: c d Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box,etc.) �—�o X �✓ S i PUMP CHAMBER /'1l/9 (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) i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(oontinued) Property Addreesi Owner. Date of Inapeetton: SOIL ABSORPTION SYSTEM (sAsr._ (locate an site plan, if poesibls;excavation not required,but may be approximated by non-intrusive methods) If not determined to be present, explain: Type: leaching per, number: 6 k.c. L leaching chambers,number_y •� c� (, P�-�— / y S�h C leaching galleries, number leaching trenches, number,length: leaching fields, number, dimensions: overflow cesspool, number: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,etc.) ✓c,VA t off , CESSPOOLS: l�jq (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 construction: 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: (locate on site plan) Materials of construction: Depth of solids: ::,�, r_ Comments: (note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.) + r, .1 1 a, (revised 11/03/95) 8 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ► ,K� PART SYSTEM INFORMATION (contlnuc4 Property Address: Owner: r—# �z�G✓ A' � ' h: �_ Date of Inspection; SKETCH OF SEWAGE DISPOSAL SYSTEM: indude ties to at least two permanent references landmarks or benchmarks locate all wells within 100' 5# d- a2 a -l 7•r DEPTH TO GROUNDWATER ell t0 fOU , ndwater . -adjusted high groundwater level' DeP S naUorr or r t ,4 met/hod of determi app oximation r Gz�✓ L r/�'d 1 a F+,iX• ��} '`� .L,4`p ' y /3 •,F•S fly i'�'��,»tee- �+'•..,M s �". 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