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Home My WebLink About0025 BRIDGET'S PATH - Health 25 Bridgets Path M, Centerville P A = 169 102 r art LIPC 12543No 53LOR tee; HASTINGS, rjN �p 21 2015 1422 Jim The Inspector Man 5085349919 page 1 ,�/,0 Commonwealth of Massachusetts Title 5 Official Inspection Form X Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 25 Brid ets Path 9 c,;>t Property Address lam; John Moloney X.- Owner Owner's Name / information is Centerville ✓ required for every MA 02632 9-17-15 •" page. Cityrrown State Zip Code Date of Inspection ti Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A. General Information filling out forms ��qunnpr Use onlythe tab `\`on the compurter, ZH OF 1. Inspector. �� //SZ. , �� • •. y '. key to move your cursor-do not James D. Sears JAMES m use the return key. Name of Inspector c c5 Capewide Enterprises,LLC Company Name ��7t�� ` 153 Commercial Street N let SI S\' r'rj Company Address Mashpee MA 02649 at R y °W^ State Zip Code 508-477-8877 S 1623 Telephone Number License Number B. Certification. 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 16.340 of Title 5 (310 CMR 16.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails i ❑ Needs Further Evaluation by the Local Approving Authority 1 . �— 9-18-15 spector's Signature Date 1 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 aulhodty. ""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. �o V-S t5ins•3/13 Title 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 1 of 17 Sep 21 2015 14:22 Jim The Inspector Man 5085349919 page 2 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 25 Bridgets Path Property Address John Moloney Owner Owners Name information is required for every Centerville MA 02632 9-17-15 page. CitylTown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E!always complete all of Section D A) System Passes: ® 1 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: j ,I The system is a 1000 Gal Tank D Box and pit B) System Conditionally Passes: ❑ 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. i Check the box for"yes", "no"or"not determined" (Y, N, ND)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 Heaection if the existing tank is replaced with a complying septic tank as approved by the Board of i "A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of { Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND(Explain below): 5 i 1 i Wins•3113 Title 5 Official Inspection Form:Subsurfooe Sewege Disposal System•Page 2 of 17 Sep 21 2015 14:22 Jim The Inspector Man 5085349919 page 3 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments •' 25 Bridgets Path Property Address John Moloney Owner information Is Owner's Name required for every Centerville MA 02632 9-17-15 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ 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 ❑ Y ❑ N ❑ ND (Explain below): a ❑ obstruction is removed ❑ Y ❑ N ❑ NO (Explain below): 1 ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ NO (Explain below), i ❑ 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 ❑ Y ❑ N ❑ NO (Explain below): � ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): i t j I 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. I. 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 j 1 ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5in5•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 or 17 1 Sep 21 2015 1422 Jim The Inspector Man 5085349919 page 4 Commonwealth of Massachusetts = Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 25 Bridgets Path Property Address John Moloney Owner information is Owner's Name required for every Centerville MA 02632 9-17-15 page. CitylTown State Zip Code Date of Inspection J B. Certification (cont.) 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 1 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: i i This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent 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. 3. Other: j 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 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 is less than 6" below invert or available volume is less than 1/day flow oo617 15ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Sep 21 2015 1422 Jim The Inspector Man 5085349919 page 5 Commonwealth of Massachusetts Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 25 Brid9 ets Path Property Address John Moloney Owner Owners Name information is required for every Centerville MA 02632 9-17-15 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® 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 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 i tributary to a surface water supply. 1 ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. I ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. i ❑ ® 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 fecal coliform bacteria indicates absent and the presence J 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 and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® 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. j E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply I ❑ ❑ 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 I I 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. 15ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Sep 21 2015 14:22 Jim The Inspector Man 5085349919 page 6 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 25 Bridgets Path Property Address John Moloney Owner Owner's Name information is required for every Centerville MA 02632 9-17-15 page. Cityfrown State Zip Code Dale of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: i Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? I I ® ❑ 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 El ® this inspection? ® ❑ 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? ® ❑ 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? i ❑ ® 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 i been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. i ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue f approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information i Residential Flow Conditions: Number of bedrooms(design): 2 Number of bedrooms(actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 220 t5ins•3113 Title 5 Official Inspection Form;Subsurface Sewage Disposal System•Page 6 of 17 Sep 21 2015 1422 Jim The Inspector Man 5085349919 page 7 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 25 Bridgets Path Property Address John Moloney Owner Owner's Name information is required for every Centerville MA 02632 