HomeMy WebLinkAbout0267 SALT ROCK ROAD - Health 267. halt oc oa
'Barnstable'
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TOWN OF BARNSTABLE _
LOCATION ��c.0 KC SEWAGE
VILLAGE ASSESSOR'S MAP & LOT 3/L `Z'-17
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY f ycs b
LEACHING FACILITY: (type) (size) `Xr
NO.OF BEDROOMS oy 3
BUILDER OR OWNER
PERMTTDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility -26+ Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) i Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by i .l t.K»-
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TROY WILLIAMS - 7
SEPTIC INSPECTIONS
Certified * MA Department of Environmental Protection (508) 385-1300
19 Hummel Drive
South Dennis, MBA 02660
-\ COMMONWEALTH OF MASSACHUSETI'S
EXECUTIVE OFFICE OF ENVIRONMENTAI,AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
TITLE 5
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY �SSE '
SUBSURFACE SEWAGE DISPOSAL SYSTEM
PART A
CERTIFICATION
Proper(N Address: 267 Salt Rock Road BLE
Barnstable,MA
Ossner's Name: Richard&Ethel Cummings Estate 1
Owner's Address: C/o Joan Solomon e n
18 Pilgrim Drive, Winchester,MA 01890 �I I
Date of Inspection: April 17,2002 0 \vl
Name of Inspector: Troy M. Williams
Company Name: Troy Williams Septic Inspections
Mailing Address: 19 Hummel Drive
South Dennis,MA 02660
Telephone Number: (508)385-1300
CERTIFICATION STATEMENT
1 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
apprm ed system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The sv�tem
Passes
Conditionall\• Passes
Needs Further 1:valuation by the Local Approving Authority
Fails
Inspector's Signature: A-122 ?161AKC�,r,,,,,. Date: 9//-7 /o.z
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of I lealth 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
Although system meets the minimum requirements set forth by the Massachusetts Department of
Environmental Protection,certification is not to be construed as a guarantee of future working condition
of system,piping or components. This inspection represents the conditions of the system on the Date of
Inspection noted above.
+`••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 saute or different
conditions of use.
Title 5 Inspection Form 6/15/M00 pace I
Page 2 of I I
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 67 2 Salt Rock Road
Owner: Barnstable,MA
Date of Inspection: Richard&Ethel Cummings Estate
April 17,2002
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. /System Passes:
✓ I have not found any information which indicates that anv of the failure criteria described in 310 CMR
15.303 or to 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below.
Comments:
B. System Conditionally Passes:
One or more system components as described in the"Conditional Pass"section nee o be replaced or
repaired. The system, upon completion of the replacement or repair,as approved by the and of Health,will pass.
Answer yes. no or not determined(Y,N,ND)in the_ for the following state tits. If"not determined"please
explain.
The septic tank is metal and over 20 years old* or the septic tan• whether metal or not)is structurally
unsound,exhibits substantial infiltration or exfiltration or tank failur is imminent. System will pass in if the
existing Caul: is replaced with a complying septic tank as approve y the Board of Ilealth.
•A metal septic tank will pass inspection if it is structurally so d,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is availabl
ND explain:
Observation of sewage backup or bre out or high static water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken,settle or uneven distribution box. System will pass inspection if(with
approval of Board of Health):
oken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
The syste required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will
pass inspectio f(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain:
2
Page 3 of I I
OFFICIAL INSPECTION FORM.- NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address:
267 Salt Rock Road
Owner: Barnstable,MA
Date of frtspection: Richard&Ethel Cummings Estate
April 17,2002
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 public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 C�I5.303(I)(b)that the
System is not functioningin a manner aner which will protect public health,safe an
d nd the environment:
5 n ►ronment:
— Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetlan or a salt marsh
2. System will fail unless the Board of Health(and Publi ater Supplier,if anya determines that the
system is functioning in a manner that protects the pub 'c health,safety and environment:
_ The system has a septic tank and soil absorp 'on system(SAS)and the SAS is within 100 feet of a
surface water supply or tributary to a surface •ter supply.
_ The system has a septic tank and S and the SAS is within a Zone 1 of a public water supply.
The system has a septic tank a SAS and the SAS is within 50 feet of a private water supply well.
