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Home My WebLink About0271 OLD JAIL LANE - Health 271 OLD JAIL LANE, BARNSTABLE PF • 4 x • •? ra b tl s 4 a F b , j a F t � a w r , v. ti ry ` a r r � y .. ate.. _ �. _.. ....z : , f , H i �� Y• � '; �, ,. u +.,, L Thy .... ,, .- ^ r "�' , .. -�� : u . , ^ , a y Y, BORTOLOTTI CONSTRUCTION, INC. h. 45 INDUSTRY ROAD, MARSTONS MILLS,MA 02648 508-771-9399 508428-8926 FAX: 508-428-9399 SUBSURFACE SEWAGE DISPOSAL-SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: Date Of Inspection Inspect 's Name: O ner's Nam and Address: zM CERTIFICATION STATEMENT: I Certify that I have personally Inspected the Sewage Disposal System at this address and that the informa- tion reported below is true,accurate and complete as of the time of Inspection. The Inspectioin was perform- ed based on my Training and Experience in the Proper Function and Maintenance of On-Site Sewage Dis- posal Systems system: R, Passes Conditionallyipasses Needs Zr Evalua ' By the Local'Approving Authority Failure, Inspector's Signature Date: TheSystem Inspector shall submit a copy of this Inspection Report to the Approving Authority with 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 Offie 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: A) SYSTEM PASSES: I have not found any Information which indicates that the System violates any of the fail- ure criteria as defined in 310 CMR 15.303. Any Failure Criteria not evaluated are indi cated 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,nor,or not determined(Y,N,OR ND). Describe bases of determination in all instan es6lR=n107 1:' 9� • determined",explain why not. The Septic.Tank is Metal,Cracked,Structurally Unsound,shows Substantial Inn tg on o fil -tration,or Tank Failure is iimminent. The System will PasiInspection if Existi�g�eptic Tattle !A� -is Replaced with a conforming Septic Tank as Approved by the Boatrd Of Heal - Sewage Backup or'Breakout or High Static Water Level observed in' the Distribution Boil ue j 0 broken or obstructed pipe(s)or due to a broken,settled or uneven Distribution FBq Th teW will pass Inspection if(With Approval of the Board Of Health): 9c9 - ?� SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM :.." 'PART A CERTIFICATION(continued) Broken pipe(s)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 Obstnrction'is removed 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 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 SYS TEM,IS FUNCTION- EKG IN A MANNER,THAT PROTECT THE PUBLIC HEALTH_AND.SAFETY AND THE ENVIRONMENT: T. . 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 with 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 the facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm• D)SYSTEM FAILS: I have determined that the system violates one or more of the following failure criteria as defined is identified below. The Board of Health in 310 CMR 15.303. The basis for this determination 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. Discharge or ponding of efluent to the surface of the ground or surface waters due to an {., overloaded or clogged SAS•or.cesspool. , s Static liquid level m:the distribution box above outlet invert due to an overloaded or clog- ged SAS or.cesspool:' 'Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 -dayflow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped 2- 'SUBSURFACE SEWAGE-DLSPOSAL'SYSTEMINSPECTION FORM ;.PART A CERTIFICATION(continued), 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. 1i E)LARGE SYSTEM FAILS: The following criteria apply to a large system in addition to the criteria above: The design flow of a 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 i The system is'witl"200 Feet of a tributary'to:a surface drinking water supplyThe system is located in a nitrogen sensitive area Interim Wellhead Protection Area ;. (IWPA)or a mapped Zone II 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. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST r 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 adeast 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. The facility or dwelling was inspected for signs of sewage back-up. , The system does not receive non-sanitary J� syst tary or industrial waste flow. .. The site was inspected for signs of breakout. All . . . : : . �_ system components,excluding the Soil Absorption System,have been looted-on site. _ Thesepttc tank manholes were uncovered,opened,and the iii- r_of_the'septic tank was in _. spocted 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 or approximated by non-intrusive methods. -3- SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B z'.. CHECKLIST(continued) 1/ The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of Subsurface Disposal System SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION FLOW CONDITIONS B , Design Flow: gallons Number of Bedrooms: Number of Current Residents: ya&z4. � Garbage Grinder: Laundry Connected To System: Seasonal Use: Water Meter Readings,if ailable: Last Date of Occupancy: CO MER ALIIND 1CTRIAL- A_)b Type of Establishment: �. Design Flow: aallonstday Grease Trap Present:.(yes or no).- Industrial Waste Holding Tank Present: Non-Sanitary Waste Discharged To The Title V System: 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: If yes,volume pumped: gallons Reason for pumping: TYP F SYSTEM: Septic Tank/Distribution Box/Soil Absorption System Single Cesspool Overflow Cesspool Privy Shared System(If yes,attach previous inspection records,if any) Other(explain): APPROXIMATE AGE of all components,date installed(if known)and source of information: Sewagfodors detected when arriving at'the site: i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM >'' PART C ( rGENERAI;INFORMATION (continued) SEPTIC TANK: ✓ Depth below grade: Material of Construction:•-C'-�O-ncrete metal FRP.- Other . (explain) — Dimisions:JQ_ x( ' ' Sludge Depth: 4yf" Scum Thickness: Distance from top of sludge to bottom of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: /Z ' a `Comments:(recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relationVutdieflnvert, ural integrity,evidence ofI_ ge.etc., /„GREASE TRA Depth Below Grade: Material of Construction: concrete `metal(explain) FRP Other _ Dimensions: Scum Thickness: , Distance from top of scum to top of outlet tee or baffle' , Comments: (recommendation for pumping,condition of i.nlet.and.outlet tees or baffles;depth of liquid ' level to relation to outlet invert,structural-integrity,evidence of.leakage`. etc,) TIGHT OR HOLDING TANK: w_ Depth Below Grade: Material of Construction:_concrete—metal FRP Other(explain) Dimensions: Capacity: gallons Design FIONNI: gallons/day Alarm Level: Comments: (condition of inlet tee, condition of alarm and float switches,etc.) DISTRIBUTION BOX: t/ Depth of liquid level above outlet invert: Comments: (note if el 4rtd distribution is equa eviden o solids carryover,evidence o eakag into of out of box,etc.) ii PUMP CHAMBER. Pump is in working order. r.Ati F Comments: note condition of puhip cliariibei,condition of pumps and appurtenances;etc.) -5- SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C _ w SYSTEM INFORMATION(continued) SOIL ABSORPTION SYSTEM(SAS): r/ (L,ocato`on site plan,if possible;excavation"not required,but may be approximated by non-intrusive methods) If not determined to be present,explain: _. . . Type: Leaching pits,number:Leaching chambers,number: Leaching galleries,number: .Leaching trenches,number,length: Leaching fields,number,dimensions: Overflow cesspool,number: COMMeAts:.(note condition of soil,signs of hydraulic fail a level of ndin con ition of vegetation, kw -,� zk CESSPOOLS:--A—^--' 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 soilk,signs of hydraulic failure, level of ponding,condition of vegetation, etc.) PRIVY: NCJ Materials of construction: Dimensions: Depth of Solids: Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation, etc.) _._, Ann- SUBSURFACE SEWAGE,DISPOSAL SYSTEM INSPECTION FORM PARTFC, t SYSTEM INFORMATION(continued) SKETCH OF SEWAGE DISPOSAL SYSTEM: Include ties to atleast two permanent references, landmarks or benchmarks. Locate all wells within IN Feet. 14 3 . " ` o 4 DEPTH TO GROUNDWATER: Depth to groundwater: - 32 Feet , � / Method of Determination or Ap on: /�j 7 eo �1o�1 �5, o o u � -7 ti-