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HomeMy WebLinkAbout1118 BUMPS RIVER ROAD - Health 1118 Bumps River Road A = 188 - 132 Centerville !i S M EAD Na Z-15MR UPC 12536 onad wn• Nsb tee UM An,I OIFI Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 1118 Bumps River Rd Property Address Kilroy Owner's Name Barnstable MA 02632 2/8/12 City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. A. General Information 1. Inspector: Frank Nunes III Name of Inspector saa Company Name Box 841 Company Address East Falmouth MA 02536 City town State Zip Code 508.272.6433 Telephone 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,inspectiQn was performed based on my training and experience in the proper function and maintenance of-on site. sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of--% Title 5(310 CMR 15.000).The system: -. 5 <� v N.) �^a ® Passes ❑ Conditionally Passes ❑ Fails! ❑ Needs Further Evaluation by the Local Approving Authority r-- 2/8/12 Inspecto Signature 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. ****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. Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 1118 Bumps River Rd Property Address Kilroy Owner's Name Barnstable MA 02632 2/8/12 City/Town 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: ® 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: This home has 2 complete systems. This report is for the system in the front yard 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. 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 indicating that the tank is less than 20 years old is available. ND Explain: 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 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 1118 Bumps River Rd Property Address Kilroy Owner's Name Barnstable MA 02632 2/8/12 Cityrrown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ distribution box is leveled or replaced ND Explain: 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 C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 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 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. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments wM , 1118 Bumps River Rd Property Address Kilroy Owners Name Barnstable MA 02632 2/8/12 Cityrrown State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cunt.): ❑ 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 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: n/a 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 cesspool is less than 6" below invert or available volume is less than '/z day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1118 Bumps River Rd Property Address Kilroy Owner's Name Barnstable MA 02632 2/8/12 City/Town State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No ❑ ® 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. [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 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. 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 ❑ ❑ 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 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. i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 1118 Bumps River Rd Property Address Kilroy Owner's Name Barnstable MA 02632 2/8/12 City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® 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? ® ❑ 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? ® ❑ 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: ® ❑ 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(5)] i Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1118 Bumps River Rd Property Address Kilroy Owner's Name Barnstable MA 02632 2/8/12 Cityrrown State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms(design): 3+ Number of bedrooms(actual): undetermine d DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): Number of current residents: 1 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage(gpd)): Sump pump? ❑ Yes ® No Last date of occupancy: occupied Date Commercial/Industrial Flow Conditions: Type of Establishment: n/a Design flow(based on 310 CMR 15.203): Gallons per day(gpd) 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: Last date of occupancy/use: Date Other(describe): n/a Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 1118 Bumps River Rd Property Address Kilroy Owner's Name Barnstable MA 02632 2/8/12 Citylrown State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: Pumped 3yrs ago per owner Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? 