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0171 ELLIOTT ROAD - Health
171 Elliott Road Centerville P A = 228 198 y i � �or i dn NO� 152 1/3 ORA 10% #6 I,� PARCEL 198 --- - - I 0.65 ACt UPLAND �II I 1.27 ACt WETLAND U I A I -I- I I ALL FENCING TO CONFORM TO I "*- STATE AND LOCAL �St) REQUIREMENTS FOR POOL FENCING. PROVIDE SELF-LATCHING AND SELF CLOSING GATES WHERE NEEDED. DOORS TO POOL LAWN AREA SHALL BE ALARMED. 0 0' Care 41f0 Iw ! POOL. 262 har P-ot W4,rant IZ to SI E T. 1 � PRE / fir: AA CO S AL K / + 'H Imo 129 $ WOOD STG GEPS I / �PS�MEt� �•, � LA_ 1 / GRAVEL / 4 DRIVE C N 1 EXIST. 5 6 0 1 ° FNDN. � SA TF = 28.1' % P- � L4J rn FQ #3 #2 ° EXIST. LEACHING 2S� FACILITY � 14.3 ' / 24\ (APPROX 383.10' LOCATON) A \ �3� CONSISTS OF 4 FLOW 0 \ DIFFUSORS WITH 4' STONE ♦ ��\ ALL AROUND \ ♦ ROOF COVERED DECK \\ ♦♦ gyp, 0:A a i COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION RECEIVED MAY 0 6 2003 c TITLE 5 TOWN OF HEALTH DEPT. OFFICL-kL PiSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A G CERTIFICATION Property Address: C �//a 7L Owner's Name: %o>P 7 2v Owner's Address: / Date of Inspection: y' Name of Inspector: (please print) Company Name: Mailing Address: O ,ts'Ox` MAP —ter sue-, PARCEL Telephone Number 50.-t— 2 — LOT CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 Citi1R 15.000). The system: � Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: yuthority The system inspector shallsubmit a copy of this inspection report to the Approving (Board of Health or DEP) %ithin 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,0t)0 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 authorirv. Notes and Comments ****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. Page 2 of l l OFFICIAL INSPECTION FOR1NI — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEINI INSPECTION FORM PART A l C/ERTIFICATION (continued) Property Address: 1- / v' •�� il/1 1 Owner: Date of Inspe on: Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. Sy m Passes: I have not found any information which indicates that any of the failure criteria described in 310 Cult 15.303 or in 310 Civa 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. SVstcm Conditionally Passes: ZOne or more system components as described in the"Conditional or repaired.The system, upon completion of the replacement or repair, as pproved b}the Boa d of to Health eelacwill pass. Answer yes, no or not determined(Y,N,ND) in the for the follo��ing^•;�t::i;;. g statements. If"not determined" please The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltradoa or ex'iltradon or tank failure is imminent. Synem "ill pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. A metal septic tank specti will pass inon 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: 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. Systcm will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system «ill pass inspection if(«ith approval of the Board of Health): broken pipe(s)are replaced Obstruction is removed ND explain: ratio � �t i i ` OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM VSPECTION FORM PART A CERTIFICATION (continued) Property Address: Owner: Date of inspe on: - C. FFuurther Evaluation is Required by the Board of Health: Conditions exist which require further evaluation br the Board of Health in order to determine if the slste is failing to protect public health safety or the environment. m 1. Svstcm will ass un less nless Board of Health determines in accordance with 310 CNIR 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 pri,,y 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 s}•stem (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water suppl}. The s}stem has a septic tank and SAS and the SAS is'%vithin a Zone 1 of a public water supply. _ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a Private water supply well**. Method used to determine distance **This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that faciliry and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. pro-�ided•that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3• Other: page 4 of l l OFFICL-kL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEivI ViSPECTION FORIM PART A CERTIFICATION (continued) Property Address: ���a JL )kl� / eh� (lI e Owner: Date of Inspect ,on: D. System Failure Criteria applicable to all systems: You must indicate"yes" or"no" to each of the following for all inspections: Yes No/ ackup of sewage into facility or system component due to overloaded or cloyed SAS or cesspool t/ 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 1/ iquid depth in cesspool is less than 6"below invert or available volume is less than '/_day flow Required pumping more than -t times in the last year NOT due to clo ged or obstructed i /��f times pumped go p pe(s). Number y portion of the SAS,cesspool or privy is below high ground water elevation. e �/_ ,Any portion of cesspool or privy is within 100 feet of a surface%Utter supply or tributary to a surface water supply,y portion of a cesspool or privy is within a Zone 1 of a public wel•l. Any portion of a cessp ool orprivy' is within 5 0 feet of a private water supply PP Y 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 n•ell water analysis, plerformc.` DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates t::... ;ne well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria arc triggered.A copy of the analysis must be attached to this form. (Yes/No) The system fails. I have determined that one or more of the above failure criteria exist as described in 310 C?va 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. La be Systems: To be considered a large s-_Stem the System must serve a facility vita a design flow of tt) tH)i) gpd to IS,Qgi) gpd. You must indicate either"yes" or"no" to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no the system is within 400 fe-2-t Of a surface drinldn;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 1I 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 la-,"'e 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 15.304. The system owner should contact the appropriate regional offic of the Dem m accordance with 3 10 CivtR partment. i Page 5ofII OFFICLAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM E NSPECTION FORM PART B CHECKLIST Property Address: Q Owner- Datc of Inspcction: / Check if the fofiowin�have been done. You must indicate`�•es" or"no" as to each of the folloMnz: Yes o Pumping information was provided by the o%�-ner,P , occupant, or Board of Health ere 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? U th .w ( they.were not avai]able 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 stistem 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 es or tees, material of construction, dimensions,depth of liquid, depth of sludge and depth of scum _ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems The size and location of the Soil Absorption System (SAS) on the site has been determined based on: Yes n Existing information. For example, a paan at the Board of Hcalth. Determined in the field(if any of the failure criteria related to Pan Cis at issue approximation of dis=cc is unacceptable) (310 CNN 15.302(3)(b)l Page 6 of 1 1 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORINLATION Property Address: /t7 Owner: Date of Inspe 'on: /S RES ID E NTLaI. FLOW CONDITIONS Number of bedrooms (design):2— Number of bedrooms (actual): DESIGN flow based on 310 CAR 15.203 (for example: 110 gpd x' of bedreoms): -� Number of current residents: f Does residence have a garbage grinder(yes or no):/t19 Is laundry,on a separate sewage system ves or no):AV [if ves separate inspection required] Laundry system inspected(yes or no): _ Seasonal use: ves or no : Water meter readings, if available (last 2 years usage (gpd)): Sump pump(yes or no): Last date of occupancy: Ck 1.�,c H CO tiLN1ERCIAL/LYD USTRIAL Type of establishment: Design flow(based on 310 CNIR 15.203): gpd Basis of design flow(sea(s/persons/sgft,etc.): Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no):— Non-sanitary waste discharged to the Title S system(yes or no): — Water meter readings, if available: Last date of cc::11pancy/use: OTHER Pumping GENERAL LNFORtiL-\TION p eD Records Source of information: Was system um part pumped as of the in ction(yes or no): If yes, volume pumped:_gallons --How was quantity pumped determined? Reason for pumping: T 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), Tight tank _Attach a copy of the DEP approval —Other(describe): Approximate age f j�I cpmponents, date installed(if known) and source of info Lion: l k7-if N �9 9' � /&-e v e,- ut re c� Were sewage odors detected when arriving at*he site(yes or no):�ti0 rabc i ai � i OFFICIAL INSPECTION FORM— NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYST.[EM INFORMATION FORMAON (continued) Property Address: // ��/ld l � / g,,, ✓yr �> � ©�6 Owner: Date of Inspection: BUILDING SEWER(locate on site plan) Depth below grade: Materials of constructioncast iron L" 00 PVC_other(explain): Distance from private water supply well or suction line: Comments (on condition of joints,venting, evidence of leakage, etc.): SEPTIC TA,Yh.Zoocate on site plan) Depth below grade:�_ 1/do — ke Material of construction:_concrete_metal_fiberglass—polyethylene —other(explain) If tank is metal list age:— Is age confirmed by a Certificate of Compliance (yes or no): —(attach a copy of certificate) Dimensions: Sludge depth: Q AO — Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: O A, -� Distance from top of scum to top of outlet tee or baffle: O Distance from bottom of scum to botto o outlet t orffl bae: How were dimensions determined: /'o e- PG Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet rove evidence of leaknge,etc.): H, of NUT �PtC=�G / Ain/, ors. e/ 7�e1 /h �7OOc� C�H , GREASE TRAP: /!/(locate on site plan) Depth below grade:— Material of construction:—concrete_metal fiberglass_polyethylene other (explain): — — Dimemions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments (on pumping recommendations, inlet and outlet tee or baffle condidon, structural irate tv, Liquid levels as related to outlet invert,.evidence of leakage,etc.): ' Page 3 of I 1 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C n SYSTEM INFORNIATION(continued) Property Address: Owner: /9� v✓- Date of Inspection: i� 03 TIGHT or HOLD LNG TANK:/l/ (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Nfaterial of construction: concrete metal fiberglass_polyethylene other(explain): Dimensions: Capacity: gallons. Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments (condition of alarm and float switches, etc.): DISTRLBG ijU"' 10O`;: t/ (Lf present must be opened)(locate on site plan) Depth of liquid level abov_ invert: j/I(� k-e;' Comments (note if box is 1Q•.cl of;d distribudon to outlets equal, any evidence of solids carryover,an evidence of le ge into or out of box, etc.): /S le'e/. No .Sn/�s• /1�-o Les 4-f PUP CHAIti>B E R: 1 i � ovate 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.): ragc y of t t OFFICIAL Il`1SPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM LNSPECTION FORIM PART C SYSTEM LYFORINUMON (continued) Property Address: I�� ��rnT' Ge �� 6 3� Owner: �.-2r�- Date of Inspection: SOIL. ABSORPTION SYSTEM (SAS): (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number: 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 fail etc.): ure, level of ponding,damp soil,condition of vegetation ,., CESSPOOLS: (cesspool must be pumped as part of i'nspectio�Pocate on site plan) . Numbcr and configuration: :. Depth—top of liquid to inlet invert: ixpun of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegeuation. etc.): PAY: (Iocate 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.): OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORINT PART C SYSTEM LYFORttiI-kTION (continued) Property Address: �( ���i�� -�C Owner: Date of Inspection: /5 SKETCH OF SEWAGE DISPOSAL SYSTEitiI Pro"ide a sltetch of the sewage disposal system including tics to at least nvo benchm�ccs. Locate all wells within 100 feet. Locate where public water supply�en rsPemantthe bu lding, or FI-0&4 T I 1 5 r5 ' J?• ' . n � 5 5 t,f �� �,//•1 22 Page I I of 11 OFFICIAL INSPECTION FORD[ — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORIM PART C n SYSTEM LYFORitiIATION (continued) Property Address: Owner. Al P� Date of Inspection: SITE EX--tit 5tope Surface water Check cellar Shallow wells Estimated depth to ground water /O feet Please indicate (check) all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked. date of design plan reviewed: Observed site(abutting property/observation holc within 150 feet of SAS) Checked with local Board of Health-explain: Checked with local excavators, installers-(attach documentation) Accessed USGS database-explain: You mu describe how you /established the high ground water elevation: �AN c�Gf N /Q lt�lO e�O 4 n 0 I �OF L / r If o 7e 1 Y � � ��.v ��i� . ,, ' � I � t ��� � . c COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORVvI — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A / r ` CERTIFICATION Property Address: / e ///t7 7L Od6312 Owner's Name: % RECEI�/ I o P -w, Owner's Address:_ / / , F/7-1. i Date of Inspection: /, p3 APR 2 8 Z003 TO Name of Inspector: (please print) GlY p Ste/ HELTh1tE'.PT. Company Name: / J,16 �C Mailing Address: O ,t?ox �8r Telephone Number 014 — f CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP' approved system inspector pursuant to Section 15.340 of Title 5 (310 CyIR 15.000). The system: v Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: a The system inspector shall submit a copy of this inspection report to the ApprovingYuthornity (Board of Health or DEP) «ithin 30 days of completing this inspection. If the system is a shared system or has a design Ilo%v of 10,0t)U gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. Notes and Comments ****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- Pagc 2 of l 1 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEI-I INSPECTION FORM PART A CERTIFICATION (continued) Property Address: o d� Owner: Date of �7 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. S . m Passes: I have not found any information which indicates that any of the failure criteria described in 310 CMR 13.