9-17,15 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: The system is a 1000 Gal. Tank D Box and pit. i i i Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes El No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage (gpd)): 2013-44,000Gals 2014-34-000Gal's Detail Sump pump? ❑ Yes ® No Last date of occupancy: Present Date { Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) i Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: l5ins•3013 Title 5 Official Ins pection Form'Subsur'ate Sewage Disposal Sysiem•Page 7 of 17 Sep 21 2015 14:22 Jim The Inspector Man 5085349919 page 8 Commonwealth of Massachusetts = Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 25 Bridgets Path Property Address John Moloney Owner Owner's Name information is required for every Centerville MA 02632 9-17-15 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): I i General Information Pumping Records: I Source of information: NA � Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons l How was quantity pumped determined? Reason for pumping: Type of System: I ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy i i ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) j ❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3h 3 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Sep 21 2015 1423 Jim The Inspector Man 5085349919 page 9 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 25 Bridgets Path Property Address John Moloney Owner Owners Name information is Centerville required for every MA 02632 9-17-15 page. Cityrr Nn State ZipCode Date f o Inspedlon D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: 1978 Permit#78-862. Were sewage odors detected when arriving at the site? ❑ Yes ❑ No Building.Sewer(locate on site plan): Depth below grade: 14" feet Material of construction.- 0 cast iron ❑40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints,venting, evidence of leakage, etc.): Pipeing is 4" PVC. Septic Tank(locate on site plan): Depth below grade: 4" feet Material of construction: ® concrete ❑ metal ❑fib erglass ❑ polyethylene El other(explain) i l If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 Gal. Precast H-10 Sludge depth: 3" t5ins•3/1$ Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Sep 21 2015 14:23 Jim The Inspector Man 5085349919 page 10 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 25 Bridgets Path Property Address John Moloney Owner Owner's Name information is required for every Centerville MA 02632 9-17-15 page. CdyrTown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cont.) 27" Distance from top of sludge to bottom of outlet tee or baffle j Scum thickness 1" Distance from top of scum to top of outlet tee or baffle S" Distance from bottom of scum to bottom of outlet tee or baffle 17" How were dimensions determined? Asbuilt-Plan-Tape Sludge Judge Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank at working level. Tank and covers at 4"below grade. In and outlet Tee's. No sign of leakage or over loading. Grease Trap (locate on site plan): Depth below grade: feet 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: Date 15ins•3/13 Title 5 Official Insoection Form:Subsurface Sewage Disposal System-Page 10 of 17 I Sep 21 2015 14:23 Jim The Inspector Man 5085349919 page 11 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 25 Bridgets Path Property Address John Moloney Owner Information is Owner's Name required for every Centerville MA 02632 9-17-15 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: i Material of construction: i ❑ concrete ❑ metal ❑ fiberglass g El polyethylene El other(explain): j Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: El Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): i i a `Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins-3113 Title 5 official Inspection Form:Suhsurfece Sewage Disposal System•Page 11 of 17 Sep 21 2015 1423 Jim The Inspector Man 5085349919 page 12 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 25 Bridgets Path Property Address John Moloney Owner Owner's Name information is required for every Centerville MA 02632 9-17-15 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 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.): D Box is 16"x16"-9" below grade w/one line out. Box is clean and solid. No sign of over loading or solid carry over. Pump Chamber (locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): i * If pumps or alarms are not in working order, system is a conditional pass. i Soil Absorption System(SAS) (locate on site plan, excavation not required): � If SAS not located, explain why: t5ins•W13 Title 5 Officlal Inspection Forth:Subsurface Sewage Disposal System-Page 12 of 17 Sep 21 2015 1423 Jim The Inspector Man 5085349919 page 13 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 25 Bridgets Path Property Address John Moloney Owner Owner's Name information is required for every Centerville MA 02632 9-17-15 page. City(Town State Zip Code Date of Inspection D. System Information (cunt.) Type: ® leaching pits number: 1 ❑ 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.): Leaching is a 1000 Gal. Precast pit w/ 1' stone. Pit and cover at 15"below grade 3'water in pit. No sign of over loading or solid carry over. No high stain line. I Cesspools (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 of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No l5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Sep 21 2015 14:23 Jim The Inspector Man 5085349919 page 14 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 25 Bridgets Path Property Address John Moloney Owner Owner's Name information is required for every Centerville MA 02632 9-17-15 page. Cityrrown Slate Zip Code Date of Inspeclion D. System Information (cont.) 