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) ❑ 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): Approximate age of all components, date installed (if known) and source of information: 1978 per age of the home Were sewage odors detected when arriving at the site? ❑ Yes ® No Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1118 Bumps River Rd Property Address Kilroy Owner's Name Barnstable MA 02632 2/8/12 Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): Depth below grade: 12"feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: >10'feet Comments(on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: 6"feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No -------------------------------------------------------------------------------------------------------------------------- Dimensions: 1000g Sludge depth: - 3" 11 Distance from top of sludge to bottom of outlet tee or baffle >12 Scum thickness 1/2 Distance from top of scum to top of outlet tee or baffle >2" Distance from bottom of scum to bottom of outlet tee or baffle >21, How were dimensions determined? measured Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M , 1118 Bumps River Rd Property Address Kilroy Owner's Name Barnstable MA 02632 2/8/12 City/Town 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.): Approximately 18" of the tank is within the paved driveway. This is an H-10 tank that is not designed for vehicle loading Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): n/a 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 Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): n/a Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑other(explain): n/a Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 5 1118 Bumps River Rd Property Address Kilroy Owner's Name Barnstable MA 02632 2/8/12 Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank(cont.) Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): n/a *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert level w/the bottom of the pipe 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 2' below grade and in average condition for its age Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M , 1118 Bumps River Rd Property Address Kilroy Owner's Name Barnstable MA 02632 2/8/12 City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): n/a Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: 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.): Leach Pit is 3' below grade, the liquid level at this time is 12" below the inlet invert, there is a stain line 9" below the inlet invert, no indication of backup Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1118 Bumps River Rd Property Address Kilroy Owner's Name Barnstable MA 02632 2/8/12 Citylrown State Zip Code Date of Inspection D. System Information (cont.) 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 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.): n/a Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form.-Not for Voluntary Assessments 1118 Bumps River Rd Property Address Kilroy Owner's Name Barnstable MA 02632 2/8/12 Citylrown State Zip Code Date of Inspection D. System Information (cont.) 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. T-j 1 i I � I C— LI Commonwealth of Massachusetts . Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1118 Bumps River Rd Property Address Kilroy Owner's Name Barnstable MA 02632 2/8/12 Citylrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: >12 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: 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: Elevation to nearby pond, home also sits on hill > 10'above road Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 1118 Bumps River Rd 2"d of 2 systems Property Address Kilroy Owner's Name Barnstable MA 02632 2/8/12 City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. A. General Information 1. Inspector: , I Frank Nunes III Name of Inspector saa Company Name Box 841 Company Address East Falmouth MA 02536 Cityfrown State Zip Code 508.272.6433 Telephone 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 15.340 of Title 5(310 CMR 15.000).The system: c.� ® Passes ❑ Conditionally Passes ❑ Fails; ❑ Needs Further Evaluation by the Local Approving Authority 2/8/12 Inspect s Signatur Date �J M 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. ****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. ZL 1,17 Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1118 Bumps River Rd 2nd of 2 systems Property Address Kilroy Owner's Name Barnstable MA 02632 2/8/12 CityfTown 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: ® 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: This home has 2 complete systems. This report is for the system in the backyard 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. 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 indicating that the tank is less than 20 years old is available. ND Explain: 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 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1118 Bumps River Rd 2nd of 2 systems Property Address Kilroy Owners Name Barnstable MA 02632 2/8/12 Cityrrown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ distribution box is leveled or replaced ND Explain: 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 C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 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 acid 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. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1118 Bumps River Rd 2"d of 2 systems Property Address Kilroy Owner's Name Barnstable MA 02632 2/8/12 City/Town State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ 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 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: n/a 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 cesspool is less than 6" below invert or available volume is less than '/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 SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 1118 Bumps River Rd 2"d of 2 systems Property Address Kilroy Owner's Name Barnstable MA 02632 2/8/12 Cityrrown State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No ❑ ® 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. [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 and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 1 0,000g pd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with 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 ❑ ❑ 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 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. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments , 1118 Bumps River Rd 2nd of 2 systems Property Address Kilroy Owner's Name Barnstable MA 02632 2/8/12 Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® 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? ® ❑ 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? ® ❑ 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: ® ❑ 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(5)] Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1118 Bumps River Rd 2"d of 2 systems Property Address Kilroy Owner's Name Barnstable MA 02632 2/8/12 Citylrown State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms (design): 3+ Number of bedrooms (actual): undetermine d DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): Number of current residents: 1 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Sump pump? ❑ Yes ® No Last date of occupancy: occupied Date Commercial/Industrial Flow Conditions: Type of Establishment: n/a Design flow(based on 310 CMR 15.203): Gallons per day(gpd) 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: Last date of occupancy/use: Date Other(describe): n/a Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments w„ 1118 Bumps River Rd 2nd of 2 systems Property Address Kilroy Owners Name Barnstable MA 02632 2/8/12 City/Town State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: no recent pumping Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? 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) ❑ 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): Approximate age of all components, date installed (if known) and source of information: 1978 per age of the home Were sewage odors detected when arriving at the site? ❑ Yes ® No Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1118 Bumps River Rd 2nd of 2 systems Property Address Kilroy Owner's Name Barnstable MA 02632 2/8/12 Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): 3' Depth below grade: feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: >10' feet Comments(on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): 2'6" Depth below grade: feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) Riser to outlet end If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No -------------------------------------------------------------------------------------------------------------------------- Dimensions: 1000g Sludge depth: 1" Distance from top of sludge to bottom of outlet tee or baffle >12 Scum thickness trace Distance from top of scum to top of outlet tee or baffle >2° Distance from bottom of scum to bottom of outlet tee or baffle >2" How were dimensions determined? measured Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M , 1118 Bumps River Rd 2"d of 2 systems Property Address Kilroy Owner's Name Barnstable MA 02632 2/8/12 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.): Pumping suggested every 3 yrs to prolong the life of the system Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): n/a 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 Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): n/a Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): n/a Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM 5 1118 Bumps River Rd 2nd of 2 systems Property Address Kilroy Owner's Name Barnstable MA 02632 2/8/12 City/Town State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank(cont.) Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): n/a *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert Level w/the bottom of the pipe 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 3' below grade and in average condition for its age Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 1118 Bumps River Rd 2"d of 2 systems Property Address Kilroy Owner's Name Barnstable MA 02632 2/8/12 City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): n/a Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: 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.): Leach Pit is 3' below grade. It is dry at this time w/stain line 1'from the bottom of the pit. No indication of backup Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 1118 Bumps River Rd 2"d of 2 systems Property Address Kilroy Owner's Name Barnstable MA 02632 2/8/12 Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 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 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.): n/a Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 1118 Bumps River Rd 2nd of 2 systems Property Address Kilroy Owner's Name Barnstable