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditio nally Passes: ZOne or more system components as described in the"Conditio nal Pass" section need to be replaced or repaired.The rystem, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Answer yes, no or not determined(Y,N,NDj in the for the following statements. If"not determined" please The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltradon or ex:filtradon 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 lealdng and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced NU explain: The system required pumping more than 4 times a year due to broken or obstructed pi (s). Thc system «ill pass inspection if(with approval of the Board of Health): pe broken pipe(s)are replaced obstruction is removed ND explain: Pagc 3 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTErii VSPECTION FOIM PART A / CERTIFICATION (continued) Property Address: Cep^ v�/T, :.0 Owner: Date of Inspe ion: C. FFuurther Evaluation is Required by the Board of Health: /r Conditions exist which require further evaluation by the Board of Health in order to determine if the s,-stem is failing to protect public health_ safety or the environment. I. Svstem will pass unless Board of Health determines in accordance with 310 Civ1R 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. Svstem 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 sti•stem (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 suppl}. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance "This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm_ provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: I Page d of 1 l OFFICLkL INSPECTION FORM— NOT FOR VOLUNTARY ASSESS' 1ENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: z&©y- g� Owner: Date of Inspe ion: D. System Failure Criteria applicable to all systems: You must indicate"yes" or"no" to each of the following for all inspections: Yes 1 Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool t/ 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 ��esspool iquid depth in cesspool is less than 6"below invert or available volume is less than '/:day flow Rcquired pumping more than t times in the last year NOT due to clogged or obstructed i /of times pumped p pe(s). Number ,Any portion of the SAS,cesspool or privy is below high ground water elevation. _ ,Any portion of cesspool or privy is within !00 feet of a surface�4'a supply or tributary to a surface water supply. y 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, performe ' DEP certified laboratory,for coliform bacteria and volatile oceanic compounds indicates t::... :ne well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria �j arc triggered.A copy of the analysis must be attached to this forma v �(Yes/No) The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CLIR 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 systerr, the system must serge a facility with a design flow of 10,o4p) gpd to 15,Qt)t) gpd• You must indicate either"yes" or"no" to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no the system is within 400 feet of a surface drinking water supply _ the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well If you have answered"yes" to any question in Section E the system is considered a significant threaL or answered "yes" in Section D above the la," 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 CLfR 15.304.The system owner should contact the appropriate regional office of the Department. Page S of l I OFFICLXL INSPECTION FORM— NOT FOR VOLUNTARY ASSESSiNIENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: oa Owncr• �l Date of inspection: Ir Check if the following have been done. You must indicate`ves" or"no" as to each of the following: Yes o Pumping information was provided by the owner, occupant, or Board of Health _ ere any of the system components pumped out in the previous two weeks Has the system received normal flows in the previous two week period t/ 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 th ,were no/ ( cy t available note as N/A) L/ Was