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.): I I i I I 15ins•3A 3 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Sep 21 2015 1423 Jim The Inspector Man 5085349919 page 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 25 Brid ets Path Property Address John Moloney Owner Owner's Name information for every Centerville required for eve MA 02632 9-17-15 page. Cityrrown State Zip Code Date of Inspection D. System Information (Cont.) Sketch Of Sewage Disposal System: Provide a view 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. Check one of the boxes below: ' ' hand-sketch in the area below ❑ drawing attached separately 13 I' Ef '— q Do13 i 15ins-3113 Title 5 Official Insp ection Form;Subsurface Sewage Disposal System•Page 15 of 17 Sep 21 2015 14:23 Jim The Inspector Man 5085349919 page 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal : Form-Not for Voluntary Assessments k 25 Bridgets Path Property Address John Moloney Owner Owner's Name information fo is Centerville MA 02632 9-17-15 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope - ❑ Surface water ❑ Check cellar ❑ Shallow wells /Vo Estimated depth t high ground water: feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: 12-7-78 Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ 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: T.H.on Design plan 12-7-78 no G,W. at 12'+. Bottom of pit at 7'below grade. Bottom of pit at 15' above T.H. Depth. Before filing this Inspection Report,please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 Sep 21 2015 1424 Jim The Inspector Man 5085349919 page 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 25 Bridgets Path Property Address John Moloney Owner Owner's Name information is required for every Centerville MA 02632 9-17-15 page. Citylfown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary; A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file i i i I I I 15ins•3/13 Title 5 Official Inspection corm:Subsurface sewage Disposal System•Page 17 of 17 1 _ _--___/ `.may.., w�f�• /C � � L f , /r TOWN OF BARNSTABLE cc LOCATION —� J EI-I«C64�- SEWAGE # ,,),6U2- 25-1 �'VB.LAGE Cef ��L/6 IP ASSESSOR'S MAP & LOT 1- 102 INSTALLER'S NAME&PHONE NO. .✓ SEPTIC TANK CAPACITYS , LEACHING FACILITY: (type) eces- L (size) NO.OF BEDROOMS '2— BUELDER OR OWNER PERMITDATE: U2 MPLIANCE DATE: b 1t 0 Separation Distance Between the: Maximum Adjusted Groundwater Table to the 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 l w No. �a v � Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes �✓ PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Zipplication for Migooal *p6tem Construction permit Application for a Permit to Construct( )Repair(X Upgrade( )Abandon( ) ❑Complete System O Individual Components Location Address or Lot NO.a5 k) i Owner's/Name,Address and Tel.No. Assessor's Map/Parcel Ins ler's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Y1 vie-ieob`� 571�.�Y)ST �j Type of Building: ' ) Dwelling No.of Bedrooms N Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil hr Nature of R pairs terations(A wer wh n applicably 6IQ3 Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisi&Rs of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been iss ed bF this Boar of ealth. Signe Date Application Approved by Date Application Disapproved for Yie following reasons Permit No. Date Issued / 0? ——————————————————————————————————————— y No. �aU� Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes ./ s PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLES MASSACHUSETTS 0(ppYication for 30igo5al *p5tem Construction Permit Application for a Permit to Construct( )Repair(V/)Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No.aJ Owner's Name,Address and Tel.No.�l eh n i r7 Assessor's Map/Parcel Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. �I Vi e.l2ober+55 5'Tkf,n76nS-r-LA1, . ff7 lob! Type of Building: Dwelling No.of Bedrooms rl Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow ate! ! 1! 1 gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil >"1 f Nature of Rf-pairs r-Alterations(Answer wh n applicablA � 4�I UA./ 11,93 �!!�� 4 .. Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisioT of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this Boar of ealth. Signed Date/ "� Application Approved by -10J, �W Date —fit/—U 4 -; Application Disapproved forge following reasons Permit No. 7Ci02_ ?C"/ Date Issued /V 02 - --------------------------------------- f If THE COMMONWEALTH OF MASSACHUSETTS _BARNSTABLE, MASSACHUSETTS Certificate ib,f Compliance THIS IS TO CERTIFY, t at the On-site lewage Disposal System Constructed( )Repaired (V Upgraded( ) Abandoned )by ':! at Crr hi has been constructed i accordance with the pr visions of Title i the for Disposal System Construction Permit No. DW D 4 S'/ dated 6 Installer I 1Gl ,P / Designer The issuance of �s ermit shall not be construed as a guarantee that the syste will function as esig ed. Date l� Inspector --------------------------------------- No. Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS lwiopoml *pgtem n5truction Permit Permission is hereby granted to Consquct( )Re air( U grade( Abandon( )/ System located at r - and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided: Construction must be completed within three years of the date of thi t Date: �/y U.2 ''-` Approved by < -7 TOWN OF BARNSTABLE cc LOCATION J rJ3rj �Y�r / 1 SEWAGE # oZGU 2- �SI VILLAGE �e�(�✓(/o If-� ASSESSOR'S MAP & LOT /0)_ INSTALLER'S NAME&PHONE NO. ✓ , SEPTIC TANK CAPACITY K+S OIJD !4 LEACHING FACILITY: (type) CC (size) NO. O BEDROOMS �• BUILDER OR OWNER PERMITDATE:/Ua MPLIA'4E10E DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the 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 p 0 -7 .......................... ....................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH To.w-,N...............OF.........c ar.R S 7-4 13 e- .......................... Appliratiou for Dhipviial Vvrk� Tvmuurtion Vamit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: .......p4Tff.........Cez . 1,�&1111_44 ............... ...................................................................... 1177 i Addr�e or Lot ......... .4) eflIfIl of- //j .......................................................................................... .... ....... ................................. 40 Address ............. .......................................... .................................................................................................. Installer Address Type of Building Size Lot....l0......Sq. feet U ................Expansion Attic Garbage Grinder (NO) Dwelling—No. of Bedrooms............................ �Vo) Other—Type of Building .... ............ No. of persons............................ Showers Cafeteria Other fixtures ------------------------------------ a -------------------------------------------------------------------------------------------- Design Flow..........._/Z.0-_------------------gallor g9ff-per day. Total daily flow---- .........2_2_0............gallons. 9 Septic Tank—Liquid capacityJAK?Pgallons Length-6.X...... Width.1_2®**".. Diameter................ Depth..S.-,.@...... Disposal Trench—No..................... Width............._____.. Total Length............_....... Total leaching area....................sq. f t. Seepage Pit No...__ _/---------- Diameter---- *........ Depth below inlet......6.!o....... Total leaching area..a..O.-.O..sq. ft. Z Other Distribution box ( I-f' Dosing tank ( ) 0 h - Percolation Test Results Performed by.