MA 02632 2/8/12 Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 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. c 0 o � CD i O Commonwealth of Massachusetts v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 1118 Bumps River Rd 2nd of 2 systems Property Address Kilroy Owner's Name Barnstable MA 02632 2/8/12 City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: >12 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: 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: Elevation to nearby pond and home sits on hill >10'above road COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL DEPARTMENT OF ENVIRONMENTAL PRO �N ONE WINTER STREET, BOSTON MA 02108 (617) 292, 50 ILLIAM F.WELD � 'IRUDY CORE W tio9y j Secretary Governor s ^ FA/'7 f.Yp ai ARGEO PAUL CELLUCCI DA : B. STRUHS A Governor ♦� Commissioner SUBSURFACE SEWAGE DISPOSAL ASYSTEM INSPECTION FO' ,p t i — 1 CERTIFICATION Property Address:111$ v� S �w tit— e�. tst.0���.v Address of Owner: Date of Inspection: Q,ky\5 E�b3Z (If different) Name of Inspector: ir. z\ 1e Vie. tv I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000) Company Name: .0 ` L_ - i—i Mailing Address: t; �•� _r� �4'e{— Telephone Number: S n9— 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 _ Conhionally Passes _ Needs Further Evaluation By the Local Approving Authority Fails Inspector's Signatur • 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 thr 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: S�5 v,n C Q S S S � rS�SI G1�T'Q t w Z --v d? vL 1 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 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 exftltration, 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 04125197). Page 1 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) . Property Address: Owner: r: Date of Inspection. BI 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: 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 DETEILMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A • MANNER WH-CH 'WILL PROTECT THE PUBLIC HEALTH AND SAFETY A.N`D 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) DETER, THAT THE SYSTEM IS FUNCTIONING IN A DIANNER 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 (raised 04M/97) Page 2 or io SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORIM PART A CERTIFICATION (continued) Property Address: Owner: s Date of Inspection: DI 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 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. 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/ZS/47) Page 3 or to SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: Owner: K\'L Date of Inspection: e 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. 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.g . depth of scum. The size and location of the Soil Absorption System on the site has been determined based on: it owner and occupants, if different from owner) were provided with information on the proper maintenance of Sub- The facility ( p Sub- Surface Disposal System.tem. S p y 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/ZS/97) Page 4 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owoer:lk9 Date of Inspection: ciW!:i BUILDING SEWER: a (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:4 > ( 2 (locate on site plan) Depth below grade: 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: k- \QO 'h Z- 1 O(-- O Sludge depth: " • L-3" ti Distance from top of sludge to bottom of outlet tee or baffle: 1'N" Z Scum thickness: `&1-1` 11%02101,6 Distance from top of scum to top of outlet tee or baffle: ¢\ �t A L' IZ►� Distance from bottom of scum to bottom of outlet tee or baffle:"1U'A it L- ILk How dimensions were determined: tnnQS .d Comments: (recommendation for pumping. condition of'nlet and outlet tees or baffles, depth of liquid level in relation t outlet invert, structural integrity. evidence of leakage, etc.) N e t ' 6 SOOK I v�V-T riev GREASE TRAP:__ry (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 Propert�ddress. Owner: R\14— Date of Inspection: �-kt4� 6 FLOW CONDITIONS RESIDENTIAL: Design flow:TiU G.p.d./bedroom for S.A.S. Number of bedrooms: Number of current residents: CZ- Garbage grinder (yes or no): t— Laundry connected to system (yes or no): Seasonal use (yes or no):t-.J Water meter readings, if available (last two (2) year usage (gpd): tJ Sump Pump (yes or no): Last date of occupancy: 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 I]STOR.MATION PUMPING RECORDS and source of information: ]vv"0"-a S\C') System pumped as part of inspection: (yes or no)_L,3d If yes, volume pumped: Gallons Reason for pumping: TYPE OF SYSTEM n oZ Septiticcttank/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: Sewage odors detected when arriving at the site: (yes or no) (revised 04125197) Page 5 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C c SYSTEM INFORMATION (continued) Property Address: Il I p�Vqs igw ek, Owner: l� Date of Inspection: TIGHT OR HOLDING TANK:-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.) ►ISTRIBUTION BOX:—IS (locate on site plan) Depth of liquid level above outlet invert:—�%-C'� � kft\ �IVVA\C I Comments: (note if level and distribution is ual. evidence of solids carryover evidence of leakage into