_ The system has a septic to • and SAS and the SAS is less than 100 feet but 50 feet or more front a
private water supply well"* ethod used to determine distance
*"This system passes i e well water analysis, performed at a DEP certified laboratory, for coliform
bacteria and volatile rganic compounds indicates that the well is free from pollution from that facility and
the presence of onia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
failure criteria a triggered.A copy of the analysis must be attached to this form.
3. Other:
3
Page 4 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 267 Salt Rock Road
Barnstable,MA
Owner: Richard&Ethel Cummings Estate
Date of Inspection: April 17,2002
D. System Failure Criteria Y
applicable to all systems:
P
You must indicate"yes"or"no"to each of the following for all inspections:
i
Yes No
-Z Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
_V Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
LO 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''/]day flow
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number !
of times pumped
An onion of the e SAS cesspool or P p privy is below high ground water elevation.
Any onion of cesspool or privy i w'prl9. P p p vy s within 100 feet of a surface water supply or tributary to a surface
water supply. „
— &Z�2 Any portion of a cesspool or privy is within a Zone 1 of a public well.
Any portion of a cesspool or privy is within 50 feet of a private water supply well.
,14 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. (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.)
N b (Yes/No)The system fails. I have determined that one or more of the above failure 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 facility with design flow of 10,000 gpd to 15,000
gpd.
You must indicate either"yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the cr' eria above)
yes no
_ the system is within 400 feet of a surface drink' g water supply
the system is within 200 feet of a tribu o a surface drinking water supply
_ the system is located in a nitrogen nsitive area(Interim Wellhead Protection Area—IWPA)or a mapped
Zone 11 of a public water suppl ell
If you have answered"yes"to any stion in Section E the system is considered a significant threat,or answered
"yes"in Section D above the lar system has failed.The owner or operator of any large system considered a
significant threat under Sectio or failed under Section D shad upgrade the system in accordance with 3I0 CMR
15.304.The System owner ould contact the appropriate regional office of the Department.
4
Page 5 of 11
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address:
267 Salt Rock Road
Owner: Barnstable,MA
Date of Inspection: Richard&Ethel Cummings Estate
April 17,2002
Check if the following have been done. You must indicate"yes"or"no"as to each of the following:
Yes No
_ !'::;:,king information was provided by the owner,occupant,or Board of I leald,
✓ Were 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?
_ Nl,9 Were as built plans of the system obtained and examined?(If they were not available note as N/A)
_ 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
✓" _ Wag the septic ", 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?
__ Was tite facility owner(and occupants if different from owner)provided with information on the proper
maintenance ol'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))
5
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Page 6 of 1 I
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address:
267 Salt Rock Road
Owner: Barnstable,MA
Date of inspection: Richard&Ethel Cummings Estate
April 17,2002 FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design):
( gn): Number of bedrooms(actual): o o_v 3 -r A
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 9P`t. s y S 4- w-+
Number of current residents:�_
Does residence have a garbage.grinder(yes or no): A o
Is laundn on a separate sewage system(yes or not No [if yes separate inspection required]
Laundry system inspected(yes or no): P//4
Seasonal use: (yes or no): Ivo
Water meter readings,if available(last 2 yearslisage(gpd)):o 1 -- zY,�s 4r/,,._, oo = z S�Vuo j,��/,..s
Sump pump(yes or no): ,io
Last date of occupancy: r , s u t , s 4 .