___ Date....Djr.C_,......?.,../,I.�> Test Pit No. I-----<.2—minutes per inch Depth of Test Pit...11..r....... Depth to ground water.-A-1_0 Test Pit No. 2................minutes per inch Depth of Test Pit____.___.._.._._.... Depth to ground water......__._..._......._.. ............................................................................................................................................................. ..................... 0 Description of Soil------_. tv.7.>....... . .......................................... .......... .f ...................................................................................... -- ..................................................................................................................................................................................................... U Nature of Repairs or Alterations—Answer when applicable------------------------------------------------------------------------------------------------ ................................................................ ....................................................................................................................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in 'L operation until a Certificate of Compliance has been is ed by -he L- d g ealth. Sigd _. .... . ................... 46. Date Application Approved By... .. .... ... ... w — -------------0------ Z7_7 ..../7 Date Application Disapproved for the following reasons:................................................................................................................ ........................................................................................................................ ....................................... ............................... Date PermitNo......................................................... --------------------------- Date 1 , No..........t' ....... Fes$........................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Alipfiration for Mipaiial Workii Cana iitrur#inn rani ll Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal �. System at: ............... .............. , c�t'io -Addj}�ss� =f �?�°ner / 0, Addresb�f . `- ------------------------------------------ ------ Installer Address QType of Building � Size Lot....r.5w.0-----Sq. feet V Dwelling—No. of Bedrooms............._..........................Expansion Attic .Q'") Garbage Grinder (00) Other—Type of Building ---N)__ /q No, of ersons_________________r__ ____ Showers — Cafeteria Other fixtures W Design Flow______._..//.0......................gallons perTcrson.per day. Total daily flow__.__..__._-`r�-_�. _C�_._._____.___gallons. WSeptic Tank—Liquid*capacity/jq?O_galions LengthO_.A"____ Width'`l'!�_"_..__ Diameter________________ Depth__`J'__�$_„_. x Disposal Trench-No_ ____________________ Width.................... Total Length.................... Total leaching area....................sq. ft. , ......___.. ::_._.Depth below intJG'_��;p .,,Total leaching area: ._sq. ft. Seepage Pit No._._ Diameter.___.... Z Other Distribution box Dosing tank ( ) Percolation Test Results Performed by..._7%5._0__NA_k._P...., r -'-Z ' AW... Date__.-�::...._%?¢_�!`� ' aTest Pit No. I....<.I.^__minutes per inch Depth of Test Pit---i�_Z__o______. Depth to ground water.A.0 N. ..__. Test Pit No. 2.................minutes per inch Depth of Test Pit.................... Depth to ground water........................ R+' .......... ....IF---------------------------------•...............-------------------------------------------------------------•------•----•---•-------_------ Description of Soil ... _t? _.... 7n.------.S.a.. s''-"-�?�............................................................... � W --- -- - ------------ ---------•--- ---•---------.....•.------------------------------------------------------------------.. U Repairs nsw.er when applicable--------•----- •_____________ .............................................................. Nature of Re airs or Alterations A Agreement: r ' The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has ben ' ued by the o j-d iealth. - Si -•• ....... � --- -- -- ............. -tea' %O' ---• Application Approved By &Iz— .................. ----•---------••'----------•---- ........................... ........................................ Date Application Disapproved.for the following reasons-----------------------------•----------------------------- ..................................................... ---......-•---•--------------------••--------------•------------•--------•--------------•-------------------••------•---------------------•-----••------------•---•-----•--......•-•-•--•-------••••-••- Date PermitNo......................................................... Issued......................................................... Date ' THE COMMONWEALTH OF MASSACHUSETTS BOAR, OF Hq Z`T I ..........................................OF..................................................................................... A Trr ifiratr of Tuntplitinrr THIS IS TO CERTIFY 1ggt nd4W4 ge Disposal System constructed ( ) or Repaired ( ) by /t.._..... c... ------ 1'2 1 � 7�5...-;---�'--ter, er 4ri'-A.tf, 2&C/+Ja ----------------------- ------ at................................................................................................ �1 ---� •-----------...............-------•-•-----•-------------------------------------- has been installed in accordance with the provisions of TV t &j Xhe State Sanitary )C;1de as7desccAmed in the application for Disposal Works Construction Permit No...................!%................... . dated_.'.._____._._.-______._______-________________ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE................................................................................ Inspector......................................... ........................................... c THE COMMONWEALTH OF MASSACHUSETTS BOAF11a Z ...........................................OF...�APO/ :............_.._.._......................_._.._..--...._...---._.._.._......_..R No......................... FEE........................ �t��as raka �nr�uan rrnti� Permissip.4TSereby granted______________________________ _____________.__........ to Construct ( 4 g�r/Rep# �. *diy 4 4ewae Jasp� t atNo............................................................................................................................................................ et / a� as shown on the application for Disposal Works Construction N __ D to r P✓ ................................................7---------- 4 Board'of He a ..................................... th 1 DATE.