HomeMy WebLinkAbout0066 WINDSOR WAY - Health 6�VI1�DSbWAY,_".. � R�
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TOWN OF BARNSTABLEa
LOCATION t^ SEWAGE # S/—
VILLAGE
ASSESSOR'S MAP & LOTS l �" l 0 I
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) (size)
NO.OF BEDROOMS
BUILDER OR OWNER
PERMTTDATE: COMPLIANCE DATE: 4
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
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TROY WILLIAMS \tip\ -
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SEPTIC INSPECTIONS
Certified by MA Department of Environmental Protection (508) 385-1300
19 Hummel Drive
South Dennis, NA 02660
COMMONWEALTH OF MASSACHUSETTS
EXECLITIVF, OFFICE, OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
TITLE 5
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Proper(N Address: 66 Windsor Way
Barnstable,MA .�
O"ner's Name: Bill Hickman (�
Owner's Address: P. O. Box 1284 �►vt
Barnstable,MA 02630 Q
Date of Inspection: February 13,2001 Q
RECEIVED
Name of Inspector: TroyM. Williams �l fJ
Company Name: Troy Williams Septic Inspections �J
Mailing Address: 19 Hummel Drive FEB 16 2001
Telephone Number: South Dennis,MA 02660
p 508 385-1300 TOWN OF BARNS7ABLE
HEALTH DEPT.
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
appro%ed system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The sx•stem
Passes
Conditionally Passes
Needs Further Evaluation b} the Local Approving Authont)
Fails
Inspector's Signature: S '��,�,Q(/QQ, Date:
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
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. phis inspection does not address how the system will perform in the future under the same or different
conditions of use.
Title 5 Inspection Form 6/15/2000 pace I
Page 2 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
66 Windsor Way
Property Address: Barnstable,NIA
Owner:
Bill Hickman Date of Inspection: February 13, 2001
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
V// I 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. System Conditionally Passes: N/,1 J
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.
Answer yes. no or not determined(Y,N,ND)in the for the following statements. If"not determined"please
explain.
The septic tank is metal and over 20 years old* or the septic tank(whether metal or not)is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the
existing tank is replaced with a complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicatine that the tank is less than 20 years old is available.
ND explain:
Observation of sewage backup or break out or high static water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken,settled 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 pumping more than 4 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
N'D explain:
2
Page 3 of 1 I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 66 Windsor Way
Barnstable,MA
Owner: Bill Hickman
Date of inspection: February 13,2001
C. Further Evaluation is Required by the Board of Health:N1.1
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 CMR 15.303(1)(b)that the
system is not functioning in a manner which will protect public health,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 any)determines that the
system is functioning in a manner that protects the public health,safety and 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 SAS and the SAS is within a Zone I of a public water supply.
_ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
_ The system has a septic tank and.SAS and the SAS is less than 100 feet but 50 feet or more from a
private water supply well**. Method used to determine distance
**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 foim.
3. Other:
3
Page 4 of 1 1
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
66 Windsor Way
Property Address: Barnstable,MA
Bill Hickman
Owner: February 13, 2001
Date of Inspection:
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all inspections:
Yes No
_ Backup of Sewage into facility or system component due to overloaded or cloei,.ed SAS or cesspool
Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clo-ued 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 %day flow
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number
of times pumped
VAny portion of the SAS,cesspool or privy is below high ground water elevation.
.,vlq Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
— N/.o4 Any portion of a cesspool or privy is within a Zone 1 of a public well.
v o Any portion of a cesspool or privy is within 50 feet of a private water supply well.
— L 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 %%ater 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.]
N0 (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as
de>crihed 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: N/y
To be considered a large system the system must serve a facility with a 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 criteria above)
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
If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered
"yes"in Section D above the large system has failed.The owner or operator of any large system considered a
significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
15.304.The system owner should contact the appropriate regional office of the Department.
4
Page 5 of I 1
OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 66 Windsor Way
Barnstable,MA
Owner: Bill Hickman
Date of Inspection: February 13, 2001
Check if the following have been done. You must indicate"yes"or"no"as to each of the followine:
Yes No
—/ information was provided by the owner. occupant, or Board of 1 scald.
v/ 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?
- N/j 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 ?
— y for signs of sewage back u
g P g g— P
Was the site inspected for signs of break out?
Were all system components,excluding the SAS, located on site?
Wert 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?