COMM ERCIALANDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): gpd
Basis of design flow(seats/persons/sgft,etc.):
Grease trap present(yes or no):
Industrial waste holding tank present(yes or no): _
Non-sanitary waste discharged to the Title 5 system ( s or no):
Water meter readings, if available: _
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information:A/o�,�, ,K 7"� �
Was system pumped as pan of the inspection(yes or no):
If yes, volume pumped: gallons-- How was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM
Septic tank,-istbttien-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 of information:
0 �.�e..�� 1 y 7 3
Were sewage odors detected when arriving at the site(yes or no): ,V6
6
Page 7 of 1 I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
267 Salt Rock Road
Owner: Barnstable,MA
Date of Inspection: Richard&Ethel Cummings Estate
April 17,2002
BUILDING SEWER(locate on site plan)
Depth belu%% grade:
Materials of construction: /cast iron _40 PVC_✓other(explain):
Dktancr fron' private water supply well or suction line: A,/A� '
Comments(oncondition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK: (locate on site plan)
Depth below grade: )
Material of construction:Zconcrete_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: _ S'�g ru c ' /ooa
Sludge depth I '
Distance from top of sludge to bottom of outlet tee or baffle: 2 '
Scum thickness: 1yDNr
Distance from top of scum to top of outlet tee or baffle: Aio
Distance from bottom of scum to bottom of outlet tee or baffle: i rJ s
flow were dimensions determined: Pez>..4,
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert,evidence of leakage, etc.):
w-!~c.�'—'�i��`�—t�Y— . - i..c.! .L.. wo•-�.'..n q orJl•c..,_�_/y cvi_c.l.z_�} y 7C/4.l�a
f v
� y
70 S. v✓+f- w41 .•,:woc_ c:.+.t �J»s� l: Gf /�t+r./�
GREASE TRAP:_(locate on site plan)
Depth below grade:_
Material of construction:_concrete_metal_fiberglass_p yethylene_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 t or baffle:
Date of last pumping:
Comments(on pumping recommendations, ' et and outlet tee or baffle-condition,structural integrity,liquid levels
as related to outlet invert,evidence of le ge,etc.):
7
- Page 8 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
267 Salt Rock Road
Owner: Barnstable,MA
Date of Inspection: Richard&Ethel Cummings Estate
April 17,2002
TIGHT or HOLDING TANK: (tank must be pumped at time of• spection)(locate on site plan)
Depth below grade:
Material of construction: concrete metal fiberg s_polyethylene other(explain):
Dimensions: _
Capacity: gallons
Design Flom: gallons/day
Alarm present(yes or no):
Alarm level: Alarm in working er(yes or no):
Date of last pumping:
Comments(condition of alarm and at switches, etc.):
DISTRIBUTION BOX:N//) (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert:
Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover, any evidence of
leakage into or out of box, etc.):
11 k I A A
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,conditio f pumps and appurtenances,etc.):
8
Page 9 of I 1
OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
267 Salt Rock Road
Owner: Barnstable,MA
Date of Inspection: Richard&Ethel Cummings Estate
April 17,2002
SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required)
If SAS not located explain H-h).
Type
✓ leaching pits. number: I ' (o Xty `��t. f'; ,,,;(I� l•s'Shy_
leaching chambers,number:
leaching galleries,number:_
le
aching trenches numb
er, lengt
h:
h
g _
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,Eondition of vegetation,
etc.):�{oJu S _S_u•.1... . Lt.�..mot.. 1'�• 1� �w ( Y4✓,..✓t WI f'/. w c a.�/ ti. i .t-- �7�' I
�7 p�f[J.-.J(.� !l bt J •. I •.1 l W cry tH- /I+vcr�.
CESSPOOLS: (cesspool must be pumped as part of inspect' n)(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 no):
Comments(note condition of soil,s' s 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 hydra c failure, level of ponding,condition of vegetation,etc.):
9
Page 10 of 1 I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 267 Salt Rock Road
Barnstable,MA
Owner: Richard&Ethel Cummings Estate
Date of Inspection: April 17,2002
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 wh
ere public water supply enters the building.
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-Page I I of I I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
267 Salt Rock Road
Owner: Barnstable,MA
Date of Inspection: Richard&Ethel Cummings Estate
April 17,2002
SITE EXAM
Slope ✓
Surface water
Check cellar ✓
Shallow wells
Estimated depth to ground water 70+ feet Adjusted high ground water elevation — feet
Please indicate(check)all methods used to determine the high ground %cater elevation:
Obtained from system design plans on record- If checked,date of design plan reviewed:
Observed site(abutting property/observation hole within ISO feet of SAS)
Checked with local Board of Health-explain:
Checked with local excavators, installers-(attach documentation)
Accessed USGS database-explain:
You must desccribe how you
established the high groundwater elevation:
a;.l'- Ina _ w .} V �_' 12.�3-�i .i. q// mot.'�•J
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• 11