---•••......--•---. - 1:-_�._.. ................................ FORM 1255 HOBBS & WARREN. INC., PUBLISHERS TO BARNSTABLE J_OCATION l �� SEW E °JILLAGE ASSESSOR'S MAPP L04�- INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY !O d0 LEACHING FACILITY: (type) 6'� (size) !Wy NO.OF BEDROOMS BUILDER OR OWNER PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the 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 AA �a ' � c j . t 1 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTI N RECEIVED ^' F x � JUN 2 4 2002 TOWN OF BARNSTABLE HEALTH DEPT. ' TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM .y PART A CERTIFICATION Property Address: 25 BRIDGET.S PATH CENTERVILLE, MA 02632 M169 P102 L11 Owner's Name: MARIE HERB 8 �9 Owner's Address: 25 BRIDGETS PATH CENTERVILLE,MA 02632 PA ,.. PAM Date of Inspection: 6/10/02 ,, LOT - Name of Inspector: (please print),,h�, ,;JOHN GRACI Company Name: SEPTC INSPECTIONS Mailing Address: P:O: 130X'2119 TEATICKET,MA.02536 Telephone Number: 508-564-6813 FAX 508=564-7270 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 systerns. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The systerr.: _ Pasges X Conditional asses _ Needs•Furt valuation by the Local Approving Authority Fails Inspector's Signature: Date: 6/10/02 The system inspector shall submit copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspec ion. If the system is a shared system or has a design now 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 '=*.t.. SYSTEM CONDITIONALLY PASSED TITLE V INSPECTION. D-BOX HAS ROTTED. ****This report only describes conditions at the time of inspection and under the conditions of Ilse at that time This inspection does not address how the'system will perform in the future under the same or different conditions of use. F i y Page 2 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) N. Property Address: 25 BRIDGETS PATH CENTERVILLE,MA 02632 M169 P102 L11 Owner: MARIE HERB Date of Inspection: 6/10/02 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D 11, 11, A. System Passes: .t _ I have not found any information'wliich 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: SYSTEM CONDITIONALLY PASSED TITLE V INSPECTION. D-BOX HAS ROTTED. B. System Conditionally Passes: X 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'cr repair,as approved by the Board of Health,will pass. y Answer yes, no or not determined(Y,N,ND) in the for the following statements. If"not determined"please explain. L n/a 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'iank 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 indicating that the tank is less than 20 years old is available. ND explain: n/a n/a 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: n/a n/a 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 ND explain: n/a 'f Ri i' Page 3 of I I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A ' CERTIFICATION(continued) Property Address: 25 BRIDGETS PATH CENTERVILLE,MA 02632 M169 P102 LII Owner: MARIE HERB Date of Inspection: 6/10/02 C. Further Evaluation is Required,by.the Board of Health: _ Conditions exist which require further evaluation by the Board of Health in orde,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 mater supply. _ The system has a septic tank and SAS'and the SAS is within a Zone 1 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 n/a "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. 3. Other: n/a t e ;t ;I. Page 4 of 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY,ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 25 BRIDGETS PATH CENTERVILLE, MA 02632 M169 P102 L11 Owner: MARIE HERB ' Date of Inspection: 6/10/02 ' D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the.following for all-inspections: Yes No X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool X Discharge or pond ing'of,e,ffluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool X Liquid depth in cesspool is less than 6"below invert or available volume is less than '/z day flow X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped PUMPED IN 1996 BY OWNER. X Any portion of the SAS,cesspool or privy is below high ground water elevation. X Any portion of cesspool or p'rivyis within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone 1 of a public well. X Any portion of a cesspool or privy is within 50 feet of a private water supply well. X 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 forma (Yes/No)The system fails. l,have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system9fails3`: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 sy'stem'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 X the system is within 400 feet of a surface drinking water supply X the system is within 200 feet of a tributary to a surface drinking water supply X 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 Nas 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 C M R 15.304.The system owner should contact the appropriate regional office of the Department. d , y Page 5 of 11 t . OFFICIAL INSPECTION.FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE,SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 25 BRIDGETS PATH CENTERVILLE, MA 02632 M l69 P102 L11 Owner: MARIE HERB Date of Inspection: 6/10/02 Check if the following have been,done. You must indicate"yes"or"no" as to each of the following: Yes No X _ Pumping information was provided by.the owner,occupant,or Board of Health _ X Were any of the system components pumped out in the previous two weeks i X _ Has the system received"nortial flows in the previous two week period" _ X Have large volumes of water been introduced to the system recently or as part of this inspection? R 1 _ X Were as built plans of the system obtained and examined?(if they were not available note as N/A) X _ Was the facility or dwelling inspected for signs of sewage back up`? X _ Was the site inspected for`signs of break out? X _ Were all system components,excluding the SAS, located on site'? X _ 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 X _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal system''?� The size and location of the Soil Absorption System (SAS)on the site has been determined based on: Yes no X _ Existing information. For example,a plan at the Board of Health. X _ 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))' I L •ill'. 