the facility or dwelling inspected for signs of sewage back up Was the site inspected for signs of break out Were all sv t s em 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 es or tees, material of construction, dimensions,depth of liquid,depth of sludge and depth of scum _ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems The size and location of the Soil Absorption System (SAS) on the site has been determined based on: Yes n 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 dis=cc is unacceptable) (310 CMR 15.302(3)(b)j - Page 6 of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTENI INSPECTION FORNI PART C SYSTEM INFORMATION Property Address: �jjl/�1✓ Owner: Date of Inspe 'on: /S RESIDENTIAL FLOW CONDITIONS Number of bedrooms(design): Number of bedrooms (actual):-3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x-of bedrooms): Number of current residents: f Does residence have a garbage grinder(yes or no):&''0 Is laundry on a separate sewage system 'cs or no):/W (if yes separate inspection required] Laundry system inspected es or no): Seasonal use: (yes or no): Water meter readings, if available (last 2 years usage(gpd)): Sump pump(yes or no): /9/,0 Last date of occupancy: C,// .l CONfIi IERCIALr NDUSTRUL Type of establishment: Design flow(based on 310 CNIR 15.203): gpd Basis of design flow(seaWpersons/sgf,etc.): Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no):— Non-sanitary waste discharged to the Title 5 system(yes or no): _ Water meter readings,if available: Last date of ec::!lpancy/use: OTIUR he): Pumpin Records GENERAL LNFORNUTION b Source of information: Was system pumped as part of the�inction(yes or no): IVO If yes,volume pumped:_gallons --How was quantity pumped determined'? Reason for pumping: T OF SYSTEM Septic tarty distribution box, soil absorption system _Single cesspool _Overflow cesspool _Privy _Shared system(yes or no) (if yes, attach previous inspection records. if any) _hmovative/Alternative technology. Attach a copy of the current operation and maintenance contact(to be obtained from system owner)' Tight Link _Attach a copy of the DEP approval —Other(describe): Approximate agepf,�I c9mponents, date instilled(if known)and sours of info don: sl�e el /99d- (fiver usp s-�ew► is ye�.� Were sewage odors detected when arriving at*he site(yes or no):_�f/O Page 7 of 1 l OFFICIAL INSPECTION FORM— NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTE1i INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: Date of Inspection: BUILDING SEWER(locate on site plan) /, Depth below grade: Materials of cons trurtiocast iron _ 00 PVC_other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage, etc.): SE • ✓SEPTIC TANK._(locate on site plan) Depth below grade: -2 11 d o — zl'9"A e Material of construction:_concrete_metal fiberglass_polyethylene —other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no): _(attach a copy of certificate) Dimensions: 6 A //L? Sludge depth: O /4-0 Distance from top of sludge to bottom of outlet tee or baffle: 0 do s/y Scum thickness: p f Distance from top of stun to top of outlet tee or baffle: O Distance from bottom of scum to botto 0 outlet tg�or baffle: How were dimensions determined: .e e_ X4 y �� G Comments (on pumping recommendations, uilet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invertl evidence of leakage, etc.): _ ���"�/�t �s eo ne G / c�✓,� 40��el—Cp P7 GREASE TRAP:/!/(locate on site plan) Depth below grade:_ Material of construction:_concrete_metal fiberglass_polyethylene other (explain): — — Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): Page 8of it OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C / n SYSTEM INFORMATION(continued) Property Address: / /� E11OI Owner: '4 �v- Date of Inspection: 15 03 TIGHT or HOLD LNG TAN K:4 (tnnk must be pumped at dme 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(yes or no): Alarm level: Alarm in worldng order(yes or no): Date of last pumping: Comments (condition of alarm and float switches, etc.): DISTRLB0-10- (if resent must ust be opened)(locate on site plan) Depth of liquid level abo�_ invert: i(/� ,-e./ Comments (note if box is lc-.cl u ;d distribution to outlets equal, any evidence of solids carryover,any evidence of le ge into or`out of bo. 'etc.): iS /Q�e� o L �' e� r PUMP CHAMBER: locate on site plan) Pumps in working order Cves or no): Alarms in working order(yes or no): Comments (note condition of pump chamber,condition of pumps and appurtenances. etc.): Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORIN ATION (continued) Property Address: //W - /' /- Owner: 2v- Date of Inspection: SOU- ABSORPTION SYSTEM (SAS): (locate on site plan,excavation not required) If SAS not located e.