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Home My WebLink About0024 PALOMINO DRIVE - Health 24 Palomino Drive i Barnstable P A = 297 046 ,r o e r a e ° o O ' ° c o f COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION A RECEIVED DEC 8 2003 TOVVN OF BARNSTABLE TITLE S HEALTH DEPT. OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Q-7 Property Address: 214 Palomino Drive MAP ��' 1 Barnstable PARCEL Owner's Name: Judy Antonucci 7 34 Owner's Address: LQ -- Date of Inspection: 11/21/2003 Name of Inspector: (please print) Kevin J. Sullivan Company Name: Ready Rooter Mailing Address: P.O.Box 371 Sandwich,MA 02563 Telephone Number: (508)888-6055 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 the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The System: _LZFasses Conditionally Passes Needs Further Evaluation by the Local Authority Fails Inspector's Signature: , 4 /6p,._.-- Date: o The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 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 DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Page 2 of I 1 Il OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 214 Palomino Drive Barnstable Owner: Judy Antonucci Date of Inspection: 11/21/2003 Inspection Summary:Check A,B,C,D or E/ALWAYS complete all of Section D C. System Passes: have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B. SystemConditionallyPasses: : One or more system components as described in the"Condit" nal Pass"section need to be replaced or repaired.The system,upon completion of the replacement or rep ' ,as approved by the Board of Health,will pass. Answer yes,no or not determined (Y,N,ND)in the fo the following statements.If"not determined"please explain. The septic tank is metal and over 20 years old*o the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration r tank failure is imminent.System will pass inspection if the existing tank is replaced with a complying septic tan as approved by the Board of Health. *A metal septic tank will ass inspection if it is s rally sound,not leaking and if a Certificate of Compliance P P P Y g P indicating that the tank is less than 20 years old i vailable. ND explain: Observation of sewage backup or br out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,sett or uneven distribution box.System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required p ping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with appr al of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: Page 3 of 11 • OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 214 Palomino Drive Barnstable Owner: Judy Antonucci Date of Inspection: 11/21/2003 C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evalu/protect d of Health in order to determine if the system is failing to protect public health,safety or the envi 1. System will pass unless Board of Health d accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner whect public health,safety and the environment: Cesspool or privy is within 50 feet of a rCesspool or privy is within 50 feet of agetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water S plier,if any)determines that the system is functioning in a manner that protects the public health,saf and environment: The system has aseptic tank and soil absorption system(SA 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 SAS and the SAS is thin a Zone t of a public water supply. The system has a septic tank and SAS and the SAS' within 50 feet of a private water,supply well. ` _The system has a septic tank and SAS and the S is less than 100 feet but 50 feet or more from a private water supply wells;. Method used to dete ne distance "This system passes if the well water analysis, erformed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates t at the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitr gen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the anal y is must be attached to this form. 3: Other. , Wv. Page 4 of 11 • OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 214 Palomino Drive Barnstable Owner: Judy Antonucci Date of Inspection: 11/21/2003 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No _ZBackup of sewage into facility or system component due to overloaded or clogged 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 and overloaded or clogged SAS or cesspool f Liquid depth in cesspool is less than 6"below invert or available volume is less than %Z day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped _ __,Z—Any portion of the SAS,cesspool or privy is below high ground water elevation. Any portion of 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 1 of a public well. — _,ZAny portion of a cesspool or privy is 50 feet of a private water supply well. --ZAny 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. [This system passes if the well water analysis, performed at a DEP certified laboratory,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,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] l�(Yes/No)The system fails. I have determined that one or more of the above criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a fac' ty with a design flow of 10,000 gpd to 15,000 gpd• You must indicate either"yes"or"no"to each of the follo ' g: (The following criteria apply to large systems in addition the criteria above) yes no the system is within 400 feet of a surface d nking water supply the system is within 200 feet of a tribu to a surface drinking water supply _the system is located in a nitrogen s sitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone 11 of a public water supply w If you have answered"yes"to any questi in Section E the system is considered a significant threat,or answered "yes"in Section D above the large syst has failed.The owner or operator of any large system considered a significant threat under Section E or led under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should co tact the appropriate regional office of the Department. Page 5 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 214 Palomino Drive Barnstable Owner: Judy Antonucci Date of Inspection: 11/21/2003 Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No Pumping information was provided by the owner,occupant,or Board of Health _ZWere any of the system components pumped out in the previous two weeks . Has the system received normal flows in the previous two week period? Have large volumes of water been introduced to the system recently or as part of this inspection? Were as built plans of the system obtained and examined. f the were not available note as N/A P Y � Y ) _ Was the facility or dwelling inspected for signs of sewage back up? . _ Was the site inspected for signs of break out? _ Were all system components,excluding the SAS,located on site? _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum ? _tZ— Was the facility owner(and occupants if different than owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes No Existing information.For example,a plan at the Board of Health. Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)] Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 214 Palomino Drive Barnstable Owner: Judy Antonucci Date of Inspection: 11/21/2003 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 3c�C Number of current residents:_A/_ Does residence have a garbage grinder(yes or no):&_-)j Is laundry on a separate sewage system(yes or no):rjD[if yes separate inspection required] Laundry system inspected(yes or no): Seasonal use:(yes or no):, _JZ> Water meter readings,if available(last 2 years usage(gpd)): a��'•6�'.J� 3< 3 �-�`� ' Sump Pump(yes or no)::?,2Zj Last date of occupancy: COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.2 ): gpd Basis of design flow(seats/persons/s etc.): Grease trap present(yes or no): Industrial waste hol/dank nt(yes or no):_ Non-sanitary wasteothe Title 5 system(yes or no):Water meter readinle:Last date of occupaOTHER(describe) GENERAL INFORMATION Pumping Records Source of information: r +.► �� 5 � � Was system pumped as part of the inspection(yes or no): Yc- If yes,volume pumped: allons--How was quantity pumped determined? ;•C� �v�o, �.,e Reason for pumping: �'C'�,....v,ti TYPE OF SYSTEM _�e4eptic tank,distribution box,soil absorption system Single cesspool Overflow cesspool _Privy Shared system(yes or no)(if yes,attach previous inspection records,if any) _Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight tank Attach a copy of the DEP approval —Other(describe): Approximate age of all components,date installed(if known)and source f information: Were sewage odors detected when arriving at the site(yes or no): e �' ' r Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 214 Palomino Drive Barnstable Owner: Judy Antonucci Date of Inspection: 11/21/2003 BUILDING SEWER(locate on site plan) Depth blow grade:��j' g r` �n Materials of construction:_cast iron 0 PVC other(explain): Distance from private water supply well or suction line: /J//A Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK:-XZ<0cate on site plan) Depth below grade: Material of construction:_,,!�65ncrete_metal fiberglass_polyethylene —other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions: l x Sludge depth: Distance from the top of sludge to bottom of outlet tee or baffle: fl� Scum thickness: ( r 3" ,�, as x\�' Distance from top of scum to top of outlet tee or baffle: 47 AV Distance from bottom of scum to bottom of outlet tee or baffle: 3 " How were dimensions determined:NLr� '% %'.b' Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): oc-plc t GREASE TRAP:_(locate on site plan) Depth below grade: Material of construction concrete_metal_fibrgl _polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or e: Distance from bottom of scum to bottom of outl tee or baffle: Date of last pumping: Comments(on pumping recommendations nlet and outlet tee or baffle condition,structural integrity,liquid levels g as related to outlet invert,evidence of lea ae,etc.): Page 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 214 Palomino Drive Barnstable Owner: Judy Antonucci Date of Inspection: 11/21/2003 TIGHT or HOLDING TANK: (tank must be pumped at f e of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fibergl _polyethylene_other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order es or no): Date of last pumping: Comments(condition of alarm and floats 'ches,etc.): DISTRIBUTION BOX: ,000Zif present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Comments(not if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): PUMP CHAMBER: (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,con ' ion of pumps and appurtenances,etc.): Page 9 of l 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 214 Palomino Drive Barnstable Owner: Judy Antonucci Date of Inspection: 11/21/2003 SOIL ABSORPTION SYSTEM(SAS): locate on site plan,excavation not required) If SAS not located explain why: Type aching pits,number: leaching chambers,number; leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number: innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): �..��lr.. O;Ti' �Gli.:-zs'�(G. -- ` �L •-..�v.c,�,-��rz��a - '�;�rm Q �� -r�.� CESSPOOLS: (cesspool must be pumped as papt of inspection)(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(yes or o): Comments(note condition of soil,si of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: (locate on site plan) Materials of construction: Dimensions: Depth of solids: j Comments(note condition of soil,signs of by aulic failure,level of ponding,condition of vegetation,etc.): Page 10 of 11 • OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 214 Palomino Drive Barnstable Owner: Judy Antonucci Date of Inspection: 11/21/2003 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage.disposal system including ties to at least two permanent reference landmarks or benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building. a D7 10 00 �•'� - 7 7 O - i = Q 3 3 7 3`N s Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 214 Palomino Drive Barnstable Owner: Judy Antonucci Date of Inspection: 11/21/2003 SITE EXAM Slope Surface water Check cellar�� Shallow wells Estimated depth to ground water>tQ feet Please indicate(check)all methods used to determine the high ground water elevation: --,,/'Obtained from system design plans on record—If checked,date of design plan reviewed: 3LIA9 Observed site(abutting property/observation hole within 150 feet of SAS). Checked with the local Board of Health-explain: Checked with local excavators,installers-(attach documentation) _,.eAccessed USGS database-explain: ,rv\g,, ;�,.s; r , tj�ecn5,eao•w s You must describe how you established the high ground water elevation: c" ' r