HomeMy WebLinkAbout1103 CRAIGVILLE BEACH ROAD - Health y y v-� CRAIG VILLE BEACH A RI)., C'VILLE
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No. 42101/3 ORA
F
ESSELTE
10%
0 0 0 0
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WINDOW ROUND WINDOW
WALK IN FIULL BATH
CLOSET
N/ v
FLAT ROOF 12'-3" DOWN
WITH PT DECK 10
CLOSET FLAT ROOF
OVER EXISTING WITH PT DECK
OVER EXISTING
e+
ao
WET
BAR
it-i vz" AREA
GREAT ROOM
m
m
N
POSSIBLE AREA FOR SHED DORMER
DEAD SPACE STORAGE
lPICTURE WINDOW WITH SIDE FLANKS a
< < Y
HEAT SYSTEM?
BATH BATH BED 1 LAUNDRY
S
DEN AREA ILL III 1 11
;KITCHEN
Ln
1 N
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i
PECK RESIDENCE
1 ST FLOOR PLAN
1 s4-
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LIAR-24-00 03:35PLI FROM-PURE ENCAPSULATIONS 9764439664 7-396 P.02/12 F-412
PW
t '
COMMON' E TH OF.u'iMSACHUSETTS \v
"' ECUTnT OFFICE OF EN JROtV.�MNTAL AFFAMS
DZPARjwMqT Q>P'ENVMNMENTAL Piaoqc�*rpN
ONE %9 T R STREET,BOSTOH MA 02108 (617)E,92• N R l�
to",Or moo a l
h1 �9Aps 2BUDY G07E
ARCE0 PAUL CELLUCCT `t'� �OFPT��E
Goverror
r DAVYD B�STEIIHS
SUBSURFACE S�INAGE DW03AL SYSTEM HSPECT)ON FORM �
PART A 4r; sier
C9rIFICATI3N
Property All
CAV ErrL-ICvsze_E f3A^�C
D.<:of M1epe�&m: a jn jd a Address of 0ir► r:�7.e...
Morrie of Inspector.(Please fthm �"
I a>rn a DFP appreved system
co verry Name: 4a:4�to S*cd"18-M of lido 8(310 CUR 15,000)
Mairq Addlreaa:
Telephone Ntanber; 1�
STA
t ratify that J have pereortaFy inspected the end oompJete as of the sewage d{apoeel system at this address and that the infOrmatiore reported below is true,accurst•
*#a of Inspection. The Indpeoticn was performed based on my training and experfence In the proper function and
maintenance of on•shm sewage Saposal systems. The system.
�aaeea
Conditionally Passes
1 _ Needs"or Evaluation BY the Local Approving Authority
— Falls
tmspeotor's Sign w -
Date: �o c
The System Inspector shelf submit a copy of Na inspection report to the Approving Authority(Board of Health or DEP{within t},Irty(30)days of
Inspection. If the system is a s►,tged system or has s design flow of 10,000 gpd or greater,the Inspeoter and the system owner
shah m Owner
the report to the appropriate r, fonal ofrtce of the Department of Environmental Protection. The original should be Sant 10 the
system owner and espies cant m the buyer,tf applloable,and the approving authority.
NOTOS AND COMMENTS
revised 9/2/98
hsae 2 el It
&JO pnnr.d an RocrcAm p„w
NFL
MAR-24-00 03:36PM FROM-PURE ENCAPSULATIONS 9784439664 T-398 P.03/12 F-412
SUMU<FACE SEWAGE D( pOM BYSTtiaS p�nOM FbRW
PART A
COMFICATiON(&court..
NVP-ty Addrsas:
Owns:
Deb of k"pecdan:
WSP@Cr1O1M aUbo""Y: Chest A 9 C,
1A. SYSTM PA22n,
I have rat found any Information which in
crit dieetes that any of the
criteria Act&valuated are indicated bek>tiv, failure eonditigm described In 310 CMR 15.303 axial Any failure
COLUMW1'S:
B' SYSTDA CONW WALLY PASSES.-
One or mere systan Components as described in the "Con
eempleUon of the replacement er repair,as a Bead of H lth will
need to be
moved by the Board of Health, wlli pats. weed ar repaired, The system,upon
indcate Yes,no,or not daterminsd y
( lM, l' of) besalbe basis of determination in s0 Instmaas. if-not determined e:
The a&ptto tank is meld,unless the owner a operator has provided the syttarn inspector with s
Comp(iarupe!attached)lndlCatinQ that the tarrlt was' ��why not.