1 5 =t 3 'Page 6 of 1 I q Pt OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 25 BRIDGETS PATH.CENTERVILLE, MA 02632 M169 P102 LI I Owner: MARIE HERB Date of Inspection: 6/10/02 FLOW CONDITIONS RESIDENTIAL ` Number of bedrooms(design): ! Number of bedrooms(actual): 2 DESIGN flow based on 3 10 CMR 15.203 (for example: 110 gpd x#of bedrooms): 220 Number of current residents:3 Does residence have a garbage grinder(yes or'nb): NO Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required] Laundry system inspected(yes-or no)::,NO Seasonal use: (yes or no): NO Water meter readings, if available(fast 2 years'usage(gpd)):ft a Co 2�r OOD Sump pump(yes or no): NO o t _ Last date of occupancy: n/a COMMERCIAL/INDUSTRIAL Type of establishment: n/a Design flow(based on 310 CMR 15:203):,u/agpd Basis of design flow(seats/persons/sgft,etc.): n/a Grease trap present(yes or no): NO Industrial waste holding tank present(yes or no): NO Non-sanitary waste discharged to the Title 5 system(yes or no): NO Water meter readings, if available: n/a Last date of occupancy/use: n/a OTHER(describe): n/a x GENERAL INFORMATION Pumping Records Source of information: PUMPED IN 1996 BY OWNER Was system pumped as part of the inspection(yes or no): NO If yes,volume pumped: n/agallons--How was quantity pumped determined? n/a Reason for pumping: n/a TYPE OF SYSTEM X 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) _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): n/a Approximate age of all components,date installed(if known)and source of information: 1979 BY OWNER Were sewage odors detected when-arri'ving at the site(yes or no): NO ""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: 25 BRIDGETS PATH CENTERVILLE,MA 02632 M169 P102 LI I Owner: MARIE HERB Date of Inspection: 6/10/02 BUILDING SEWER(locate on site plan) Depth below grade: 8" Materials of construction:_cast iron _40 PVC Xother(explain): 20 PVC Distance from private water supply well or'suction line: n/a Comments(on condition of joints,venting,evidence of leakage,etc.): TOWN WATER SEPTIC TANK: X(locate on site plan) Depth below grade: 2" Material of construction: Xcoricrete_metal_fiberglass_polyethylene other(explain)n/a If tank is metal list age: n/a Is age confirmed by a Certificate of Compliance(yes or no): NO(attach a copy of certificate) Dimensions: 1000G L 8' 6" H 5' 7" W1j4' 1011 " Sludge depth: 2" Distance from top of sludge to bottom of.outlet pe or baffle:32" Scum thickness:2" Distance from top of scum to top of outlet tee or baffle: 6" Distance from bottom of scum fo bottom of outlet tee or baffle: 16" How were dimensions determined: MEASURED Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY. RECOMMEND PUMPING EVERYiWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE.SEPTIC TANK NEEDS INLET TEE. GREASE TRAP:_(locate on site plan) Depth below grade: n/a Material of construction:_concrete—metal—fiberglass_polyethylene_other(explain): n/a Dimensions: n/a Scum thickness: n/a Distance from top of scum to top of outlet tee or baffle: n/a Distance from bottom of scum to bottom of outlet tee or baffle: n/a Date of last pumping: n/a : Comments(on pumping reconunendatio.ns, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc): n/a �� 7 Page 8 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM I:"LSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 25 BRIDGETS PATH CENTERVILLE,MA 02632 M169 P102 LI1 Owner: MARIE HERB Date of Inspection: 6/10/02 TIGHT or HOLDING TANK: (tank must be.:pumped at time of inspection)(locate on site plan) Depth below grade: n/a Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a Dimensions: n/a Capacity: n/a gallons Design Flow: n/a gallons/day Alarm present(yes or no): N/A Alarm level: N/A Alarm in working order(yes or no): NO Date of last pumping: n/a Comments(condition of alarm and float switches,etc.): n/a DISTRIBUTION BOX: X(if present.must be opened)(locate on site plan) Depth of liquid level above outlet invert: n'a . Comments(note if box is level and distribdtion to outlets equal,any evidence of solids carryover, any evidence of leakage into or out of box,etc.): D-BOX IS CRACKED AND STRUCTURALLY UNSOUND. PUMP CHAMBER:_(locate on site plan) Pumps in working order(yes or no): NO Alarms in working order(yes or no):NO Comments(note condition of pump chamber,condition of pumps and appurtenances, etc.): n/a u 'Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 25 BRIDGET&PATH CENTERVILLE, MA 02632 M169 P102 Lil Owner: MARIE HERB Date of Inspection: 6/10/02 SOIL ABSORPTION SYSTEM (SAS): X (locate on site plan,excavation not required) If SAS not located explain why: n/a Type 1000 GAL 6' X 6' leaching pits, number: 1 n/a leaching chambers, number: n/a n/a leaching galleries, number: n/a n/a leaching trenches, number, length: n/a n/a leaching fields, number: n/a n/a overflow cesspool, number: n/a n/a innovative/alternative system .; Type/name of technology: n/a Comments(note condition of soil,Is'igns'of hydraulic failure, level of ponding,damp soil,condition of vegetation,etc.): LEACH PIT IS STRUCTURALLY SOUND AND FUNCTIONING PROPERLY. PIT WAS 3/4 FULL AT TIME OF INSPECTION. PIT HAS 6" OF LEACHING LEFT IN IT. BOTTOM IS AT 816". CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: n/a Depth—top of liquid to inlet invert: n/a Depth of solids layer: n/a Depth of scum layer: n/a Dimensions of cesspool: n/a Materials of construction: n/a Indication of groundwater inflow(yes or no): NO Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): n/a PRIVY: (locate on site plan) Materials of construction: n/a' Dimensions: n/a Depth of solids: n/a Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): n/a :., f :4 n • Page 10 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 25 BRIDGETS PATH CENTERVILLE, MA 02632 M169 P102 L11 Owner: MARIE HERB Date of Inspection: 6/10/02 SKETCH OF SEWAGE DISPOSAUSYSTEM 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. 