HomeMy WebLinkAbout0064 CAPTAIN BELLAMY LANE - Health 64 CAPTAIN BELLAMY ROAD
Centerville
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RECEIVED
TROY WILLIAMS MAR 0 8 2000
SEPTIC INSPECTIONS TOWN Or BARNSTABLE
HEALTH DEPT.
Certified by MA Department of Environmental Protection (508) 385-1300
19 Hummel Drive
South Dennis, MA 02660
COPY
-- COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
ONE WINTER STREET, BOSTON.MA 02108 (617) 292-5500
TRUDY CORE
Secretary
ARGEO PAUL CELLUCCI DAVID B.STRUHS
Governor Commissioner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
rr u CERTIFICATION
Property Address: b 7 C l p*. e a-v'+�/ L r^. Name of
Ce- 4 c r}✓/i I/,- Address of Owner: 6�/ (�f_& /
Date of Inspection: a/o�9 /,v0
I le, M` d2 6 3.z
Name of Inspector:(Please Print) Trey Williams
1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000)
Company Name: Troy Williams So 'c Inspections
Mailing Address: 19 Hummel Drive, So. Dennis, MA 02660
Telephone Number: (508) 385-1300
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate
and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems. The system:
Passes
_ Conditionally Passes
Needs Further Evaluation By the Local Approving Authority
_ Fails
Inspector's Signature�✓l-�+� Date: .2 1 6o
The System Inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)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.
NOTES AND COMMENTS
Although system meets the minimum requirements set forth by the Massachusetts Department of
Environmental Protection,certification is not to be construed as a guarantee of future working condition
of system,piping or components. This inspection represents the conditions of the system on the Date of
Inspection noted above.
revised 9/2/98 P.-I wr 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PARVA
CERTIFICATION (continued)
Property Address:Owner: 64 Captain Bellamy Lane, Centerville,MA
Date of Inspection: Michael P. Galvin
February 29, 2000
INSPECTION SUMMARY: Check A, B, C, of D:
A. SYSTEM PASSES:
I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist. Any failure
criteria not evaluated are indicated below.
COMMENTS:
B. SYSTEM CONDfiIONALLY PASSES: /V/
One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system,upon
completion of the replacement or repair, as approved by the Board of Health, will pass.
Indicate yes, no,or not determined(Y.N,or ND). Describe basis of determination in all instances. If "not determined", explain why not.
The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate of
Compliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection;or
the septic tank, whether or not metal, is cracked,structurally unsound, shows substantial infiltration or exfiltration, or tank
failure is imminent. The system will pass inspection if the existing septic tank is replaced with a complying septic tank as
approved by the Board of Health.
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).
broken pipes)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
i
revised 9/2/98 Pagt2of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
64 Captain Bellamy Lane, Centerville, MA
Property Address: Michael P. Galvin
Owner: .
Date of Inspection: February 29, 2000
C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:/V//,
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 IN ACCORDANCE WITH 310 CMR 15.303(1)(b)THAT THE SYSTEM
IS NOT FUNCTIONING W A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
Cesspool or privy is within 50 feet of 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 AND SAFETY AND THE 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 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).
t
3) OTHER
revised 9/2/98 Page 3of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
64 Captain Bellamy Lane, Centerville,MA
Michael P. Galvin
0rProp"Ache::. February 29, 2000
Date of Inspection:
D. SYSTEM FAILS: Al//A
You must indicate either 'Yes" or"No" to each of the following:
I have determined that one or more of the following failure conditions exist as described 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 160 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: V/,g
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:
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 11 of a public
water supply well
The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional
office of the Department for further information.
revised 9/2/98 page 4orit
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Prop"Address: 64 Captain Bellamy Lane, Centerville,MA
Owner: Michael P. Galvin
Dete of kispecc.: February 29,2000
Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following:
Y No
Pumping information was provided by the owner, occupant,or Board of Health.
Y _ 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.
Y _ 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:
_✓ _ Existing information. For example, Plan at B.O.H.
_ Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable)
115.302(3)(b))
�- _ The facility owner(and occupants,if different from owner)were.provided with information on the.
p proper maintenance of
Subsurface Disposal Systems.
revised 9/2/98 page soril
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Prop"Address: 64 Captain Bellamy Lane, Centerville,MA
Date of Inspection: Michael P. Galvin
February 29, 2000
RESIDENTIAL: 110 Pc-#- FLOW CONDITIONS
Design flow: : 30 g,p,d./bedroom.
Number of bedrooms(design):Total DESIGN flow 3 3 0 Number of bedrooms(actual): a
Number of current residents: I
Garbage grinder.(yes or no):_"
Laundry(separate system) (yes or no):No; If yes, separate inspection required
Laundry system inspected (yes or no)
Seasonal use(yes or no):�/o.
Water meter readings,if available(last two year's usage(gpd): 7.) = $d oo 9 4 Uo•,r
Sump Pump(yes or no):_Alo
Last date of occupancy:
COMMERCIAL/INDUSTRIAL: N�/9
Type of establishment:
Design flow: opd (Based on 15.203)
Basis of design flow
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:
C,11 l o e- ..
System pumped ad part of Inspection:(yes or no)-LA/per
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)
1/A Technology etc.Attach copy of up to date operation and maintenance contract
Tight Tank Copy of DEP Approval
Other
APPROXIMATE AGE of all components,date installed{if known)and source of information:
�cr
Se-age odors detected when arriving at the site:(yes or no) /V e
revised 9/2/98 Page 6ofII
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address` 64 Captain Bellamy Lane Centerville MA
Owner: P Y
Dace of Inspection: Michael P. Galvin
February 29, 2000
BUILDING SEWER:
(Locate on site plan)
Depth below grade:
Material of construction:_cast ironj,/40 PVC_other(explain)
Distance from private water supply well or suction line
Diameter_l
Comments: (condition of�'oints, venting, evidence of I ak8g1a,etc.)
lN G 9 V.I c/� e (ft-u r it-� T/wi a t o e Cdr.
SEPTIC TANK:
(locate on site plan)
i
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:_ .S X 9 X G ' /b o u
Sludge depth: S "
Distance from top of sludge to bottom of outlet tee or baffle: r'
Scum thickness: Z r�
Distance from top of scum to top of outlet tee or baffle: 0
Distance from bottom of scum to bottom of outlet tee or baffle:
How dimensions were determined: I�✓?�6< .
Comments:
(recommendation for pump) condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structurs Mtegrity,
evidence of leakage,etc.) ✓c-— f -r" CoH�raf —.- +)t.�
W o rAlt
J
GREASE TRAP_4//j
(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 9/2/98 Page 7of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 64 Captain Bellamy Lane,Centerville,MA
Owner:
Date of inspection: Michael P. Galvin
February 29, 2000
TIGHT OR HOLDING TANK:N1,1 (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 present
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:
(locate on site plan)
Depth of liquid level above outlet invert:
Comments:
(note•H level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box;etc.)
ho
PUMP CHAMBER- A
(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 9/2/98 Page 8 ortr
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Address: 64 Captain Bellamy Lane, Centerville,MA
Date of Inspection: Michael P. Galvin
February 29, 2000
SOIL ABSORPTION SYSTEM(SAS)LL
(locate on site plan,if possible; excavation not required,location may be approximated by non-intrusive methods)
If not located,explain:
Type:
leaching pits,number c>r.z_
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 by aulic failure,level of ponding, damp soil, condition of vegetation, etc.)
G''�j I N r i.. vda.-4-t.+ 7� I �N G Gl. S � ��✓ Gar.
CESSPO LS:�(/,q
(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: Ali 14
(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 9/2/98 Page 9of II
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM NFORMATION(continued)
Property Address:
Owner: 64 Captain Bellamy Lane, Centerville,MA
Date of Inspection: Michael P. Galvin
February 29, 2000
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent reference landmarks or benchmarks
locate all wells within 100'(Locate where public water supply comes into house)
Fro,.,-1 .