the aep$Q tank, whether or not meta}, Installed withkt twentY(20) opy of a Cerdficate of
fidure is Imminent. The system w1Y Crocked,st►uctt�eYy unsound,shows subs prior to the date of the Inspection;or
approved b the B Pass Inspection if the exist)n a at0�infiltration a eXfUbation, or tank
Y card of Health. fi optic tank is raplsead wltlf&°ORIMying Septic tank as
Sewage backup n breakout or Mph Static water Iaval obaorved in the diatrlbutlon box is due to broken or Obstructed
Of due to a broken,settled or uneven distributlon Health). box. The system win pass inspection if(w}t}t a plps(s)
broken pprOYal°f the board of
-- pipe(a}are replaced
obstruction im rernoved
distribution box Is levelled or r&pl.Cad
The system rectr;rod pumping
iWactton If(with a th more tlnn
PR►owl four time.a yea due to broken or obstructed pipe(s). The system will part
of
a Board of Health);
broken Pipe(@)are replaced
obstruction is removed
revised 9/2/g8
no2oru
MAR-24-00 03:36PM FROM-PURE ENCAPSULATIONS 9764439664 T-396 P.04/12 F-412
8U5SURFACti"Aft MSPOSAL SYSTP.lYI NSPECTIM FORbr
PART A
CERTU4CATLON famorrtudl
Property Addnaa:
Owrsa:
Dab at kwpef:tlon,
C. FiJRT M EVALUATION IS REOL4M BY THE BOARD OF HEALTH:
Corx"911s exist which/squire further.valuatJon by the Board of Health in order to determine if the system Is failing to protect the
Pubic health,safety and the ormrorrnent.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH PITgthMU IN ACCORDANCE WTrk 310 CUR 1l�3p;f1Nb1 THAT TH>:SYSTEM
is NOT FUNC71oNRiG W A MAhNF3t WHICH WA1L
PROTEt:i THE pUet.IC MALT"
AND SAFETY AND THE Cesspool ar privy Is within 60 fast of surface water COMMENT.
CasSPW 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 ptjoW WATM SUPPLIER.IF ANY)
FUNCTXMWQ IN A MANNER THAT PROTECTS THE pUBLIC HEALTH AND SAFETY MOIN THAT THE SYSTm IS
AND THIS ENVMO DETERN6MIT:
The eystam has a septic tonk and 30 absorption system(SAS)and the SAS Is within 100 fort of a surface water supply or
tributary to a surface water supply.
_ The system has a septic tank and sell absorption s stem
— The system has a S.Ptia tank and soli Y and the SAS Is within a Zone 1 of■public watofPPIy wsA.
The system her,s septic tank end Sol absorption system andW the SAS is within 60 foot of a private water supply wel.
Private water supplyabsorption ayetar„and the SAS is leas than 100 feet but SO feet Or more from
a
Mhlll.>mssss a wall water analya)s for oofiform bacteria and vniattle organic eaRlPOYrlda indicates that>fia
well is free from poffudon from that fsaEity and the pnaanca of ammonia dtro en and nitrate nC o Fs a al
than S ppm. Method used to dsurnikm dlstance 0 o9e 4u to or less
t0WOkimatlon not valid).
sl oTrll:a
reviSed 9/2/98
Payls�or 11
LIAR-24-00 03:37PM FROM-PURE ENCAPSULATIONS 9784439664 T-398 P.05/12 F-412
SUBSURFACE SEWAQH DISPOSAL SYSTEM&j.9p n0j4 FGR>N
PART A
artTI ICATMN 100"lrued)
Property AQdres•r
01wrw:
Date of kapeadom.
0- SYSTEM FALS:
You must indicate"or'Yes"or"No" to each of the following:
I have determined tnti ed el more of the fotowing f■nure conditone exist as described in 310 CMR 16.303, The basis for this
determination to IdentiAsd below. The Board of HaaHh should be contacted to detemUns what vrn)be neeaseary to correct r 1e fallnro,
Yea No
Backup of sewage into facility or system eamponent due to sn overloaded or clogged SAS or cesspool.