4 IA- 64 i1N I c'C'IL F 4 P v L c G 4 "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: 25 BRIDGETS PATH CENTERVILLE,MA 02632 M169 P102 L11 Owner: MARIE HERB Date of Inspection: 6/10/02 SITE EXAM _Slope , a _Surface water _Check cellar F Shallow wells ; Estimated depth to ground water 12+feet Please indicate(check)all methods used to determine the high ground water elevation: NO Obtained from system design plans on record- If checked, date of design plan reviewed: n/a YES Observed site(abutting property/observation hole within 150 feet of SAS) NO Checked with local Board of Health-explain: n/a NO Checked with local excavators, installers-(attach documentation) NO Accessed USGS database-explain: n/a J You must describe how you established the high ground water elevation: HAND AUGER- 12+FT. Il COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS; DEPARTMENT OF ENVIRONMENTAL PROTFCTION�. ONE WINTER STREET,BOSTON MA 02108 (617)292-5500 f ' SFP WUJJ M F.WEtZ 2 9 I Governor Towne�r COXE AMR GovernorG CMUCCI SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION DAVID B.VMUHS PART A Commiwoher CERTIFICATION lYg Property Address: 25 Bridgets Path, MWmmrMft, MA Address of Owner: Date of Inspection: September 16, 1998 Of different) Name of Inspector: James M. Ford I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000) Company Name: James M. Form Mailing Address: P.O. Box 49, Ostem7le. MA 02655-0049 Map:169 Telephone Number: (M 86279400 Parcel:102 Lot:11 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 Eval n By the Local Approving Authority ails Inspector's Signature: Date: e r of mbe 16 1998 The System Inspector shall submit a copy of thi 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 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: B] SYSTEM CONDITIONALLY PASSES: 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. 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. (revised 04/2S/9>) Page 1 of 10 DEP on the Wald Wide Web: MW:HMrww.mspnetstste.ma.usroep Printed on Recycled Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 25 Bridgets Path, Marston Mills, MA Owner: Bill Henning Date of Inspection: September 16, 1998 .A B] 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). 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: r� 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 WELL 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 1 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 (revised 04/25/97) Page 2 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 25 Bridgets Path, Marston Mills, AM Owner: Bill Henning Date of Inspection: September 16, 1998 D] SYSTEM FAILS: You must indicate either "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 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 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. 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. E] LARGE SYSTEM FAILS: 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. (revised 04/25/997) Page 3 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 25 Bridgets Path, Marstons Mills, MA Owner: Bill Henning Date of Inspection: September 16, 1998 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, 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. IAarge volumes of water have not been introduced into the system recently or as part of this inspection. n/a 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 or industrial waste flow. ✓ _ The site was inspected for signs of breakout. } ✓ _ 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 on: ✓ _ 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) [15.302(3)(b)]. (revised 04/25/97) Page 4 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 25 Bridgets Path, Marston Mills, AM Owner: Bill Henning Date of Inspection: September 16, 1998 FLOW CONDITIONS RESIDENTIAL: Design flow: 330 g.p.d./bedroom for S.A.S. Number of bedrooms: 3 Number of current residents: 2 Garbage grinder(yes or no): No Laundry connected to system(yes or no): Yes Seasonal use(yes or no): No Water meter readings, if available(last two(2)year usage(gpd): 1998- 17.000; 1997-46.000,• 1996-38,000 Sump Pump(yes or no): No Last date of occupancy: Currently occupied. COMMERCIAL/INDUSTRIAL: 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: Pumped in 1996-per owner. System pumped as part of inspection(yes or no): No If yes, volume pumped: gallons Reason for pumping: 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) I/A Technology etc. Copy of up to date contract? Other APPROXIMATE AGE of all components, date installed(if known)and source.of information: Unknown. I Sewage odors detected when arriving at the site(yes or no): No (revised 04/25/97) Page 5 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 25 Bridgers Path, Marstons Mills, MA Owner: Bill Henning Date of Inspection: September 16, 1998 BUILDING SEWER: _ (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: Yes (locate on site plan) Depth below grade: 2" 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: 8' X S'X 4'6" (1000 gal.) �.- Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle: 30" Scum thickness: 2" Distance from top of scum to top of outlet tee or baffle: 10" Distance from bottom of scum to bottom of outlet tee or baffle: 12" How dimensions were determined: Measuring stick 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.) The baffles were in good condition. The liquid level was even with the outlet invert. There were no signs of leakage. GREASE TRAP: None (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.) (revised 04/25/97) Page 6 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 25 Bridgets Path, Marstons Mills, MA Owner: Bill Henning Date of Inspection: September 16, 1998 TIGHT OR BOLDING TANK: None (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: Yes (locate on site plan) Depth of liquid level above outlet invert: 0" Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) The box was level and there were no signs of solids or leakage. PUMP CHAMBER: None (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.) (revised 04/25/97) Page 7 of 10 I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 25 Bridgets Path, Marstons Mills, AM Owner: Bill Henning ` Date of Inspection: September 16, 1998 SOIL ABSORPTION SYSTEM(SAS): Yes (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: 1 -6'X 6' 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, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) The pit was one-half full. There were no signs of failure. The bottom to grade was 8'6". CESSPOOLS: None (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: None (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 04/25/97) Page 8 of 10 " r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PANT C SYSTEM INFOMIA71ON (continued) Property Address: 25 Bridgets Path, Marston Mills, AM Owner: Bill Henning Date of Inspectiao: September 16, 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). i asp you y 6 34 G (revised 09/25/9 5 Page 9 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 25 Bridgets Path, Marstons Mills, MA Owner: Bill Henning Date of Inspection: September 16, 1998 Depth to Groundwater: 15' +/- feet (from top of leaching mound) 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) Using the Barnstable topographic map, and the water contours map, the maps were showing 15'to water at this site. Thus report has been prepared and the system inspected and passed as of September 16, 1998. This report is not a warranty or guarantee that the system will function properly in