HomeMy WebLinkAbout0140 INDIAN TRAIL - Health 14b INDIAN TRAIL; BARNSTABLE
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CO�LMONZ iEALTH OF MASSACHL;SETTSEXECLTArE OFFICE OF EN-MONME\TAL AFFAIRS
li� _ DEPARTMENT OF ENVIRONMENTAL PROTECTION
OXE tiZ\'TER STREi'. BOS: hi.O\ A 0210� 16I71 292-550i
TRU DT COX-7
Secre.a_-y
ARGEO PALL CELLUCCi
DAVID B STP.'-'??S
Governor Commissioner
SUBSURFACE SEWAGE DISPOSAL SYSTEM WSPECTION FORM
PART A
CERTF=T10N
Property Address: 140 Indian Trail NcimeofOwner FnrPst Rroman
Cummaquid Address of Owner:
Date of Inspection:
Name of inspector:(Please Prina Wm. E. Robinson Sr.
1 am a DEP approved s errl inspector to Seetkm 15-W of title S 1310 CMR 1S.000)
CompoWkame: Wm. E. Robinson Seepttic Service
MaliingAddress: PO Box 1089, Centerville , MA.
Tel""ne Number: 7 7 -R 7 7
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:
Passes
Conditionally Passes
_ Needs Further Evaluation By the Local Approving Authority
Fails
Inspector's Signature: L• Dater
The System Inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)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 ttre
system owner and copies sent to the buyer, if applicable, and the approving authority.
NOTES AND COMMENTS -
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION Iconti u+ed)
Nap"Address: 140 Indian Trail, Cummaquid
-3
wrteeB .
roman
Date of Inspection.t-1�'
INSPECTION SUMMARY: Check A, B, C, of D:
A. SYSTEM PASSES:
C '
1 have not found any information which indicates that'any of the failure conditions described in 310 CMR 15.303 exist. Any failure
criteria not evaluated are indicated below.
CO MENTS:
B. SYSTEM CONDITIONALLY PASSES:
One or more system components as described in the "Conditional Pass"section need to be replaced or repaired. The system.upon
completion of the replacement or repair,as approved by the Board of Health,will pass.
Indicate as,no. or not determined(Y. N.or NO). Describe basis of determination in all instances. N"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 lattached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection: or
the septic tank, whether or not metal,is 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 complying septic tank as
approved by the Board of Health.
Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipets)
or due to a broken, settled or uneven distribution box. The system will pass inspection if twith 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 pipets). The system will pass
inspection if(with approval of the Board of Health):
'{\ broken pipets)are replaced
obstruction is removed
revised 9/2/96 Page 2ofII
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued!
Property Address: 140 Indian Trail, Cummaquid .
Owner: Rp
Date of IrtSt
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 is failing to protect the
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public health, safety and the environment.
�1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES W ACCORDANCE WITH 310 CMR 15.303(1)(b)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 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 ANY)DETERMINES THAT THE SYSTEM IS
NCTIONING IN A MANNER THAT PROTECTS 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 of a surface water supply or
tributary 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 supply well.
The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply 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, 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. Method used to determine distance (approximation not valid).
3) OTHER
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re%7isea 9 2 98 PsQc3of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ti
PART A
CERTIFICATION fcorrtinued)
Property Ad&essl 40 Indian Trail, Cummaquid
Date of Inspects 1�
D. SYSTEM FAILS:
You must indicate either "Yes" or "No" to each of the following:
1 have determined that one or more of the following failure conditions exist as described 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.
)Ye No
Backup of sewage into facility or system component due to an over orclogged 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 112 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.
E. LARGE SYSTEM FAILS:
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:
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:
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)
The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional
office of the Department for further information.
reViSAC PaRr4ofII
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM.
PART B
CHECKLIST
Prop"Address: 1 40 Indian. Trail, Cummaquid`Owne
Daten�apeeaton:6_11.,Ut7
Check if the following have been done: You must indicate either "Yes" or -fvo•' as to each of the following:
Ygs No '
_ Pumping information was provided by the owner, occupant, or Board of Health
_1L None of the system components have been pumped for at least two weeks ks and-the stem has been
sY a receiving nvnnal 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 NIA:
N _ The facility or dwelling was inspected for signs of sewage back-up.
V _ The system does not receive non-sanitary or industrial waste flow.
V _ 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 ttie'septic tank was inspected for condition of baffles
or tees, material of construction, dimensions,depth of liquid, depth of sludge, depth of scum.
The size and location of the Soil Absorption System on the site has been determined based on:
_ Existing information. For example, Plan at B.O.H. "
_ Determined in the field (if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable)
115.302(3)(b)1
- _ The facility owner (and occupants,if differeni from owner) were provided with information on the pro per maintanaaca of
SubSurface Disposal Systems. ,.
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
tiop"Address: 140-- Indian Trail, Cummaquid
Owner: Broman
Date of Inspeebon:�d,i� OJ
FLOW CONDITIONS
RESIDENTIAL:
Design flow:I 0 g.p.d./bedroom.
Number of bedrooms Idesign):'!I_ Number of bedrooms(actual):_
Total DESIGN flow (a
Number of current residents
Garbage grinder(yes or no):
Laundry(separate system) (yes or no): �if yes, separate inspection required
Laundry system inspected (yes or no)
Seasonal use (yes or no):jW
Water meter readings, if available (last two year's usage(gpd): 1999 R `.400 as l
Sump Pump (yes or no): Q 1998 16,000 gal.