--- — Ditspool, or goading
easpool,
e of effluent to the,„-face of the ground at surface waters due to an overloaded or clogged SAS or
Static liquid level In the distribution box above outlet Invert due to an overloaded Of Clogged SAS or eesstrooi,
Liquid depth In c•aapoel is lass than 6"below Invert or available volume is less than 1/2 day flow,
Required pumping more then 4 tines in the last year JOT due to dogged or obstructed pipe(s).
Number of times purnped_
Any portion of the Soil Absorption System,cesspool or privy Is below the high groundwater ebvatior,
Any PORion of a ceaspaot or privy is within t 00 feat of a surface water supply or trill u?arY to a surface oats-supply,
_. Any portion of a cosspod or privy is within a Zone I of a public wall,
— Any portion of a cesspool Or privy is within 60 foot of a private water supply well.
-- Any porton of a cesspool or privy is teas than 100 feet but greeter than So feat from a private water supply well with no
acceptable water quality analysis, If the wen has been analyzed to be tleoaptabi0.attach Copy of weq water
conform
bacteria' voiatj)e Organic compounds,ammonia nitrogen and nkrate rtkt ogen.
analysis for
E. LARGE SYSTEM FAILS.-
You moat indicate either-Yes"or"No" to each of the following:The foliowing eriterla apply to large eyt•ma In addition to the criteria above;
The system serves•faOBity with a design flow of 10,000 gpd or greater(Large System)and the system is a s+gni{;cant threat to bile
teeth and safety and the environment because one or more of the following conditions exists
Iw
Yes No
the system Is within 400 feet of a surface drinking water supply
dye System Is whMn 200 feet of a tributary to a surfs*drinking water
the aystam is located in a supply
water supply wolf! fOgen sensitive area(In, WatRtead PrOtecrion Area-
t1NPA)or a mapped Zone Ili of a public
The owner or operator of any Kmh system shall upgrade the system in acco
office of the DoPt for further information. danft witfi 310 CMA 15.30412). -lease consult the loom TOgional
i
J
revised 9/2/98
Page 4 atti
MAR-24-00 03:38PM FR0M-PURE ENCAPSULATIONS 9784439664 T-398 P-06/12 F-412
SUSSLIFIFACS SEWAQE DapOSAL SYSTM INSPECTM NQRM
PART S
CHtCKMT
Prop"Address;
Owner:
Dab of der borc
Ch•ak if the following have been done:You must indicate elthar^Yes•or"No"all
to each of the following:
Yam
L No
Pumping information was provided by the owner,occupant,or Board of Heaith4 oOJ
None of the eyst•m components have been
rates during that period. Large volumes of Wat•r�hever At nptl6ee�Inc weeks and the system has been receiving normal
Ks�on• tr�rced into the system recently er as part of fl
As built plans have bean obtained and examined. Note if they are not available with N/A. /.®t —
^, The faclity or dwelling was Inspected for signs of sewage back-up. 00Lj �C�D POO
C� The system does not recalva non-senhary or Industrial waste flow.
— The site was inspected for slg;rrs of breakout.
All system COMR*nants'4o'chrrfing the Soil Absorption SYstern,have been located on the site.
._ The aeptlo tank manholes were ur►caversd,opened,and
or tees,material of construction, into►�of the septic tank Was mspscted for oonadon of baffles
the SOn,dimensions,depth of flytgtod.depth of srudge,depth of acurn.
The size and location of the SWI Absorption System an the site has bean detsrrrt;rted based on: K
., Existing information,For exempla.Plan et S.O.M. r'ars�
f'r�7rib f 17UAIG✓�]
�- Oetarmtlned in the field fif any of the faikrre ortteria related to Part C Is et issue,a r
f18.302(3)Ib)) pP oxinmr1lan of distance la unacceptable)
L The facility owner(and occupants,if differe
SubSurfoce Disposal Systems. nt from owner)ware provided withinformation on the
woper ntaintanenoe of
revised 9/Z/98
Pope 3 ar It
LIAR-24-00 03:38PM FROG(-PURE ENCAPSULATIONS 9784439664 T-398 P.07/12 F-412
8UBSLNWACE SEWAGE D)SPOSAL SYSTM WSPECTM FORM
PAW C
1 SYST'3FA MWORMATM
F+'ope.ty Address.