,000 y'.►%"
V—
/y
L ao,
3y'
50 '
y3'
52 ' 3r
i
revised 9/2/98 Page 10of II
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 64 Captain Bellamy Lane, Centerville,MA
Owner:
Date of Inspect«,: Michael P. Galvin ;
February 29,2000
NRCS Report name
Soil Type_
Typical depth to groundwater
USGS Date website visited
Observation Wells checked /
Groundwater depth: Shallow Moderate Deep V/
SITE EXAM Slope v/
Surface water
Check Cellar
Shallow wells
Estimated Depth to Groundwater 15+Feet
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from Design Plans on record
Observed SiteiAbutting property,observation hole• basement sump etc.)
Determined from local conditions
Checked with local Board of health
Checked FEMA Maps
Checked pumping records
Checked local excavators,installers
Used USGS Data
Describe how you established the High Groundwater Elevation. (Must be completed))
h c/
Na ti rll 0.u� c✓ b �t T� c. cx�p ' o j� 7. Q G 4-
0 0 fle, Gi/c.uC. ✓cvC h H/ 0.fC✓ �ou ►. A .
O T ��er C. C. • k S w`` S �f. y c�r. r.�r+� s 4 o 4- C-
revised 9/2/98 Page 11 of 11
TROY WILLIAMS
SEPTIC INSPECTIONS
Certified by MA Department of Environmental Protection ®far + (508)760-1819
40 Old Bass River Road
South Dennis,MA 02660
Commonwealth of Massachusetts
Executive Office of Environmental Affairs
Department of .
Environmental Protection
William F.Wald Trudy Cox*
Go�rwr .see-tary
Argeo Paul Celluoci David B.Struhs
LL Govemor Conwnkslorwr
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
/ PART A
�iJ rUe10 Y CERTIFICATION
Property Address: 6 7 C" o'� 8_,/I vl rh �-a. (,C:, c.�✓ e Address of Owner. 1?d 6,,+ /t -
Date of Inspection: /G G (If different)
Name of Ins . '
P�to Oyy(�� (�ra•+, s
Company Name,Address X'Telephone Number.
ScG.CERTIFICATION STATEMENT
STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate
and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems. The system:
Passes
Conditionally Passes
Needs Further Evaluation By the Local Approving Authority
Fails
Inspector's Signature Date:
The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this
inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the
report to the appropriate regional office of the Department of Environmental Protection.
The original should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority.
INSPECTION SUMMARY:
Check A, 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.
B] SYSTEM CONDITIONALLY PASSES: ��fJ
One or more system components need to be replaced or repaired. The system,upon completion of the replacement or repair, passes
inspection.
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, 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 ponforming septic tank as approved
by the Board of Health.
(revised 11/03/95) 1
II
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: G / Cop f. de-ljo-m y
Owner. K-,A oA
Date of Inspection: s/�G /etc
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):
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
Cl FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Aal?
Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the
public health, safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A
MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE)
DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND
SAFETY AND THE ENVIRONMENT: __...
The system has a septic tank and soil absorption system and 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 is within a Zone I of a public water supply well.
The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well.
The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water
supply well, unless a well water analysis for ooliform 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.
3) OTHER
(revised 11/03/95) 2
i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address:
Owner. K �,d
Date of Inspection: / /
/4 Y 6
D1 SYSTEM FAILS: W/19
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
failure. determine what will be necessary to correct the
— Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool.
Discharge or ponding of emuent 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 tunes in the last year NOT due to clogged or obstructed pipe(s).
Number of tunes 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 yx be acceptable, attach ce
ce• copy of well water is Worm bacteria vanalysis for
volatile organic compounds, ammonia nitrogen and nitrate nitrogen. __...
El LARGE SYSTEM FAILS: 11114
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 lic
health and safety and the environment because one or more of the following conditions exist: to pub
— 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 CUR 5.00 and 6.00. Please consult the local regional office of the Department for further information.
(revised 11/03/95) 3
r
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECIQ.IST
Property Address:
Owner. K CA, a
Date of Inspection: 511 c. /y 6
Check if the following have been done:
JZ'Pumping information was requested of 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. Large volumes of water have not been introduced into the system recently or as part of this inspection.
JL As built plans have been obtained and examined. Note if they are not available with N/A.
ZThe facility or dwelling was inspected for signs of sewage back-up.
_ZThe system does not receive non-sanitary or industrial waste flow
ZThe site was inspected for signs of breakout.
i/All system components, excluding the Soil Absorption System, have been located on the site.