`cplain why: Type �{ leaching pits,number:— / / ���v c4 vim,f p e f C v 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.): ,� G CESSPOOLS: (cesspool must be um d as r pumped part of inspec tioii��locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Dept of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil, signs of hydraulic failure, level of ponding condition of vegetation, etc.): PRIVY' �ut'I/ onsite plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation,etc.): OFFICIAL INSPECTION FORM— NOT FOR VOLUNTARY ASSESSME SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOEtMNTS PART C • SYSTEM INFORtti1ATION (continued) Property Address: GeH v4 Owner: c°i �6 3"? � � Date of Inspection: /S SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two peent reference benchmarks. Locate all wells within 100 feet. Locate where public water supply the bu ldin.g. or Frot-i4 v �y r r J 2 ,1 1� ^) r �� -cz y Page Hof11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM LNFORINIATION (continued) Property 'EI C4 llqd Owner._ -e Date of Inspection: s�p3 SITE EXAM Scope Surface water Check cellar Shallow wells Estimated depth to groundwater l0 f eet Please indicate(check) all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with local excavators, installers-(attach documentation) Accessed USGS database-explain: , You mum describe how you gstablished the high ground water elevation: ti $� f-O /0 /f/D rO k n c�b✓c �^ loca ;170 Z, 21 vt 6vci'7C I OF 9 r C r ' / TOWN OF BARNSTABLE LOCATION �l i ®7 RD. SEWAGE # ?C C VILLAGE ASSESSOR'S MAP & L Tg^ t i tl INSTALLER S NAME PHONE NO._�a� SEPTIC TANK CAPACITY IS't9® LEACHING FACILITY:(type)�p� 10�:�4�or,3 (size) 4 NO. OF BEDROOMS _3.PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER 0. DATE PERMIT ISSUED: ' — Qj) DATE COMPLIANCE ISSUED: .>e'— / A cp ?0 VARIANCE GRANTED: Yes No I i I 3 .ra e 14 Its F%lea 7L 2� �� ���- �1, is � ` ,, N�V- - THE COMMONWEALTH OF MASSACHUSETTS 14g BOARD OF HEALTH " -0-------__......OF_— 47TABLE 7............................ 0, for Disposal Works Pustnution Frrutit Appli on is hereby mTade for a Permit to Construct or Repair an Individual Sewage Disposal pp a 4-0-Aef Lie............... .........L.-talou.....1. . 11,11,11cW�111�-1- "I',,-,,,-,-,-----,...............Llt.r..........1.1............................. dre or Lot No. ...................... ................. ........................................ ......................7...................... ............................................... ner / Address ............................. .... ..... ........................ ...................................................... ...17r....... Installer Address Type of Building Size Lot 41:R2.... . feet Dwelling—No. of Bedrooms......................3...................Expansion Attic Garbage Grinder Other—Type of Building ............................ .No. of persons..................__._...... Showers Cafeteria aOther fixtures . ...................................................................... < --------------------------*--------------------- -------------- Design Flow.......................5 . -gallons per person per day. Total daily flow._._........_.__.______4 A* W "?, 11.1..........gallons. �4 Septic Tank—Liquid*capacity .TCO'gallons Length................ Width....._._ ..... Diameter__-_.........._. Depth--_j---------- Disposal Trench—No..................... Width......Z&........ Total Length.__... Total leaching area----q&_ --sq. ft. Seepage Pit No..................... Diameter.._..............._. Depth below inlet......._........_... Total leaching area..................sq. f t. Other Distribution box ( .-< Dosing tank ( ) Percolation Test Results Performed bX.&0Vi,.4:AjS......................................... Date....._._.r ..... Test Pit No. 1.....:7-I—__tninutes per inch Depth of Test Pit........1:2 Depth to ground water--—--------------- 4� Test Pit No. 2.....Z......minutes per inch Depth of Test Pit.................... Depth to ground water_AZ,=..A&,3 P4 .................................................................................................................................... 0 Description of Soil...........M55DI.V_V%&...�A tj.p............................................................................................................. U .................................................................................................................... lir ........... W 13E .................... .............................................................................................j _TALLATJ0,N-.AND-,C--E T lTq WP I IFY U Nature of Repairs or Alterations—Answer when applicable......... 