Own":
Dr>d of limpeetion:
RES�Ei ML, FLOW COhpmoa
Design flow;-&'—g g,p,d,�room.
Number of bedrooms(das)gn),
Total DESIGN Pow. - Number of bedrooms(ilctu")�.1
Humber of parent residents;�
Garbage g"nder(yes or nol:
Laundry(aeporate system)
Laundry Ystttrn s (Yai or Inapeetad (ya$Of no}o) N Ye!,6"rato 1ASPOct1Mequ required
Seasonal use(yes or no)f*V 0
Water meter ra ,if
Sump Pump(Yesg at available(last two year'$Uaaga(gpd): 7--
or nq)�Q d
Last date of occupancy:
�"vT
_QA!lAle<RCULInlfeef�nu�;
Type of establishment:
Design Pow, d (8aaed on 19.203)Sasia of design Pow
Grease trap present:(yea or AD)_
Indust""Waste Holding Tank present:(Vag or ne'l
Non.senitary waste discharged to the T;tte 5 sys
Water meter readings.If evailsibia; tem:(yes or no),
Last date of oceupaney�
OTHR:(Daseribe)
Last data Of Occupancy.,
r'ENI;w WR)RMATION
PUIUPWQCO RECORDS and source of information;
BVEC
SYitem pumped as part Of Inspection:(yes or no)laft ,If vet, vduma pumped:_ Y-r
pumping:
Reason for �-�-g�
g:
TMpe 9F SYST MM
SOPHO /sotl absorption
Single cesspool system
-+_ overflow cesspool
Shared syitarn(yes or no) (it yes,attach previous Impaction raoords,it any)
l/A Teehno)ogY to.Attach copy of up to data operatfen and+halntena if conbaet
Tight Tar*
---COPY of DEP Approval
Other
APPROXINtATE AGE of all components.date)nstalfed(if known)and so
ur"of Inierrnet)on:
sen'm"odors detected when arriving at the site:(Yea or no), ,�
a
eVised 9/2/98
Pao 6of11
• LIAR-14-00 03:39PLI FROM-PURE ENCAPSULATIONS 9764439664 T-398 P.08/12 F-412
SUBSURFACE SEWAGE DISPOSAL SYSTEM VaPECTM FORM
PART c
SYST8,1 SWORMATM(oesee/rhrsd)
�Y Address:
ow -
Deab of lrtapecyan;
BUMDWG SEWER:
(Locate on site plan)
Depth below grade:_
Material of oonetructlon: cast iron,40 PVC
Other(e:plain)
Distance from private water
Diameter °e+t�y w°tt auet)on line __
Comments:(oondition Of Joints,venting, evidanea of leakage,•te,)
S�'f7c TAfill(t
(locate on sits glen)
Depth below grade•
eAL
Material of constructllDn c 11 o 11 nente—mct6l—Flberglasa ,pa s
Y Vr4Vne_othet(explein)
If tank Is metal.Gat sge: Is age confirmed Is
�L Y Ca'tiflcate of Compliance��(Ye./N
Dimensions;4 > x yn~
Skkdge depth;, ,
Diatanee front top of dud to bottom of outlet tee ar Scum tscknosa,� 33��
Dlttsnoe from top of scum to top of oatiet tee or QkI A -
Distance from bottom of scum to bottom of outlet tee or bafffet.'I ,/S/
How dimensions were daterrnmed,4W- ,, ,1 r�
Comments:
(►•Comrttbndat(an , t,:.) n ,condition of inlet and outlet tees or battles,depth of liquid level to r
evidence of leakage,ate.)