_ Was the facility owner(and occupants if different from 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))
5
Page 6 of 1 1
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 66 Windsor Way
Barnstable,MA
Owner: Bill Hickman
Date of inspection: February 13, 2001
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): 3 Nutnber of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms):
Number of current residents: d,
Does residence have a garbage grinder(yes or no): YE5
Is laundn on a separate sewage system (yes or no): &o f if yes separate inspection required]
Laundry system inspected(yes or no): 9
Seasonal use: (yes or no): No
Water meter readings, if available(last 2 years Lisage (gpd)): 00 = 57 Odd c u iio.,s yq=�j�quo 9u da„.I
Sump pump(yes or no): No
Last date of occupancy:
COMMERCIAL/INDUSTRIAL Nl,9
Type of establishment:
Design flow(based ony 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 (yes or no):
Water meter readings, if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
SUt11'CC ofinforntation: ��� _F a-.__,:�_ /Yf8 c. .••, �4±�_;.�,_�
Was system pumped as pan of the inspection(yes or no): ,vo
If yes, volume pumped: gallons How was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM
Septic tank,distfibuti@u bomx,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:
C.F,T,�r. ;� r96y���� ;N U6az ��J
Were sewage odors detected when arriving at the site(yes or no): ,vo
6
Page 7 of I I
OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 66 Windsor Way
Barnstable,MA
Owner: Bill Hickman
Date of Inspection: February 13, 2001
BUILDING SEWER(locate on site plan)
' nle;.:
Depth below grade: `/ + � Qri.y J ,�•/
Materials of construction: cast iron _40 PVC other(explain): �,-,��s{ �"""` °' 7^� A,
Distance front private wate supply well or suction line: 6, .'"
Comments(on condition of joints,venting, evidence of leakage,etc.):
f / c d 1.v,c. w.„1 ✓n,l I c ✓ t ra�� 41 I ,h i c <, r 4 r+iv,—
got Io �+7i�c .- �r 11a�+.c 7Lt Scjo lit
N•S�L,�� Uf �f.53. ,..�. � �c�St �»<�S c✓.a. IDS la. ncr. A I. n
.. )f
SEPTIC TANK: locate on site�( plan) �
Depth below grade: y ' h<.s r s C 1,
Material of construction: concrete_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: 5')-.1 , )e 6 /000 9 of
Sludge depth: 31,
Distance from top of sludge to bottom of outlet tee or baffle: .2 /o"
Scum thickness: 3"
Distance from top of scum to top of outlet tee or baffle: 6
Distance from bottom of scum to bottom of outlet tee or baffle: It,'
How were dimensions determined: pr-o 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.):
„k w e S ..<u r 1 4 C.0 r <: r U✓n. , u t '/�. S '2 -e'R ..
GREASE TRAP:N/i(locate on site plan)
Depth below grade:
Material of construction:_concrete_metal_fiberglass_polyethylene_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 tee or baffle:
Date of last pumping:
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels
as related to outlet invert,evidence of leakage,etc.):
Page 8 of 1 1
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 66 Windsor Way
Barnstable,MA
Owner: Bill Hickman
Date of Inspection: February 13, 2001
TIGHT or HOLDING TANK: iv/g (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:
Material of construction: concrete metal fiberglass_polyethylene other(explain):
Dimensions:
Capacity: gallons
Design Floe: gallons/day
Alarm present(yes or no):
Alarm level: Alarm in working order(yes or no):
Date of last pumping:
Comments(condition of alarm and float switches,etc.):
DISTRIBUTION BOX: NIA (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.):
PUMP CHAMBER: N//j (locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no):
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
i
8
Page 9 of 1 1
OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 66 Windsor Way
Barnstable,MA
Owner: Bill Hickman
Date of Inspection: February 13, 2001
SOIL ABSORPTION SYSTEM (SAS): (locate on site plan,excavation not required)
If SAS not located explain why:
Type
leaching pits, number: <�2- X6 ' c�a �, �ti;f t, 2
leaching chambers,number:
leaching galleries,number:
leaching trenches,number, length:
leaching fields,number, dimensions:
overflow cesspool,number:
innovative/altemative system Type/name of technology:
Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation,
etc.):
i�c`t /c✓a l oti {,' *- n ' f wc,i � l./. t<i 1 ✓ 1
t3 .-. 6 J y --u
-- � I—
i n✓<✓ F `^+ v;..11 3 -�.,✓..J' C 1l .... c,.Su.<. �/T.r''N I ,..< . A/u .� ✓. .1 <..�...- o� �i ..A y ra ✓l . 7A.I .✓�
U/ h1y6 1,a✓..3 r, 'f�.� �c,f.r' ,.Jc,.. �✓..n ..+4 A�. -ri,.tia ✓.L .�)�s..��o.., J✓Y '1'L , , J h�f ..j.✓w i..,,;�,s
CESSPOOLS: AI/A (cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration:
Depth—top of liquid to inlet invert:
Depth of solids layer:
Depth ofscumla\er. _
Dimensions of cesspool:
Materials of construction:
Indication of groundwater inflow(yes or no):
Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
PRIVY: ti/n (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.):
9
Page 10 of 11
OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
66 Windsor Way
Property Address: Barnstable,MA
Bill Hickman
Owner: February 13, 2001
Date of Inspection: ^
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
6
Key- A 76
AIQ =. lo5 ,6
O A E
�000,.li 13
O
10
Page I l of l l
OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 66 Windsor Way
Barnstable,MA
Owner: Bill Hickman