Last date of occupancy:
COMMERCIAL/INDUSTRIAL:
�4ype.of establishment:
Design 1)'Qw: gpd ( Based on 15.203)
Basis of design flow
Grease,trap present: lyes or no)_
Industt4al Waste Holding Tank present: (yes or no)_
Non sanitary waste discharged to the Title 5 system: (yes or no)_
W er meter readings, if available:
L t date of occupancy:
ER: (Describe)
st date of occupancy:
GENERAL INFORMATION
PUMP G RECORDS and source of information:
System pumped as part of inspection: (yes or nolO
If yes, volume pumped: gallons
Reason for pumping:
TYP 0 YSTEM
Septic tank%distribution box/soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system (yes or no) (if yes, attach previous inspection records;if any)
I/A Technology etc. Attach copy of up to date operation and maintenance contract
Tight Tank Copy of DEP Approval
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)
=Vised Page 6(if II
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION Icontimsod)
"ropeny Address: 140 -Indian Trail r Cummaquid
Owner: Brom ,
Date of Inspection:V11.-W
-!A�LDING SEWER:
(Locate on site plant
Dep h below grade:
Ma erial of construction:_cast iron_40 PVC_other(explain)
Dist nee from private water supply well or suction line
Di eter
omments: (condition of joints, venting, evidence of leakage,-etc.)
SEPTIC TANK: r f
(locate on site plan)
Depth below grade: '
Material of construction: concrete_metal_Fiberglass Polyethylene_other(explain)
If tank is metal,list age_ Wage confirmed by CertEficate of Compliance (Yes/No)
Dimensions:
Sludge depth: ='
Distance from top of sludge to bottom of outlet tee or baffle: J
Scum thickness: _
Distance from top of scum to top of outlet tee or baffle: �3
Distance from bottom of scum to bottom of outlet tee or baffle:
r
How dimensions were determined: alas)
comments:
(recommendation for pumping, condition of inlet and outlet tees orbaffles, depth of liquid level in relation to outlet invert, structural integrity,
evidence of leakage, etc.) 061-' (l0CAJie,^
-GRFASE TRAP:
floc to on site plan) .
De h below grade:_
M erial of construction: concrete_metal_Fiberglass _Polyethylene_otherlexplain).
nsions:
Scu thickness:
Dista a from top of scum to top of outlet tee or baffle:
Distan a from bottom of scum to bottom of outlet tee or baffle:
Date last pumping: -
C ments:
Ir ommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity,
evid nce of leakage. etc.) _
c.'i 2/9c Page 7ofli
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
''°pens Address: 1 40- Indian Trail, Cummaquid
Owner:
B
Date of Inspi-Q
Tni OR HOLDING TANK: (Tank must be pumped prior to, or at time of, inspection)
(loco a on site plan)
Dep h below grade:_
Met riel of construction:_concrete_metal_Fiberglass_Polyethylene_other(explain)
Di ensions:
Cap ity: gallons
Desig flow: gallons!day
Alarm resent
Alar level: Alarm in working order: Yes_ No—
, of previous pumping:
Co ments:
(con 'tion of inlet tee, condition of alarm and float switches, etc.)
DISTRIBUTION BOX:_
(locate on site plan)
Depth of liquid level above outlet invert:_
Comments:
Inote if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.)
MP CHAMBER:_
Ilo ate on site plan)
umps in working order: (Yes or No)
Ala s in working order(Yes or No)
Com ents:
(note condition of pump chamber, condition of pumps and appurtenances,etc.)
TL
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Yoperty Address:
Owner. 140 Indian Trail, Cummaquid
Date ofd�
SOIL ABSORPTION SYSTEM(SAS):_ + r.
(locate on site plan, if possible;excavation not required,location 'q y be ap
proximated pprozimated by non-intrusive,methods) t
If not located, explain:
L h :.
Type: t r
leaching pits, number: '
leaching chambers, number._ 1
leaching galleries, number._
leaching trenches, number, length:
leaching fields• number, dimensions:
overflow cesspool, number._
Alternative system:
�,.
Name of Technology:
Corments: A
(note con tion of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.)
CES POOLS:_
floc to on site plan)
Nu ber and configuration: _
De -top of liquid to inlet invert: " r
Depth f solids layer:
)epth of cum layer:
Dimensions �f cesspool:
Materials of ccn str .ucti n:o
Indication of roundwater: ,
inf w (cesspool must be pumped as part of inspection)
. a.- .. -
om
Inote c dition of soil, signs of hydraulic failure, level of ponding. condition`of vegetation,'etc 1
PRIVY: t
(locate site plan)
Ma rie's of construction
Depth of solids: Dimensions:
Comments:
Inote condition of soil. signs of hydraulic failure. level of ponding, con ditiontof vegetation, etc.) ,{•'
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM �
PART C
SYSTEM INFORMATION Icontirmed)
'ropertyAddress: 140 Indian Trail, Cummaquid
'"fw* Broman
Date of Inspection:
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent reference landmarks or benchmarks
locate all wells within 100' (Locate where public water supply comes into house)
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. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(con*wedl
ropertyAddi`ess` 140 Indian Trail, Cummaquid
Owner: 1p�
Date of
NRCS Report name
Soil Type_
Typical depth to groundwater
USGS Date website visited
Observation Wells checked Moderate Deep
Groundwater depth: Shallow'
SITE EXAM Slope
Surface water
Check Cellar
Shallow wells
Estimated Depth to Groundwater a Feet .
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from Design Plans on record
Observed Site(Abutting property,observation hole.basement sump etc.)
Determined from local conditions
V Checked with local Board of health {
Checked FEMA Maps
Checked pumping records
Checked local excavators, installers
Used USGS Data
Describe how you established the High Groundwater Elevation. IMust be completed) z w-
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revised 9/2/96 Page 11orii y a
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