F slaUan to outlet invert,etructursd Integrity,
GREASE TRAP:
(locale On cite plan)
Depth below grade;
Material of coneroyobp`concrete_metal,_Flbergisaa —Polythylsne—other(explain)
Qlmeneierie;
Scent►thiek>,ese:
�latane.,from top cf SCUM to top of ouyat tee or ba�ei
at@ of lost P mping:txmom of scum to bottom of outlet too or baffle;
Date of loaf)sUmping;"
Comments:
(reeommsndetlon tot pumping,condition of We,and
evtdance of leakage,etc) artlet tees or baffles,depth of hquld level In relation to outlet invert,structural irttegr(t.,
7evized
Pace t of 11
-" MAR-24-00 03:39PN FR0M-PURE ENCAPSULATIONS 9784439664 T-398 P.09/12 F-412
SUBSURFACE SIEWAI DISKkSAL SYSTMA INSPWTWX MW
' PART C
SYSTD4��ATRW(corrbrttasd)
P'�y Address:
Owner
Data at Wapec6m•
TIONTOR ntlV TANK:
(facetslocole on site plan!) (Tank must be pumped prior to, or at tirne of, Irtapaotion)
Depth below Grade;
Materiel Of conatnutie`n:'oonereta`Mqtv,
-�Flbwolus`paiyethyleft—other(e)plain)
Dimensions:
Capscity;�T Golans
Deafen flow:
Alarm present 94110ns/day
Alarm)eve': Alarm in working order;Yea
Date of Previous purwp-k p: No
—
Comments:
fcwwfton of inlet tee,eonditlon of alarm end float switches,ate,)
DISTRISUT?ON tsOXq�Q
flocate on site plan)
Depth of liquid level above outlet invert
Comments:
(note If level and ditribution Is equal,
evidence of Solids ear►yever,evidence of leakage into or out of box, eto.)
>'t1G1J•tftAY
flockla on site plan)
pumps in werkinq order;(Yes or No)
AWMS if,working order(Yes or AIoJ_
Cof„rnenta:
(note eondition Of pump chamber, condition of pine and appurtenances,etc,)
revised 9/2/98
Page a of 11
" MAR-24-00 03:40PM FROM-PURE ENCAPSULATIONS 9764439664 T-32e P.10/12 F-412
SUBSURFACE SEWAGE DWPOSAL SYSY M POPECT)ON Pow
PART C
` SYSTEM NPORKATIMI jcwW n4
J P►epwty Addreasc
Omer:
Dame of lnspec$an:
SOIL ABS01111107MIN SYSTEM(SAS)YZS
(locate on site plan,M possible;escevadon not required,location may be spprox'msted by nOr14rttru9ive methods)
If not located,explain;
Type:
laseNne pits,number:_
Iseehlmr chambers,number:,_
141001dnfl 96"-*s,number.,
Keaching nenchea,number, ;;thl —yam
leaching fields,number,dimensions:
Overflow aesepoo(,number: -
Alternative,system: �—
eahnol egy:
Commerrta: Name of T
(note condition of soli,signs of hydraulic}allure,level of pondMg, damp soil,cond'rt)on of vegetation,etc.)
CESSPOOM
flocea on she plan)
Number and cortllpursdon.
Depth-top of liquid to inlet invert:
)Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Matar,als of construction:
Indication of groundwater,
inflow loaespool must be pumped as part nsef pection)
Comments:
(note eonc6tlon of SON,signs of hydraulic failure,level of ponding, condition of
vegetation,ate.)
PRfYY,�
(locate on SIN plan)
Materials of conmuctfon:
Depth of solid@: D)manaiona; _
Commom:
(note condition of sa,signs of hydraulic failure,level of pondin , condition of
g vegetation,etc.)
revised 9/2/98
Pyle 9 or 11
f
MAR-24-00 03:40PM� FROM-PURE ENCAPSULATIONS: 9T84439664 T-396 P.11/12 F-412
$UMURFACE SEWAGE DtapOSAL 8Y3 W NSPECT"Foust
PART C
SYSTEM pro PART
(ao"w wme
PIVPWtY Addraaa:
Owns;
Dab OF tnspacam
l SKETCH OF SEwAQi DISPOSAL SYSTEMt
iaoluds ties to st Iseat two Pwmanant rs/a►anoa landmarks or banehmarks
boats aM wags wkMn I DO'(Loests whfn Public water supply gems"into heuu)
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s�( L(ar
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revised g
f2/98
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` MAR-24-00 03:41PM FROM-PURE ENCAPSULATIONS 8784439664
T-388 P.12/12 f-411
SUBSURFACE SEWAGE DISPOSAL SYSTW MPWMm FORM
PART C
SYSTEM WO1t"TKN(eonprsrwo
Prwmty Address:
omw: a .