Date of Inspection: February 13, 2001
SITE EXAM
Slope ✓
Surface water
Check cellar ✓
Shallow wells
Estimated depth to ground water 'poi feet Adjusted high ground water elevation feet
Please indicate(check)all methods used to determine the high ground %kater elevation:
Obtained from system design plans on record- If checked,date of design plan reviewed:
Observed site(abutting property/observation hole within 150 feet of SAS) S lop, 0, ';L
Checked with local Board of Health-explain:
Checked with local excavators, installers-(attach documentation)
Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
ll
A^
TROY WILLIAMS
SEPTIC INSPECTIONS
Certified 1 y MA Department of Environmental Protection 0� / -1 00
19 Hummel Drive
South Dennis, MA 02660 � ✓ �
COMMONWEALTH OF MASSACHUSETTS Jilt 6
, EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS 1998 w
DEPARTMENT OF ENVIRONMENTAL PROTECTIQ'`�f!! '
ONE HINTER STREET. BOSTON, MA 02108•617.292.5500
WILLIAM F-WELD TRUDYCOXE
Govcmor
Sccrctary
ARGEO PAUL CELLUCCI DAVID B.STRUHS
Lt.Govcmor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Commissioncr
PART A
CERTIFICATION
)
Property Address: 66 �'� '�r �"k1 Address of Owner: . JcycC_ ct,.rtCA KCsn)je_f-4 �3r✓�C✓
Date of Inspection: Of different) P6. 3aX
Name of Inspector: Troy Williams d /
I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR /5.000) / /M c-
Company Name: Troy .Williams Septic Inspections 'o
Mailing Address: 19 Hummel DrivP - 'South Dpnnis , MA 02660 Do?(,30
Telephone Number: (5 0 8) 3 8 5-13A 0
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
� J q
Inspector's Signature. Slw_� !�-�/`� -Date:
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, 8, C, or D:
A) SYSTEM PASSES:
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.
COMMENTS:
81 SYSTEM CONDITIONALLY PASSES: N//g
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 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,unless the owner or operator has provided the system inspector with a copy of a Certificate of
Compliance(attached) 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 conforming septic tank
as approved by the Board of Health.
(—i—d 04/2S/97) Paq• 1 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
66 Windsor Way,Barnstable,MA
Property Address: Joyce&Kenneth Fowler
Owner: June 19, 1998
Date of Inspection:
B] SYSTEM CONDITIONALLY PASSES (continued) A/M
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). Describe observations:
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
C] FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: III/19
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 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 to 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
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 66 Windsor Way,Barnstable,MA
Owner: Joyce&Kenneth Fowler
Date of Inspection: June 19, 1998
D] SYSTEM FAILS: Al/,I-
You must indicate ei;,.er "Yes" or "No" as to each of the following:
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.
Yes No
Backup of sewage into facility or system component due to an 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 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.
El LARGE SYSTEM FAILS: A/M
You must indicate either "Yes" or "No" as 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 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.
(rw1sed 04/25/97)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
66 Windsor Way,Barnstable,MA
Property Address: Joyce&Kenneth Fowler
Owner: June 19, 1998
Date of Inspection:
Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following:
Yes, No
Pumping information was provided by the owner, occupant, or 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.
_/ /d�9 As built plans have been obtained and examined. Note if they are not available with WA.
_jC _ The facility or dwelling was inspected for signs of sewage back-up.
_ The system does not receive non-sanitary or industrial waste flow.
�L _ The site was inspected for signs of breakout.
JC _ 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 the 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 one
The facility owner(and occupants, if different from owner) were provided with information on the proper maintenance of
Sub-Surface Disposal System.
Existing information. Ex. 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)]
(—i-.d 04/25/91)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 66 Windsor Way,Barnstable,MA
Owner: Joyce&Kenneth Fowler
Date of Inspection: June 19, 1998
RESIDENTIAL: FLOW CONDITIONS
Design flow: 330 g.p.d./bedroom for S.A.S.
Number of bedrooms: 3
Number of current residents:
Garbage grinder(yes or no):—!ec5
Laundry connected to system (yes or no):j!y-S
Seasonal use (yes or no): Alb
Water meter readings, if available (last tH•o (2) year usage (gpd): q7 = �JODU ��� s 96 _ 8a��00
Sump Pump (yes or no): NO
Last date of occupancy: 6C 0101,- d,
COMMERCIAUINDUSTRIAL• ^/h
Type of establishment:
Design flow: aallons/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:
L f �N, �.�
System pumped as pan of 000,
ins No
ADection: (yes or no) `r ~ '
If yes, volume pumped: gallons
Reason for pumping:
TYPE OF SYSTEM
_%ol Septic tank/&q�-1 /soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system (yes or no) (if yes, attach previous inspection records, if any)
VA Technology etc. Copy of up to date contract?