or out of box, etc.) )< �e�o Q .c\�¢\\0 y T�S l\ tD.sul rl J� /�,F• (y s r, � 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.) (revised 03/25/97) Page 7 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C - ,n SYSTEM INFORMATION (continued) a - Property Address: ((l PQtpq Owner:'T(}\yL- Date of Inspection: 'A(K lei SOIL ABSORPTION SYSTEM (SAS):jAg (locate on site plan, if possible: excavation(lnof required, but may be approximated by non-intrusive methods) If not determined to be present, explain: Type: leaching pits, number: leaching chambers, number:_ leaching galleries, number: leaching trenches. number,length: leaching fields. number, dimensions: overflow cesspool, number: Alternative system: Name of Technology: Comments: (note condition of soil. signs of hydraulic failure, level of ponding, c ndltion veg lion, etc.) sw. E S Tc �`. _ y r „ w. 4 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: wb (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 a of 10 i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Addrtss: Owner: 1 Date of Inspection: a 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) SSst-ctn. � Z. r (, 30 ol :v\�� 1�� f L a 3 S�CTtv,,. tt t y k, kZ - tst �Z_ aI'(.V rk 3 all 6`( V03_ (gl (revised 04/25/97) Page 9 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C Gr SYSTEM INFORMATION (continued) Property Address: Owner: TNkti Date of Inspection: ( 6 Depth to Groundwater Feet 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) 1A z,' c.•► d (revised 03/2S197) Page 10 of 10 _0 7 No.. ,9)?.. THE COMMONWEALTH OF-MASSACHUSETTS BOARD OF HEALTH ..................6, 'L------OF.....1-1)..... ... .. ....................................... Appliration -for ]Niipoiial Workii, Totw1rurtion Vanfit Application is hereby'.made for a Permit to Construct or Repair an Individual Sewage Disposal System at: ................. r--- ------------ ................... . . ....R_ . . 9,� ------. ........................................................................ Loca n Aldre s or Lot No. ......................... ...................... ................................. ............ ..... wn___4 r Address ... ....... ............................. ...... Installer Address Type of Building Size Lot_QQ,�_3tPA:_Sq. feet U Dwelling—No. of Bedrooms________________?).........................Expansion Attic Garbage Grinder ( ) Other—Type of Building ------------_------------- No. of persons------------------------- Showers Cafeteria ( ) Otherfixtures ----------------------------------------------------------------------------------------------------------------- ----------------------------_ Design Flow................-------------55----------- ...gallons per per-son per day. Total daily flow....__....... ......__._._.._.-_..gallons. -9.. Septic Tank,:1--Liquid capacity-APPPgallons Length________________ Width-__-_..-_-.--- Diameter._._--.._.____. Depth----_----_-_. Disposal Trench—No. .................... Width........ .... Total Length.....0". Total leaching area------M1KPe_F-_.sq. ft. ' Seepage Pit No_____ I ......'Piameter-------------S---- Depth belo inLyt ----- Total leaching are. _.sq. ft. Other Distributi(?�ox Dosing tank 11-S-77 Percolation Tesf-R-e�ults Performed by.----?..Ih.....61 _W------------------------------------ Date_-- ------------- Test Pit No. I......:a-----niinutesperinch Depth of Test Pit____________________ Depth to ground water_.-___..._-_--_--.-----. LL, Test Pit No. 2---_----------minutesper inch Depth of Test Pit.---------.-___----. Depth to ground water-......-.__-_---_-_----. 9 .............................................................................................................................................................. 0 Description of Soil...b'-A!i......6-0.0 ca_.j... :11.......q-(------ �4 _01,11... I U ...................................................................................................................................... ----------------------------- ----------------------------------------------------------------------------------------------------------- -------------------------------------------------------------------------------------------- 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 Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Si red e Date Application Approved By------ - ----- ;�a_, Date �� . t--------------------------- Application Disapproved for the following reasons:----------------------------------------------------------------------------------------------------------------- ...................................................................................................................................... --------------------------------------------------------- Date Permit No.------................................................. Issued...... Date ---64------ --------------------------------- 074? No......... F . ............. THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH 34 a.�......OF..... .--,i.a; , _ c l*. _. Appliratiott -for Bi,gpoottf Workii Cn> nstrurtiott rrotit Application is hereby'made for a Permit to Construct (c/) or Repair ( ) an Individual Sewage{Disposal System at: !