D.te of Mdgx 5w:
NACS Report name
Soil Type_
Tvplael depth to prourxivroter
USGS Dab wabeite Visited
Obee►vadw Wells checked
Grvrmdwater depth: Shallow Modarata Deep
SiTH EXAM Slope
Surface water
Check Cellar
shallow wells
Estimated Depth to Groundwi ter>-f. Peet
Please Indicate on the methods used to datermine High Groundwater Elavetkm..
Obtained from Design Plans on record
_IZL-'(0)barved Site(Abutting property,observation hole,bass rne i sump ate.1
Determined from lok ai cond Bons
—Checked with local hoard of health
Chocked FEMA Maps
Ch ckad pumping records
Checked local exemilers,instellera
Used USGS Dam
Describe how Vou established the High Groundwater Elevation,1--�� IW be eompietedl
Fo �y eo r� 60m.. rF 3i4� A4ivsir 7Zr✓.oT }
I. ✓
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revised 9/2/98
Papllorll
MAR-24-00 03:35PM FROM-PURE ENCAPSULATIONS 9764439664 T-396 P-01/12 F-412
S 96al la&&,
VIVIAN AND AL NAULT
REALTORS
627 SO. MAJN ST. • CENTERVILLE, MASS. 02632.3409
(50B) 775.0158
FAX (508) 775-5122 VIVN@r_APECOD_NET
- Monday,March 20, 2000 - " --- -
Mr. Peter Hamel
8 'Bridle Path
Wayland„MA 01778-
Dear Peter:
We have the information from the Centerville Osterville Water Dept.
regards the gallonage used at the house on 1103 Craigville Beach Road.
They said you only needed two years - and that for 1999 - Three
thousand gallons were used - and for 1998 - seven thousand gallons
were used.
Need anything else- let us know.
Sincerel ,
r�
Vivian F. Nault
REALTOR®
EXCLUSIVE AFFIUATE SOTHEBY'S INTERNATIONAL REALTY
3:00
Commonwealth of Massachusetts �,, ,�P
Executive Office of Environmental Affairs
+ ), ,
Department of A
Environmental protectionts�9�I �J
William P.Weld b _;''
Trudy Coxe ' !
kpeo Paul Celluccl , xe
U. R101 David B. Struhs
Contmwloruf
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A _
. CERTIFICATION
Property Address: , n 3 �( vi 6l I,,
Date of Inspection: y I �q i �J � �`�= �P'���&t-I'(�fidrcss of Owner.
Name of Inspector. H ei ru J t (1f different)
Company Name,Address and Telephone N4Alr. SUPERIOR HOME INSPECTIONS ,
544
CERTIFICATION STATEMENTT
CARVER.MA02330
I certify that I Dave personally. inspected the sewage disposal "tern at this addross and that the information reported below)a true, accurst,
and complete es of the time of inspection. The inspection' performed based on my training and ex
maintenance of on-site sewage�pOW systems. The system. perienca in the proper function a-nd
Pajsses
Conditionally Passes
Needs Further Evaluation By the Local Approving Authority
_ Fails
Inspector's Signature; /
V V Date:
The System Inspector shall submit a of this
inspection. If the PY inspection report to the Approving Authority within thirty(30)days or completing this
system)a a shared rysum or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the Appropriate regions.)orrice 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.
.•t
INSPECTION SUMMARY,
'Check A,B. C,or D:
Al SYSTEM PASSES:
have not found ary information which indicates that the system violates of the
Anl fa ur•e criteria not evaluated are indicated below. �' failure criteria u deflned in 310 CMR 16.303.
3) SYSTEM CONDITIONALLY PASSES:
One or more system components need to be replaced or repaired. The system,upon completion of the replacement or repair, passes
inspection.
ndicate yes, to, or not determined(Y, N,or ND). Describe basis of determination in all instances. If"not. eternuned", explain why sot)
The septic tank is meta), cracked structurally unsound, shows substantial infiltration or e:rdtration, or tank failure is
imminent. The system wtU pass inspection if the existing septic tank is replaced with a ronformiag septic tank as approv
by the Board of Health. ed
revised.11/03/95)
I
One VVinter Street a Boston, Massachusetts 02108 a FAX(617) 556-1049 a Telephone(617)292-SSW
�, Pnnted on It"IM Paper 6
V .
p
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property dress: (103 ..Crr (!� �Q �� n { •
Owner. T , ef
Data of Inspection:
b
BJ SYSTEM CONDITIONALLY PASSES (continued)
— Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed
or due to a broken,settled or uneven distribution box. The system will p inspection if(with a pipe(s)
Health): approval of the Board of
broken Pipe(m)are replaced
obstruction is removed
distribution box is levelled or replaced
Thr�ed Pumping more.than four times a yw due to broken or obstructed pipe(s). The system will pass
inspection
(with
approval of the Board of Health):
broken Pipe(s)are replaced
obstruction is removed ,
C) ETHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
Conditions exist which require hither 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 IJEAL711 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.
