HomeMy WebLinkAbout2874 MAIN ST./RTE 6A(BARN.) - Health 6' BARNSTABLt
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Commonwealth of Massachusetts 8
't lop a j A
Executive Office of Environmental Affairs 1�
Department of m 1 ''` 1 �-
Environmental Protection sst t I �b
, W
W 9-74
llllam F.Weld �J/
Governor � Q
Trudy t;oxe
ec Sretary EOEA A 1
David B.Struhs
Commissioner y
SUBSURFACE SEWAGE`DISPOSAL SYSTEM INSPECTION FORM
PART A
1��2• `�ltc�c��� �v2� 1 CERTIFICATION
Property Address: ^ �' R"-Ct `e Address of Owner:
Date of Inspection: Noss 1`,Sj(�g6 (If different)
Name of Inspector: �jc„�� r(acr.��•sl�
Company Name, Address and Telephone Number:
�S�oRe t^e lv �.,clwe`
CERTIFICATION STATEMENT C��erv�«cj d`(A• �d(oSS
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: Date: ,/ov-a 8�)J7 6 .
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/"' 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 evaluated are indicated below.
B] SYSTEM CONDITIONALLY PASSES:
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, shows substantial infiltration or exfiltration, or tank 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.
(revised 8/15/95) 1
One Winter Street • Boston,Massachusetts 02108 • FAX(611)Ss6-1049 • Telephone(617)292-5500
�J Printed on Recycled Paper -
Qdy SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
s^ PART A
tttgeA1' ` CERTIFICATION (continued)
Property Address: �7L-( r1Ay S�. (�t2� 1e
Owner:. �` 'is C1�C��5 e� F�2
Date ofUspectiog,• r 4
B)N'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
Cl 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
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 soa absorption system and is within 100 feet to a Surface wale( supply or tnbutiay io 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.
T The system has a septic tank and soil absorption system and is less than 100 feet but 56 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•
DI SYSTEM FAILS:
I have determined that the system violates 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 correct
the failure.
Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool.
T Discharge or ponding of effluent to the surface of tie ground or surface waters due to an overloaded or clogged SAS or
cesspool. —,
(revised 8/15/95) 2
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 087y /`JAft7 on'e" /w/C
Owner: Mt hli el w2 e`S
Date of Inspection: NoU- c2S� 996
DJ SYSTEM FAILS (continued):
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 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 cr 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.
El LARGE SYSTEM FAILS:
The following criteria apply to large systems in addition to the criteria above:
The design flow of system is 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:
_ 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 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.
Z
(revised 8/15/95) 3
K i4"
.A% .
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 0��7�( JI �► 'ST �A2n�E�b1 e
Owner:
Date of Inspection: l�o�,o25Jlci��
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.
�/A.ZAs built plans have been obtained and examined. Note if they are not available with N/A.
Z-The facility or dwelling was inspected for signs of sewage back-up.,
kThe system does not receive non-sanitary or industrial waste flow
Z—The site was inspected for signs of breakout.
VL'AII system components, e*eted+ng the Soil Absorption System, have been located on the site.
iY 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.
ZThe 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 o%�ne. (and occupants; if different from owner) were provided with information on the proper maintenance of Sub-
Surface Disposal System.
(revised 8/15/95) 4
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: OZ 8 �`9gnyS% �aQrts/A��c
Owner: MtChad Ftze7
Date of Inspection: �oV" a6- fqq�
,FLOW CONDITIONS
RESIDENTIAL:
Design flow: w� gallons
Number of bedrooms:
Number of current residents:
Garbage grinder (yes or no): A/0' ,
Laundry connected to system (yes or no):yES
Seasonal use (yes or no):LVO
Water meter readings, if available: /V�A
Last date of occupancy: OA
C
COMM ERCIAUINDUSTRIAL:
Type of establishment: "
Design flow:_gallons/day
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:
OTHER: (Describe)
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
System pumped as part of inspection: (yes or no)
e 5
If yes, volume pumped. Sao Rallon� ,
Reason for pumping: AS
TYPE OF SYSTEM
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)
Other (explain)
APPROXIMATE AGE of all components, date installed (if known) and source of information:
Sewage odors detected when arriving at the site: (yes or no)
(revised 8/15/95) S
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
�p SYSTEM INFORMATION (continued)
Property Address: IQ
Owner: / ickinel F"2et,
Date of Inspection: ,,/ oZ 191��
SEPTIC TANK:I-CUSS foo�
(locate on site plan)
Depth below grade:
Material of construction: _concrete _metal _FRP —other(explain) S
Dimensions: 6 X
Sludge depth: ZS'n.
Distance from top of sludge to bottom of outlet tee or baffle: 1
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:
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth oCliquid I vel in relation to outlet inv rt, structural
/�
integrity, evidence of leakage, etc.) l es oo� ��rN QCOQ nQ-3 AS tPArT atrwDeCTI.o�►
GREASE TRAP:_
(locate on site plan)
Depth. belo�% 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 rd 5ro- to bottom of outlet tee or barite
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.i
(revised 8/.5/95) 6
a ,
id
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
Owner: �.C�ce� w12 ey
Date of Inspection:
TIGHT OR HOLDING TANK:_
(locate on site plan)
Depth below grade:
Material of construction: concrete _metal _FRP other(explain)
Dimensions:
Capacity: gallons
Design flow Rallons/day
Alarm level:
Comments:
(condition of inlet tee, condition of alarm and float switches, etc.)
DISTRIBUTION BOX:—'�VOne
(locate on site plan)
Depth of liquid level above outlet invert:
Comments:
(note if level and distnbct:c•• evidence of col;d= c?vnver, evidence of leakaee into or out of box etct
PUMP CHAMBER:�/g
(locate on site plan) *'
li Pumps in working order.(yes or no)
. 4
Comments:
(note condition of pump chamber, condition of pumps and appurtenances, etc.)
r
(revised 8/15/95) 7
' o
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: oZ 874
1"JAi n S j• �N2�3?A�1 C
Owner: t t'V_.ac.l FJCC,3
Date of Inspection: N"' dSj�(Z�6
SOIL ABSORPTION SYSTEM (SAS):_
(locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods)
If not determined to be present, explain:
Type:
Teaching pits, number:_
leaching chambers, number:_
leaching galleries, number:
leaching trenches, number,length:
leaching fields, number, dimensions:
overflow cesspool, number: Cme,
Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,etc.) Alo.s/ /2S 1i_FJQ :g OQio /C/yJ
CESSPOOLS: _
(locate on site plan)
Number and configuration: one -
Depth-top of liquid to inlet invert:
Depth of solids layer.
Depth of scum layer:
Dimensions of cesspool: 6ar. kb-'
Materials of construction: STor,c i
Indication of groundwater. /fOiIF
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: Dimensions:
Depth of solids-
Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
(revised 0/15/95) 8
f
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: uZ87`f 11/41xI..ST
Owner: MichAc( Fx,
2c
Date of Inspection:
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100' ST ,
31
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I
57
6 _
a� I
A5
DEPTH TO GROUNDWATER
Depth to groundwater: 6 feet ox, �,OA b- om o4CCSSP00/
method of determination or approximation:
d L. L 96 — ' s o r eCu2cc->
(revised 8/15/95) 9