ZThe 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 existing information or
approximated by non-intrusive methods.
Je/The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of Sub-
Surface Disposal System.
(revised 11/03/95) 4
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address; 6 y C-4-1-A
g
Owner. /Ic.ua.
Date of Inspection: y
RESIDENTIAL. FLOW CONDITIONS
Design flow: 3.,�llons
Number of bedrooms: 3
Number of current residents:
Garbage grinder,(yes or no): A/6
Lary connected to system(yes or no):�f
Seasonal use(yes or no):A/
Water meter readings, if available: C1 S = 1z 3
Last date of occupancy:��vk,
COMMERCIAL/INDUSTRIAL• W,4
Type of establishment:
Design flow:------ ons/day
Grease trap present: (yes or no)_
Industrial Waste Holding Tank present: (yes or no)_
Non-sanitary waste discharged to the Title 5 system: (yea 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:A/0 �J✓6ti�^-"+ 4 vt r rem S G✓y, b �t cn !/3 u-Y'r.. c�saat /� �`t
System pumped'as part of inspection. (yes or no) /Vo
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)
Other(explain)
APPROXIMATE AGE of all components, date installed'(if known) and source of information: /��✓( 7�3 f��$� <✓0.S �; �� -
Sewage odors detected when arriving at the site: (yes or no) /Y i
(revised 11/03/95) 6
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 6 V cAra,f /6,114rx 7 .
Owner. K a A
Date of Inspection: S//` /y
SEPTIC TANX: J/
(locate on site plan)
Depth below grade: / /
Material of construction: ✓concrete_metal_M_other(ezplain) `
Dimensions:__ S k �X /b v p a&,
Sludge depth
Distance from top of sludge to bottom of outlet tee or baffle: —'-�-
Scum thickness:-3"
�i
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffler
Comments:
(recommendation for pump dition of inlet and let tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,
evidence of leakage,etc.) �/ G�S �t .��.cl fit .y W o o S i
GREASE TRAP:_N ,-)
(locate on site plan)
Depth below grade:
Material of construction:_concrete_metal_FRP--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:
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 11/03/95) 6
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
c/ SYSTEM INFORMATION(oontinued)
Property Address: 6 / C&
Owner. A
Date of Inspeotion: K
TIGHT OR HOLDING TANK: /V//l
(locate on site plan)
Depth below grade:
Material of construction:_concrete_metal_FRP_other(explam)
Dime nsions•
Capacity gallons
Design flow: ¢allons/day
Alarm level:
Comments:
(condition of inlet tee, condition of alarm and float switches,etc.)
DISTRIBUTION BOX:
(locate on site plan)
Depth of liquid level above outlet invert: L
Comments:
(note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box,etc.)
tj
�✓ J )— cJ.l..CA 01rd—G/,. o
�C1MG C Lam.
PUMP CHAMBER /&11-9
(locate on site plan)
Pumps in working order:(yes or no)
Comments:
(note condition of pump chamber, condition of pumps and appurtenances,etc.)
(revised 11/03/95) 7
r
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(oontinued)
Property Address: y C'Ct,0 7-
Owner.
Date of Inspection: 5
�5// 6
SOIL ABSORPTION SYSTEM("MIZ
(locate on site plan, if possible;ezmmtion not required,but may be approximated by non-intrusive methods)
If not determined to be present,explain:
Type: �� 1
leaching Pits, number: � /k-'c
leaching chambers,number._
leaching galleries, number
leaching trenches, number,length:
leaching fields, number,dimensions:
overflow cesspool, number:
Comments: (note condition of soil,signs of hydraulic failure, level of ponding, conditionpf vegetation,etc.) S o i wCA s
a h Q S h.t A o i G,. G1 r�. t, c.
t/ _ u v t
arc.s c n . .'4— -�-�'rs, o h S/�t_!✓7�. .
v
CESSPOOLS: ,64
(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 contraction:
Indication of groundwater:
inflow(owspool must be Pumped as Part of inspection)
Comments: (note oondition 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.)
(revised 11/03/95) 8
SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION FORM
PART C
/ SYSTEM INFORMATION (continued)
Property Address: 6 y Cho �G`�a vh7
owner.