9YSTEM--WAS ASTALLED-IN-_ST ..... . ,CC F"TUT ..................................................................................................................'....'QRQAMGF_.T0.PLAg.......................................... Agreement: The undersigned agrees to install the af�edes Ll _t�,z ribed Individual Sewage Disposal System in accordance with the provisions of'L I TL 11 5 of the State S-.ni, r' e— The undersigned further agrees not to place the system in C' a _r 0 s issue operation until a Certificate of Compliance h s L', iss e the board of—health. . .... . ......... . --------------- .................... ....... ApplicationApproved By.................... ....................... . .................... .... ........................... Date Application Disapproved for the following reasons:......................................................................................... ....................... ................................................................................................. ------------------------------------------------------------------------------------------------------ Date Permit No.-....... IssuedL.......... .......... ..................... Date FEs .�....:...... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH OF........ .............. 'y . .w. _.._._......_._........ ..... .------. .............................. Applirtation for Dhipoii al ,ark_ Tonotrurtion ami# Application is-hereby made for a Permit to Construct ( ' Repair ( ) an Individual Sewage Disposal System at: _ - Location-Add s or Lot No. .� � 1 �.......-•------------r-------------- ----------..---------.... ......---------•---•..........----•-........._...-- ner Address - -- Installer Address " irt •'f d Type of Building Size Lot` feet Dwelling—No. of Bedrooms.................,z............--......Expansion Attic ( ) Garbage Grinder ( aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Otherfixtures -------------------•-------------------------------------•-------------------- --`_ _�..., ......_gallons per person per day. Total daily flow.......................`? .+../.....gallons. W Design Flow..................... � g P P WSeptic Tank—Liquid*capacity,,..)..gallons Length.............! Width --_-...... Diameter--.-- ..--..... Depth.....e.......... x Disposal Trench—No..................... Width......Lt ........ Total Length Total_ Total leaching area... a:sq. ft. Seepage Pit No----------------------Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( vy Dosing tank ( ) I p Percolation Test Results Performed by t !-T ...: "::..... { ............... Date......... Test Pit No. 1----- ...minutes per inch Depth of .Test`Pit .___ Depth to ground water .........:....... Test Pit No. 2...... ......minutes per inch Depth of Test Pit.................... Depth to ground water-a,=.. ---•-------------------•---•-------------------------------•---•-••-----•-------•---....------...----•-•-•-------•-.............---_ . . O Description of Soil...........'` , ...1,. x ----------••-------------- W -------•----------------------•-------•--•----••---------------•----- --•----••---••---••-•-------••---••----------••-------------------•••--------------•-----------•-•------------------•---•-----•--- UNature of Repairs or Alterations—Answer when applicable...-............................................................................................ ---------------------------------------------------------- •-----------......-------•-•---••------------•-----------------------------------•--•----------------------------------------....._......---- Agreement: The undersigned agrees to install the afpredes ribed Individual Sewage Disposal System in accordance with the provisions of iITLi� 5 of the State SanLt� e— The undersigned further agrees not to place the system in operation:until a Certificate of Compliance hsue y the board of h th. igne -- -- -----•--- ........................................... .......(........................ Application Approved By.................... �-------------`;-----------•--•-•-•--—------------------------ at 3 �----•-..... De Application Disapproved for the following reasons----------------------------••-------•--------------------------------------------------------•-•-----------..... -•-•------•----------------••-------------------------------......---........-----------.-•--•----------•---•--------•-•--•---•------••----•-------•--•---------------------•--------------------....... ate Permit No......... ... ----- .. . ............. Issued-..........1.