Z) 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 his a.septic tank and soil absorption system and is within 100 feet to a surface water supply or tributary to 0
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 suPP y 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 arwivsis for coliform bacteria and volatile organic compounds indicates that the well is tree
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
)
L
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property wner A•¢¢reset 103 "-"M t GJWI(,1,(, �{�t 0 -EZ A CRnj Q/ts' e,
O . �'�-}Qr^
Data of Inspection: '
DI SYSTEM FAIL9:
I have determined that the system violates one or more of the following fniltare 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 Wurs. 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 effluent to the surface of the ground or surface waters due to an overloaded or Clogged SAS or
capool.
Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool, '
_.. .Liquid depth is cesspool is less than 6-below invert or available volume ia.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 s 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 anal
coliform bacteria,volatile organic compounds,ammonia nitrogen and nitrate nitrogen. ysis for
E1 LARGE SYSTEM FAILS:
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 stem is a s'
health and safety and the environment because one or more of the following conditions exist; y rgrufutnt threat to Public
the ystem 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(MTA)or a mappod Zone 13 of a public
water supply well)
The owner or operator of any such systems shall bring the system and facility into full compliance with thu
water
requirements of.314 CMR 5.00 and 6.00. Please consult the local regiorual OMC4 of the Department for further irtfdormauon.atment program
(revised 11/03/95) • 3
I '
{
SU88URFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Props CCrt,5 vq(e; ec�� C'
Cc
Dat•of In flow
Check if the following have been done:
=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 ilow rates
during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection.
ML 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 swags back-up. .
system does.nof receive non-sanitary or industrial waste flow
Ll_�e site was inspected.for signs of breakout.
All system components,excluding the Soil Absorption System,have been located on the site.
�e septic tank manholes were uncovered, opened,and the interior of the septic tank was inspected for condition of baffles or
tea, material of construction.dimensions,depth of liquid,depth of sludge,depth of scum.
_vThe size and location of the Sod Absorption System on the site has been determined based on existing information or
approximated by non-intrusive methods.
=The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of Sub-
Surface Disposal System.
(revised 11/03195) o
0
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property A react 110 3 (f ' v l ¢_
Owner. i3e C,4` d2f_4
Date of Ian ton:
• • �t I tc�f rt(�
RE9iDENTLAes FLAW CONDITIONS
Design IIow: <l o ons
Number of bedroom$: _D_
Number of current t+wideats
Garbage grinder(yes or no): , S C v„„%j'L
Laundry connected to system(yes or no): yL S
seasonal use(yes or no): ►�-)
Water meter readings,if available: -'/o
lad data of oavpancy:��.
COMMERCL4LANDUSTRIA,;
Type of establishment:
Design flow: ¢21lons/day
Grease trap Present:(yea 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 s�of information:
'-Iti A /I S 4--11l S I �4 i2 S a d o
system Pumped as part of inspection: (yes or no) YL s
II yes,volume pumped:LLa ons
Reason.for pumPinr. -7Z�, '7z -s P L" 1:T 2,,,
'I'1PE o,F�ST'F.14!