the future. There havebeen no warranties or guarantees, either expressed, written or implied, relating to the system, the inspection and/or this report. (revised 04/25/97) Page 10 of 10 i - V r� ;ss r,. J J / T �•= v 2002 f gyp, t Date: �q'7 TOXIC AND HAZARDOUS MATERIALS REGISTRATION FORM NAMEOFBUSINESS: I/Vrwo�,7 7mk &hs BUSINESS LOCATION: MAILINGADDRESS: Mail To: TELEPHONE NUMBER: _-� Board of HealthU -370.0 Town of Barnstable CONTACT PERSON: P.O. Box 534 EMERGENCY CONTACT TELEPHONE NUMBER: Hyannis, MA 02601 TYPEOFBUSINESS: kl&AAlt� Does your firm store any of the toxic or hazardous materials listed below, either for sale or for you own use? YES NO This form must be returned to the Board of Health regardless of a yes or no answer. Use the enclosed envelope for your convenience. If you answered YES above, please indicate if the materials are stored at a site other than your mailing address: ADDRESS: TELEPHONE: LIST OF TOXIC AND HAZARDOUS MATERIALS The Board of Health has determined that the following products exhibit toxic or hazardous character- istics and must be registered regardless of volume. Please estimate the quantity beside the product that you store. NOTE: LIST IN TOTAL LIQUID VOLUME OR POUNDS. Quantity Quantity Antifreeze(forgasoline or coolant systems) Drain cleaners NEW USED Cesspool cleaners Automatic transmission fluid Disinfectants Engine and radiator flushes Road Salt (Halite) Hydraulic fluid (including brake fluid) Refrigerants Motor oils Pesticides NEW USED (insecticides, herbicides, rodenticides) Gasoline, Jet Fuel Photochemicals (Fixers) Diesel fuel, kerosene, #2 heating oil NEW USED Other petroleum products: grease, Photochemicals (Developer) lubricants, gear oil NEW USED Degreasers for engines and metal Printing ink Degreasers for driveways & garages Wood preservatives (creosote) Battery acid (electrolyte) Swimming pool chlorine Rustproofers Lye or caustic soda Car wash detergents Jewelry cleaners Car waxes and polishes Leather dyes Asphalt & roofing tar Fertilizers Paints, varnishes, stains, dyes PCB's Lacquer thinners Other chlorinated hydrocarbons, NEW USED (inc. carbon tetrachloride) Paint & varnish removers, deglossers Any other products with "poison" labels Paint brush cleaners (including chloroform, formaldehyde, Floor& furniture strippers hydrochloric acid, other acids) Metal polishes Laundry soil & stain removers Other products not listed which you feel (including bleach) may be toxic or hazardous (please list): Spot removers & cleaning fluids (dry cleaners) Other cleaning solvents Bug and tar removers WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS p - 370 TO ALL NEW BUSINESS OWNERS: - Fill in below: NAME OF NEW BUSINESS: Vy 0 V e n -rcel el/ha C TYPE OF BUSINESS W9AVI'h Ant V 5 a. IS THIS A HOME OCCUPATION?V.eS ADDRESS OF BUSINESS 7 5 QR ��qR S �� ( ,P.rtPh� _ _/r Oz6 3 2— MAP/PARCEL NUMBER ok 7 — rwopj 1(o Lo+ Y1 Kok 3Zq—p 13 If you are starting a new business there are qui few things you need to do in order to be in compliance with all rules and retulations of the Town of Barnstable. Once you have been checked off on this sheet you may apply for a business certificate at the Town Clerk's office (Ist floor-Town Hall). ?his GO TO E!LDIN INSPECTOR'S OFFICE(4TH FLOOR TOWN HALL) individual is i co plia a nd has been explained the procedures needed to start a busis Building Inspe r' i ure 2. GO TO BOARD OF HEALTH (3RD FLOOR TOWN HALL) This individual has been informed /oof,any ermit re uire nts that pertain to this type - of business. / (// ' V 6 �7 Health Inspector's Signature 3. GO TO CONSUMER AFFAIRS (LICENSING AUTHORITY)-(3RD FL SCHOOL ADMINISTRATION BUILDING This individual has been informed of any licensing requirements that will pertain to this type of business Licensing Authority Signature After being checked off by all of the above-remember to return to the Town Clerk's office to actually obtain your business certificate. ---� $6 z LOCAT ION V SEWAG PERMIT NO. VILLAGE (0,,ice/ ce lie INSTA LLER'S NAME i ADDRESS JOHN A. AALTO BACKHOE SERVICE Nest Barnstable, Mass. 02663 BUILDER OR /OWNER Pdof o -e -5e4w^1f11 Rd DATE PERMIT ISSUED DATE COMPLIANCE ISSUED !3- I- 7q � � , . - . ., . . ,� � � ,� '; Y - � �-� o ,�- �' .` ,y`� �. � ,� s„�; a TOWN,OF BARNSTABLE P_ /p� LOCATION a� gr l�ql cgs PA�1 SEWAGE# r o'- 1 VILLAGE CD Y rArIJAk ASSESSOR'S MAP&LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY I QVb GA I LEACHING FACILITY: (type) GA,(o P i r (size) /C= GA NO.OF BEDROOMS BUILDER OR OWNER Gill PERMITDATE: COMPLIANCE DATE: 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 A � 3 O � B T' oaT cam' Ho D_ Box � T Pe ;y7 b "" 3y c� .,,.. t.,�".. 2 ... ...;.`x-.. ..: -,;r+�-. •.'+k.t' '1. '°.►t. `^ 4-i-i'"R�x- . z-r- ..C�'JL+ ca �.r!`a R,�..�. ....t r.'�•�C. - ,.. - 'f "Z" ,.YY +. a.Lr tz.' *' _F +•.r`':�,_,., R.,"�%a_i,"'ac�i.'."r S :'�" .,2„ham^}:;:;_ .,..r..... +�K.:s r'as+'.. �L.1:.'�*�•'.4""Ky"' ".i;:•: *`r":+� , e. PA L)L_ Idt 0 R. RAY - Z./V SPEC TO R PATH /1AIL IN PoLt . 40R'WbE o _C) 0,4 LoA M AND SUBSOIL LOT /O a4 /4 ME/� lt'f SAND �� .4„ L COT /a / 3►�� _ 38 i83;,* F'Rd P.r ®TEST {� ti HME ab HOLE , ELEV. 2C,40 o SEPI iC ry� NO L_A T E R :ENC0UN TEREE2 4 fVK ( � : `box y to �,. �"GGs.N !,jb � �:t.. . /5 A VA l L A 34.,E 84 ' J. LEACH ;t LOT It 15000 A4 ^J A4 U/!/! SCALE J -- 40 I, F2JAv T �t%�; S/Z7E 1-0,E4 Tom' . oZ !�ED 200MS 'SEPTIC 6 y5 TAM CONS T2 41 C T/ON SH�I L OnJF02M' TO MASS . QES/G/V l=LO[.t/ GAL,DAY GN'✓/�-'ONMG-NTAL CLJ17� T/TLC Y L G A C,4•/ 2,4 TE G- oZ M/AA CfARN .S 7'A E Pizc�r=aspr�� a, TOFF OF NE�t�T�•/ fJL.A T/ONS ,O/�O,�OS�U L E�iC�•/ �.�'E� FO iJ;UJt�Ti�?n/ 2"OF PE,4 S7-OrV�-- MAA/NOLE ¢Ca✓E� TO EX TEnID 70 us � - TO ,a2E✓En/T W/ Tf-///�/ /� �F F//�//SHE=D a�AD�, � ,c20M /n./F/LT2.4T/�/v /c� /" `4'._..�✓cz� ! _ I D/5r. 1 I-`` \ /';:CO✓mac Z o Ge4DE �I ( 30X 0Vee �Ttea%ice I CI n T10 , ,y Q„ D/A. wATF zL , 3.. - 4" O/,Q. C ; /oL C,q 2 7->/ / F�Ow L,NE MiN O - /f`.'. /A. 4 ' /-aDT /O"M/ti /¢- 4 FOoT 2' M/^./ /�/TCf/ LQ- %�ZDY I M/nJ 7 Poor �: S HE4D L.DtiJO Y / G ,4 O NE /A//'J: T /VVF�T I Ll T� 4 G / T Y /, �� ELEV• Tfa /7.8 f �, BoTiOM of _"o 1j �' I I (_WAT,=,ZT/Gi/T /NVE2T ; i X�iT NO 1 / TE ILL A /V Z-0 '11-/:�/v BARN STA.�t_E__C�F �,g� R 1 v fi. SEp /G TL1/VK U/�Tl�iBiJT/ON BQ}C -lLI1. . PLAI1( .__� 4.. - f�L-?.C�_E- - _ �5 Ov7�GTs) AA � -ALC:1iI,./� �/T- /_�7T` ,TO C3.- cF �'E/A./ �.7'C�� O•v::r�ETF 0000 C K � _�' L _1'j_ � ti 9 l,V/L G C3 0 V Eti 5>`�T�•�� /n f%- �O NE 13CIILDtNG �a1r`t.'G.IA1 LSA! TH/S - PLAN 15 PROP05ED ON TjY E GROUND AS S NDGvN A IV D /7 DO i CON raR M l,S,1 f'T X 7NE MAL D IM& SE r9l4cX l?�Q L/lt�E Mf Iti, ',;;, , I! OF T#E� T U, 1V CIF l3A/?IV STA 13LE