�� c c - ..................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 71�Z................... .............................. c� Tntifirate laf Bunt li�anr�e THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed (der Repaired ( ) bY---------•--•------•-•--•..................................................................•-•-----------------.._...........--------------------------...................------------•----.....-•-- _LL Install at......... C 3� S.:..1_�4- `......--- c. {,.r')), ,�.......................................................................................... has been installed in accordance with the provisions of TITIE 5 of The State Sanitary Cod as described in the application for Disposal Works Construction Permit No.�_ems•-_----- .jam... dated....I--_ bLb)a Sz.................... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY.DATE................................................................................ Inspector.................................................................................... THE COMMONWEALTH OF MASSACHUSE1�T±TSENGINEER pp UST BOARD OF HEAIL:T�,I;LLATION AND CERTIFY IN TEM WAS INSTALLED IN S T F' .D.WA.....................oh �' .A1.. t �, b CC A lVL1E TO FLAN. N ---------------- ` FEE.---.--•-•--.......... Bigivii al Workii TFAIn#rnr#uan autit Permissionis hereb granted.............................................................................................................................................. to Construct ( Repair ( ) an Individual Sewage Disposal System atNo. �. �:{: f I G=7 = '---------` --•` C_aa --'-NLt(.lj -------•-••------------------------•-----------------------•---......---... Street _ - as shown on the application for Disposal Works Construction Permit 2.............................a..,i . Dated......!..<?12C/'.,. ............ ............................................................ Board of Health DATE.............. -----•----•-•-•--•-•-------------- FORM 1255 HOBBS & WARREN, INC., PUBLISHERS TOWN OF BARNSTABLE LOCATION j���®1 kqD . SEWAGE # ?d -y8a i VILLAGE � �� ''�� ASSESSOR'S MAP & LOT INSTALLER'S NAME & PHONE NO. ri � � *���: c.1�CS• SEPTIC TANK CAPACITY ►S'0d LEACHING FACILITY:(type)4� fb,4,sS-,> - (size) NO. OF BEDROOMS _PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER DATE PERMIT ISSUED: I - ' qj) DATE COZIPLIANCE ISSUED: I VARIANCE GRANTED: Yes No 14 PF-I j I { t , r f l' .. : i l JL -------------- CP ir AA ' ,t (1 i AiI � }. VIV ;r 7A , 3 . N ASSESSORS MAP 228 PARCEL 198 1. DATUM IS NGVD (RM 16) 2. PORTION OF CENTERVILLE RIVER FLOOD ZONE: A10 EL 11, B AND C Locus SHOWN IS FROM BARNSTABLE GIS MAP 0 LOCATION MAP NTS _DGE DRY DITCH #6 PARCEL 198 0.65 ACt UPLAND `-1.27 ACt WETLAND / A 47 WORK LIMIT LINE OF I STAKED HAY 31� I 3.63 BALES/SILT FENCE +1 .78 OPEN WORK FENCE OR OTHER PHYSICAL 50 0' MARKER TO REPLACE SEDIMENT CONTROL AT ' 24.83 COMPLETION OF Ip GRADING AND Q 22. 4 Ip LANDSCAPING Q + \+24.01 �� Ip IQ 20. 5 I 24.37 I� +2130 p +24,69 I� Ip +24.35 *UNDER DEP DEFINITION OF / I_z 19. 9 COASTAL BANK, 92-1 � SIN LE PT. 4,52 o' OA TA B NK I +24.15 +21. ° / Ip 3.98---- 8. 5 12% .4 2 i +21, 4� 69 20 I p 5 16 h +19 EXIST `/ / 25.86 . 7% 2 13 FNDN. TF 28.1 0 -4�25.92 Q.P:... 18.4 0.8 \ 0 i 211. #3 1 # + .31.59 +26.66 1109 1 * 6.08 +2 .52 �21. CIE #2 10.13 / \� 22,40 + .52 r, �0 +23,8 14. 5 \\.a% 19.0 o C. +1 .20 6 .98 EXIST. LEACHING 10.89 14.3 S`'� FACILITY #1 \ (APPROX \ 383.10' LOCATON) A CONSISTS OF 4 FLOW 0 DIFFUSORS WITH 4' STONE 1513 1 `��'\ ALL AROUND \ PROP 10 x 16 DECK 0 \ A 61, 10. 7 �F`9.51 1 D St\ B 4Q0.2 d .08 f\ E 12.02 OF #171 ELLIOTT ROAD 2 IN THE OWN OF: POND (CENTERVILLE) BARNSTABLE PREPARED FOR: TOBY ALGER 30 0 30 60 90 SCALE: 1" - 30' DATE: APRIL 22, 2002 REV. 5 15 02 FENCE = I 'mncnum 6urolFul .._I...i.._.FulmvBlcapecXmmm.wmv6Rapec�uaryac�..1-._i.....j... � a4110 61ID91cuodaw a4l awoa>q , auolttlwomryw wou>tal�wda�xro LL 606E 806 l09 aVW'cpn6fiH•bbLL b i d 6,revua slu>um>ov>saHl to '�ft..('a��inaa.�ua7 !-...� jpjauapjsa��• - aowld>n°w]saminsaoo aouonasuoo .._i.....1.......... ..!._..�.._.:...:J.. !..._�.._ ZO/G Z/b suvjd uol.}vv-tsuv�7 i- qllm6uro»ao,H�+omnasuoe,o bo.••� L�ol _i ! u81s�p Bulppnq�auatssodaid_`.....:.// \\'.. a o/�t/b sublsa�iCwulwl as ° luaw»uawu,m a4l ol.o!d.>u6pap ayi f GI- .I I V I L I ..I.....,.... i I 1 •j d )o uopu>]i.ag1o114Brom>quaga r. qua-/P..>s>Hi uo Paula W.°6.) � � O 7q7�* �sa{dl7ossy-'aIP]'�i N-Fauua-III m/pun'suoKu>wro tabu aH]ul - � �JV'1 ....i i 'i �i : : , , , r. ...j.... 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