--("Jr n#. l ? --- t^ � �t .. J Rat,Cl•. L.Ys._€a..t_. ..................................................................... Location'Address or Lot No. 7 C}.i t)C K: a.,C(1:. _ A-----------------•--------------- ....2—y=''=-�'' ,..Owner Address SLk.�n::X� �...._. { l��......x`L`x...... � t3 1.t� a��4_�{�� -------------- ---------- ._ ___._...---__._._..._.._...__'_...._.._..__._ ._......:�... Installer Address d Type of Building Size Lot_:;+%D.<.:,11. __Sq. feet U Dwelling—No. of Bedrooms--------------- _.Expansion Attic ( ) Garbage Grinder ( ) aOther —Type of Building _________________________-- No. of persons________�=.____-_._.----. Showers ( ) — Cafeteria ( ) dOther fixtures ----------------------------------------------------------------•--- W Design Flow___________________________w? gallons per person per day. Total daily flow-- .....................gallons. GY Septic Tank—Liquid capacityJ�-' gallons Length---------------- Width.____.._._..__ Diameter--------------_ Depth---------------- W =, x Disposal Trench—No_______________•-___- Width---------�-------- Total Length----- Total leaching area------ .�'1_.�.� _____sq. ft. Seepage Pit No--------------------- _lameter------------- Depth belo i t -------------- Total leaching area-----._-____-._.sq. it. 10 Z Other Distribution box ((/� Dosing. tank ( ) ' 147 7 Percolation Test Results Performed by._- dh___.61 _ _d}�................................... Date___ 7 7-___-.___-_--- a Test Pit No. 1......:)------minutes per inch Depth of Pest Pit____________________ Depth to ground water------------------------ 1:14 Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water__.__._____________.___ 19 ---------------•------------------------------------------------=---------- =------------------------- ----------------------------•------------------------ -- D Description of Soil----`=,N---- �, xt_.flx `i � 5c;,1 ._,__.. t._tu_.. C : :. '� t�.... c --------------------------------------------------------------------- W 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 Article NI of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. r A.Si ed----- y � / Dat Application Approved BY r•`' �" -�" � s } ... ------ ------_--_---_-•- Application Disapproved for the following reasons________________________________________________________ ---------------------------------- Date ---------•- ---------------------------- ---------•---------•------------------------------•--------•---------------•-------------------------•-------•------•-------=----------------•---------••---------------- Date Permit No. Issued----------------------------------. =•-=---•------------ - _ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ....... t r> G.. , Tntifiratr of TlImphaurr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed (V� or Repaired ( ) y� Installer ' t.i Yet"�_` i itlt 1r + .�.- e, t-rt' 1 at = �- 1 ---------------- -...L.. ` has been installed in accordance with the provisions of A�i�` X�i of The State Sanitary Code as describ in the application for Disposal Works Construction Permit No._6 ...;f----- ----------- dated..../"------�'-..�� THE ISSUANCE OF THIS CERTIFICATE SHALL. NOT BE CO STRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE........ Ij/ -------------------- Inspector-----v h . THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .................. .c tiu........OF. .... '--� C ,.............._.._...--------- . ... No................�..... FEE........................ Permission is hereby granted........ =-C`= �r;t,. F` _`; to Construct or Repair ( ) an Individual Sewage Disposal System at No......L!;A. .............. =CS. i t. -_s -a-� ---------------------- ------------ Street as shown on the application for Disposal Works Construction Pero Dated_________________________________________ ` DATE. - / 41 ` �� Board of Heal _ ----------------- ------------------------- ------ FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS TOWN OF BARNSTABLE SEWAGE# %ILLAE ( � ASSESSOR'S MAP &LOT INSTALLER'S NAME&YdONE NO. SEPTIC TANK CAPACITY 1- G6 V a' Imo© ab #atxn..g `1 f.2 0'1 w' size LEACHING FACILITY: (type) ( ) NO.OF BEDROOMS L BUILDER OR OWNER �- ATE: �f L{ 1 4 ) "OMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottum of Leaching Facility � `Z,� Feet Private Water Supply Well and Leaching Facility (Ifiny wells exist �V� Feet on site or within 200 feet of leaching facility) Edge of Wetland and Leaching Facility(If any wetlands exis. i within 300 feet of leaching facility) L V Feet Furnished by `b`t �c AA It'll I fQ A3 lugpLIz,I-, Q. - am o s r [19 . LO•CAThON �� SEWAGE PERIYiIT d0 VI L LAG E INSTALLER'S NAME & ADDRESS BUILDER OR OWNE ;T 5"Yi r DATE PERMIT ISSUED Owl- L DAT E COMPLIANCE ISSUED loon 3 l u ILI L0. ATION SEWA E PERMIT NO. �d ,�V/Wg� VILLAGE c 2v/I- INSTA LLER'S NAME S ADDRESS VIE e r B U I L D E R OR OWNER �m /I y DATE PERMIT ISSUED ��� DATE 40MI LIANCE ISSUED �� �20 . �7e f� c a �5 O v /000 c,11 ,�/y 3 3 TES OLE S OT 9 N 6V. 319 77' , N-S PEICTOR r RESOVE . L Y' 47 a . is "LOAM A LOT C-LEAC Prr L0� JL_ DIST- sts 1Bf� Ca SEPIK GR ' 5/9/� jr b+, , QQ t�e1 ifl"M!M- (8+� MEI?got. sy TEM KEPI SAN ?. Cr F_ROA1 EXISfIN T� F0WV TOO ,o�+,Nf so � JM l Lf '. S L C t -6TTfO .� I TEST O [ io' TANK } r , T 4 ! ' f4. No(E y .. /'Ito_ 5. 1 - PROP P. T r .5 : c.t�rca a -.T Q(�! 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