Septic taWdis�n.bez/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 componentk;date installed(if known)and source of information:
Sewage odors detected when arriving at the site: (yes or no) NJ
(revised 11/03/95) ,► 6
C
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(oontlnued)
Property A dress: C( `
I1, vt �le, apt � Gniar.�ci
owners e
�•Q f' �1,/►',,Y,��
Dace of Ins f(d 1q00,
SEPTIC TANK:
(locate on site plea)
Depth below grader
Material of construction: Con to, _metal_FRP__other(esplain)
1 �•
Dimensions: L x >C
Sludge depth;
�r
Distance from top of sludge to bottom of outlet tee or bafne:o�
Scum thickness: -2
Distance from top of scum to top of outlet tee or baMe:,--�. _
Distance from bottom of scum to bottom of outlet tee or battle:—j h�- r r
Comments;
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet Ljvert, structural integrity,
evidence of leakags, etc.) �� p 9 gri y,
Alt=i> 7 � ✓ c ✓— /)i- « V (--
GREASE TRAP:
(locate on site plan)_
Depth below grade:
Material of construction:_concrete_,metal_FRP,_other(e:cplain)
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or battle:
Distance from bottom of scum to bottom of outlet tee or baM#:
Comments:
(r-rommendation for pumping, condition of inlet and outlet tees or bashes,depth of liquid level in relation to outlet invert,structural ute t
p 9 gri y,
evidence of leakage, etc.)
(revised 11/03/95) • e
c
• o
J •�
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOR6I
PART C
SYSTEM INFORMATION(oontinued)
Property Address: f l0 3 C 4t Owner
D&W or Iaspeo&ions
TIGHT OR HOLDING TANK
(lame on site plea)
Depth below grade:
Mattrial of construction:_concrete_,metal_FRP,_,_othertesplain)
Dimensions:
Capacity:-���oas
Design flow: gaUons/3ay
Alam level:
Comments
(condition of inlet tea,condition of alarm and float switches,etc.)
DISTRIBUTION BOX: A)
(locate on site plan)
Depth of liquid level above outlet invert:
Comments:
(note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box, etc.)
e
PUMP CHAMBER;_ -
(locau on site plan)
fps in working order:(yes or no)_ '
Comments:
(note condition of pump chamber, condition of pumps and appurtenances, etc.)
(revised 11/03/95) • 7
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C '
SYSTEM INFORMATION (continued)
Propercr Ha]ar t 1h3. CYtR.i
Owner! [(([��]��,,,,''����'' 'f`
Date of Inspection. Url ,�e V
Ict(a
SOIL ABSORPTION SYSTEM (w):
(bats on site plats. If possible;excavation not required,but may be approximated by non-intrusive methods)
If not determined to be present,explain:
Type:
losching pits, number:_
leaching chambers, number:_
leaching galleries, number. i
1"leaching trenches, number,length: y w X S G
leaching Gelds, number,dimensions:
overflow empool, number.
Comments: (note condition of soil, signs of hydraulic failure,level of ponding,condition of vegetation,etc.)
`G, S
CESSPOOLS:_
(locate on site plan)
Number and configuration:
Depth-tap of liquid to Inlet invert:
Depth of solids layer:
Depth of scums layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater:
inflow(cesspool must be pumped as part of inspection)
s
Comments: (note condition of soil, signs of hydraulic failure,level of ponding,condition of vegetation,etc.)
PRIVY:_
(locate on site plan)
Materials of construction:
Depth of solids: Dimensions:
Comments: (ante condition of soil).signs of hydraulic failure, level of ponding,condition of vegetation, etc.)
(revised 11/03/95) ,� 8
C.
• 'mow '
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(oontlnued)
Property Address: ���3 'C(� V1,�1�, •�t.�.c�, � L�e�.f e�vt. ��e
Owner feDatee�t�wi/Yll'►'�Q,f�
D. of Iaspeo Ion:._f
SKETCH OF SEWAGE DISPOSAL SYSTEM:
Include ties to at least two permanent references landmarks or benchmarks
locate s11 wells within 100'
2'qz V M- A C 1-4 Ce h 7 p_\/Z L L L5
•
L�1Crl 12':noC1-1 50
1103 f
/-12 1� 7 S U
.. h
DEPTH TO GROUNDWATER
Depth to groundwater:>/- feet /
method of determination or approximation: 1 �H sT Ho
(revised 11/03/95)
9
� 1
TOWN OF BARNSTABLE
LOCATION I�U�,_�f o. rn ��r G, SEWAGE #
VILLAGE P�r�r',I�.� ASSESSOR'S MAP & LO G
INSTALLER'S NAME&PHONE NO.
SEPTIC TANG: CAPACITY C i a
LEACHING FACILITY: (type) (size)
NO.OF BEDROOMS
BUILDER OR OWNER
PERMITDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well�md 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
Ile hcxG �4
LID
p
�//d 3