Date of Inspection:
SKETCH OF SEWAGE DISPOSAL SYSTEM:
Indude ties to at least two permanent references landmarks or benchmarks
locate all wells within 100'
a ,
3y
9 �
3 36
a ' /Goa�,w II•ri
DEPTH TO GROUNDWATER u- `
Depth to groundwater.- feet adjusted high groundwater level -
method of determination or approximation:
9
u
No....F_:��Jn Fws3...�J...�:�d._
LTH
(Pl � THEOAR®AO�OF
I-IEALTH TS
Ao* ,
/..-PwN-...... oF.... AR./�1S'r .
�-3 Appliratiuu for Disposal Works Cnuuutrurtion ami#
Application is hereby made for a Permit to Construct (✓) or Repair ( ) an Individual Sewage Disposal
System at:
. Location-Ad s or Lot No.
�p� iR -..�� 1'............................
Owner Address
Installer Address
Q Type of Building Size Lot.Z_4/__________..........Sq. feet
Dwelling—No. of Bedrooms___-�...................................Expansion Attic (,o) Garbage Grinder (&oo)
Other—Type of Building ............................ No. of persons..............._............ Showers ( ) — Cafeteria ( )
Q, Other fixtures -------••---•-------•----•--•--- -
W Design Flow........ss...........................gallons per person per day. Total daily flow----- .........................gallons.
WSeptic Tank—Liquid capacity............gallons • Length................ Width................ Diameter................ Depth......_.........
x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No_____________________ Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ((/S Dosing tank ( ) /
~" Percolation Test Results Performed by 7EL:P 1 y ......i."C*t-................... Date..SI k!6/ s............•......
aTest Pit No. 1__c. -...minutes per inch Depth of Test Pit-----/Z....... Depth to ground water.-tYPNIM---_____.
(i Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water........................
----------------------------------------------•---•---......_....-•----------..._..._........---•-•.........................................................
ODescription of Soil..... - . �._ 1 .............................................................................................
V ------------------------
•----------z----� �-- S?, ~l - � `�! ��i`
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 TITI.i� 5 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-4)gard of health.
Signed............ ................................ ---61Z 6l�--_----
Date/
Application Approved By.::.:-- ------.................._.....•...: ------...... -----•
Date
Application Disapproved for the following reasons--------------------------------------------------------------•-----------------•----•-•-•--•------•.....------
................•-••........---------......--•--.........._...-•-•-•--.......-•--------------------•-•••.--------••-•--•••---•------•--•-•-••----••---•---•-•------------•----------•-----••-------•----
Date
Permit No..........5��..�._............ ............................ Issued
Date
No...............--....-- FEs...•-•.......................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
...1.. �...................OF....� .........................................
Appliration for Disposal Works Tonstrur#iutt Errant
Application is hereby made for. a Permit to Construct (e�' ) or Repair ( ) an Individual Sewage Disposal
System at:
-6= - c" - ssfi- ------------------•--.......-------._.._......._......--••--------
Location-Address or Lot No.
-' J. 5:.c .t Gt.g".. ! ':...`.- ?! f�............................. .......................ti_...
Owner Address
W
Installer Address
Type of Building Size Lot----------------------------Sq. feet
Dwelling—No. of Bedrooms....:_...................................Expansion Attic (, ) Garbage Grinder ( )
pa-, Other—Type of Building ____________________________ No. of persons---:---------_.............. Showers ( ) — Cafeteria ( )
al Other fixtures _________________________________ _
W Design Flow____..__.15 ____________________________gallons per person per day. Total daily flow...... ).........................gallons.
WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter---------------- Depth................
x Disposal Trench—No_____________________ Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No-_------------------ Diameter..............._.... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box (P/) Dosing tank ( )
Percolation Test Results Performed by__. L_'X> i„_•____._ \J.Cnti.................... Date__ &A` ...................
�--4.a Test Pit No. 1_' _ c.___minutes per inch Depth of Test Pit.....! ....... Depth to ground water_/V0,V_ .=_.____.
GT4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water_-_-___-__.________-___.