Other
APPROXIMATE AGE of all components, date installed (if known) and source of information: _� S ��I► �d t G 5
Yh t p
Sewage odors detected when arriving at the site: (yes or no)Ab
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 66 Windsor Way,Barnstable,MA
Owner: Joyce&Kenneth Fowler
Date of Inspection: June 19, 1998
BUILDING SEWER: IVIII
(Locate on site plan)
Depth below grade:
Material of construction: _cast iron _40 PVC_other (explain)"
Distance from private water supply well or suction line
Diameter
Comments: (condition of joints, venting, evidence of leakage, etc.)
SEPTIC TANK:
(locate on site plan)
Depth below grade: lk •b W;
Material of construction: ,concrete _metal _Fiberglass _Polyethylene —other(explain)
If tank is metal, list age _ Is age confirmed by Certificate of Compliance _(Yes/No)
Dimensions: S"X 9 'X 4, /000 y4//uh
Sludge depth:- y'• r
Distance from top ofsludge to bottom of outlet tee or baffle:
Scum thickness: 6 '
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle. 8��
How dimensions were determined:
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.) ,
Q0.k &- t.)orlG Jac. ora v A16 , C DT
t �o
Ala ,$ p�/ a' S q 'fi..�t o� :v.s�� �,7�y o •-� G✓c �Or-eS Gh/
GREASE TRAP:_LVl/9
(locate on site plan)
Depth below grade:
Material of construction: _concrete _metal _Fiberglass _Polyethylene _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 tee or baffle:
Date of last pumping:
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.)
(rwi—d o4/2s/97)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 66 Windsor Way,Barnstable,MA
Owner: Joyce&Kenneth Fowler
Date of Inspection: June 19, 1998
TIGHT OR HOLDING TAN : N(A(Tank must be pumped prior to, or at time, of inspection)
(locate on site plan)
Depth below grade:
Material of construction: _concrete _metal _Fiberglass _Polyethylene _other(explain)
Dimensions:
Capacity: gallons
Design flow: gallons/day .
Alarm level: Alarm in working order_Yes; No
Date of previous pumping:
Comments:
(condition of inlet tee, condition of alarm and float switches, etc.)
DISTRIBUTION BOX: A/�/a
(locate on site plan)
Depth of liquid level above outlet invert:
Comments: ,
(note if level and distribution is equal, evidence of solids carryover, 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, condition of pumps and appurtenances, etc.)
r
(rwl..d 04/25/971 _ _
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 66 Windsor Way,Barnstable,MA
Owner: Joyce&Kenneth Fowler
Date of Inspection:June 19, 1998
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: /
leaching pits, number: o� 6 /xL �,e- /01 fs Ill 4-1, �� ,5,1
leaching chambers, number:_
leaching galleries, number:
leaching trenches, number,length:
leaching fields, number, dimensions:
overflow cesspool, number:
Alternative system:
Name of Technology:
Comments:
(note condition of soil, si ns of hydraulic failure, level of ponding, condition of vegetation, etc.)
L' 'o 46o L,JH
61
k. e ' w
c. t'
CESSPOOLS:
(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(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:
Depth of solids:
Dimensions:
Comments: ) x
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
Iraviaad 04/25/97) Page I of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION;FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 66 Windsor Way,Barnstable,MA ,.'
Owner: Joyce&Kenneth Fowler
Date of Inspection: June 19, 1998
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100' (Locate where public water supply comes into house)
r e
�b
( 1000?41
P;}
(rrvlaad 04/25/97) ,_ Page 9 or 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Y
PART C'
SYSTEMINFORMATION (continued)
Property Address: 66 Windsor Way,Barnstable,MA
Owner: Joyce&Kenneth Fowler
Date of Inspection: June 19, 1998 _
Depth to Groundwater= Feet adjusted high groundwater level
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from Design Plans on record
Observation of Site (Abutting property, observation hole, basement-sump etc.)
Determine it from local conditions
Check with local Board of health
Check FEMA Maps
Check pumping records
Check local excavators, installers
Use USGS Data
Describe in your own words how you established the High Groundwater Elevation. Must be completed)
Us Gshw�f{r
a} 01d}/ b1bki,c ► 5 a /SC> �o �4fc� o,, �• '� �. �jrC �/,.�cc ��'�sr�+
T
�s.
(r.vie.d 04/7S/17) Pao• io ..i n -