04 -•-•--- --------------•---------------------------------------......................---•---•-•----•-•----•--•-----•---•------•-----••••••....••--••--•-
ODescription of Soil Q`_ .......1. .............................................................................................
V , t7_E__ +_° lg�" +el` `$ !`► ------------------------------------•--------------------
W --------- --------------------------------------------------------------------------------------------•--------------------------•-------------------•------------------------------------------------
V 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
operation until a Certificate of Compliance has been issued by thard of health.
Signed ... :-Chsa_,.4_ ................................ t` It .._....
Date
ApplicationApproved ......................................................... .......... a
Date
Application Disapproved for the following reasons-------------------------------------------------- ........................................................
-----------------
._....--------------
--------
---•--------------------------•--••-•---------------------------------------------------------------------------------------------
•-------------
Date
PermitNo......... ...... �----------• Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
-
....................OF.... .f A.- . .?. L..'................._........_..........-.
Trrtifirate of Tlampliattrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
�r Installer
at ' �_._ _ ,� _. :Fyv / ...._ E+ f?ri`Y f+aias ..................•------------
has been installed in accordance with the provisions of TITLE. 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No---------Al.:X�—'___�_ -5�-____.____ dated--....���7.�:./.�:_�=...........
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTIO SATISFACTORY.
DATE........--•-•......... .. ..:.. ......---•-----------•----....._._ Inspector--•------------ ....................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
G'th's`w
FD OF... ...............................r1tV
.. ......... ...........I......... r� 6....fir: ..............................
No. =_..�• ... FEE .t.._.. ........
Disposal orkii Taattstrudion nutit
Permission is hereby granted ....................
to Construct or,,Repair ( ) an Individual Sewage Disposal System
at No...... e�--- *e3e"".d-ny1..._ rat ' --------C ", '.'..::�? Vj L
Street _
as shown on the application for Disposal Works Construction Permit No._
.......... .. .........
-_ _ �y
DATE.......... Board of Health
FORM 1255 A. M. SULKIN, INC., BOSTON
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,EJSTMS 4POT ELEVATION Ox0
EXlBT.iNO';CONTOUR ---.p -- - CERTIFIED PLOT PLAN
1'FtN1�HED' SPOT ELEVATLON ( ] Lo r 7-7- rrPY� Awe
't �flM#lS.H.EO`.CONTOUR 0 CC�/ TzvILLE
�. �NQ'Bfk The. location of any, existing underground sewerage,
teLis, 'or other utilities shown on this plan: is approx- IN t
A te,onl as determined from records and/or verbal � �
ainoxmataon. The contractor is responsible for the ago
Er
4 at of the existing locations in the field. 9CALE� / "=�D DATES GAS I
DREDGE EN
GINEER/NQ CO! !N CLIENT. I 'CERTIFY THAT THE PROPOSED%
EQISTERE REOISTEREO JOB NO. BUILDING SHOWN `ON THIS PL AN. `
roe
LAND CONFORMS. TO THE ZONING LAWS .,,a. DR.8Y 'A' M #,
E 0 ER RV OF� BARN STABLE , MA39.
A
T12 MAIN STREET CH. BY,
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ALBER
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41 AL.1 - � 7AZMA IAV ��7_.,
4 'lM51 10 No. 19367 �5.1��A
No. Z.0
ISTS
Se A J040 A10.
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N OF BARNSTABLE
LOCATION 7.-- 14o'T-, //��/� 4'R`�.. y SEWAGE#
VILLAGE [ " � ASSESSOR'S MAP & LO O
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY V O o 0.)y
LEACHING FACILITY: (type) d— (size) h
NO.OF BEDROOMS
BUILDER OR OWNER �c�-d` _
PERMITDATE: 7 Z i ZX S^ COMPLIANCE DATE: 3 /g
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 I - tJ
3
yg
0 3
_. 3l
a30 ifs
LOCATION Cp� SEWAGE PERMIT NO.
VILLAGE
r ( �
Cf(A-�;'� y
INSTA LLER'S NAME i ADDRESS
R U I L D E R OR OWNER
I�
DATE PERMIT ISSUED :7z
DATE COMPLIANCE ISSUED 3i
0,417 ®r- Mbo Y
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