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HomeMy WebLinkAbout0423 ELLIOTT ROAD - Health 423 ELLIOTT ROAD, CENTERVILLE A= 227108 rirr Sir ® UPC 12534 No.2 3__R HASTINGS, MN _ h 2 DATE: 3/30/98---- +, a PROPERTY ADDRESS:_-435 Elliot Road �7 a Centerville,Mass . l 6 O ------------------------ 02632 ------------------------ On the above date, I inspected the septic system at the above address. This system consists of the following: 1 . 1 -1000 gallon septic tank. 2 . 1 -Distribution box. 3 . 2-1000 gallon precast leaching pits . Based on my inspection, I certify the following conditions: 4 . This is a title five septic system. ( 78 Code ) 5 . The septic system is in proper working order at the present time. 6 . Diistribution box is under the asphalt driveway could not gain access . Would rec : that this be located and a- cover brought to grade. The tank & pits have covers to grade. S I G N AT U R Name:- J ._P. _Macomber-Jr. _____ Company:Joseeh PJ_ Macomber & Son, Inc. A d d r e s s:__Box—EzCz______------ w '� AP� 9 199� 632-0066 �pyVNOFBARNS�ABEE -- HEAISHDEPS. % . Phone: 508-775-3338 ____-- ®1 , 6 A THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY JOSEPH P. MACOMBER & SON, INC. Tan ks-Cesspools-Leachflelds Pumped & Installed --- Town Sewer Connections P.O. Box 66 Centerville, MA 02632-0066 775-3338 775-6412 P1. COMMONWEALTH OF MASSACHUSETTS :u EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS s DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET. BOSTON, NIA 02108 617.292-5500 WILLIAN1 F.WELD TLI DY CO Govcmor Sc:rcr ARGEO PAUL CELLUCCI D.-\V!D 9 STRL Lt.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM COmmISSIC PART A CERTIFICATION Property Address:435 Elliot Road Centerville MA Address of Owner: Date of Inspection: 3/3 O/9 8 (If different) Name of Inspector: ber Jr. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000) Company Name: J.P.Macomber & Son Inc . Mailing Address: Box 66 Centervjlle,Mass_ 02F32 Telephone Number: CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reponed below is true acciratr and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper iurc-,on 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: C / 2( ! Date: The System Inspect 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 god or greater, the inspector and the system o�vrk r shall submit the repon to the appropriate regional office of the Department of Environmental Protection. The original should be sent to r,e sys:em own and copies sent to the buyer, if applicable, and the approving authority. INSPECTION SUMMARY: Check A, B, C, or D: AI SYSTEM PASSES: I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 C,AR 15 30: Any failure criteria not evaluated are indicated below. COMMENTS: _ BI SYSTEM CONDITIONALLY PASSES: ti"ri One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The sy>t?m, up( 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 21b The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Cer.ii,cale of Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of (re Insxction, the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or ex=fdtra:*o, or tar• failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming se:):,c tank as approved by the Board of Health. (revised 04/25/97) Page 1 of 10 DEP on the World Wide Web: http.1twww.magnet state.ma us/oep 0 Printed on Recyded Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORNt PART A CERTIFICATION (continued) A' Properly Address: 435 Elliot Road Centerville,Mass . Owner: James Sweeney Date of Inspection: 3/30/98 B) SYSTEM CONDITIONALLY PASSES (continued) &.f6 Sewage backup or breakout or high static water level observed in the distribution box is due to Droken or pipets) or due to a broken, sealed or uneven distribution box. The system will pass inspection if ;with apprC','a. Board of Health). Describe observations: broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced tj The system required pumping more than four times a year due to broken or obstructed pipe s) The system .v I .,,s inspection if(with approval of the Board of Health): broken pipets) are replaced obstruaron is removed C1 FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: 4jjL Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing .o wo ect ine public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONIN'C In A �t--,N R WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or prry is within SO feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETER�Al�ES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETI' AND THE ENVIRONMENT: XZ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet to a suriace �a.er s.. 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 pjbllc eater —I The system has a septic tank and soil absorption system and the SAS is within 50 feet of.a pri ate �,a:er The system has a septic tank and soil absorption system and the SAS is less than 100 feet bu. 50 feel or mor_ fr_,r-. a private water supply well, unless a well water analysis for coliform baaena and volatile organic compounds n_i;Xes that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen ,s cc_a to or less than 5 ppm. Method used to determine distance Z.1/t (approximation not valid) 3) OTHER (revised 04/75/57) Page 2 of 10 ` SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOR.',ti PART A CERTIFICATION (continued) rM Property Address: 435 Elliot Road Centerville,Mass . Owner: James Sweeney Date of Inspe c"on:3/3 0/9 8 DJ SYSTEM FAILS: You must indicate eft- er "Yes" or "No" as to each of the following: -fL1) 1 have determined that the system violates one or more of the following failure crilefia as defined in IS.,^; for this determination is identified below. The Board of Health should be contacted to determine wna'. will oe nece�s.— the failure Yes No Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. j} Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or c ogt;e o' cesspool. Static liquid level in the cJstribution box above outlet invert due to an overloaded or clogg?c or cessao:' CAI,# )V7A e OX? Liquid depth rn+esspeet is less than 6" below inven or available volume is less than lit da, iio- Required pumping more than 4 times in the last year NOT due to clogged or obstructed piG-'(s) Number of times pumped 6 Any portion of the Soil Absorption System, cesspool or privy is below the high ground�aler eleval,on Any portion of a cesspool or privy is within 100 feet of a surface water supply or tribuiarY :c a surface na:Er s ;: 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 prisale eater -t- �c acceptable water quality analysis. If the well has been analyzed to be acceptable, anach copy of well �a:er ar.a for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E] LARGE SYSTEM FAILS: You must indicate either "Yes" or "No" as to each of the following: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater (Large System) and the system s a s,g,,f,Cj-: ',. _„ io 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 I& the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area • IWPA) or a mapper' Zo-e 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 trea!m?--t requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for funher rnformat,on tr•v1.•d of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B u CHECKLIST c` Property Address: 435 Elliot Road Centerville,Mass . Owner: James Sweeney Date of Inspection: 3/3 0/9 8 Check if the following have been done: You must indicate either '.Yes" or "No" as to each of the following: Yes No _ Pumping information was provided by the owner occupant, or Board of Health. None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recent y or as part of this inspection. As built plans have been obtained and examined. Note if they are not available with N/A. _ The facility or dwelling was inspected for signs of sewage back-up. The system does not receive non-sanitary or industrial waste flow. The site was inspected for signs of breakout. _ All system components,.4kluding 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 con&ion of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. — The size and location of the Soil Absorption System on the site has been determined based on: The facility owner (and occupants, if cUfferent from owner) were provided with information on the proper maintenance of Sub-Surface Disposal System. Existing information. Ex. Plan at B.O.H. _ Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) [15.302(3)(b)J (revised 04/25/97) Pegs 4 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 435 Elliot Road Centerville,Mass . Owner: James Sweeney Date of Inspection: 3/3 0/9 8 FLOW CONDITIONS RESIDENTIAL: Design flow: 'YVd g.p.d./bedroom for S.A.S. Number of bedrooms: Number of current residents: - Garbage grinder (yes or no):aZ Laundry connected to systep (yes or no): Seasonal use )yes or no): 7`GS _ �q Water meter readings, if available (last two (2) year usage (gpo): X �3�7 Sump Pump (yes or no): !Q'9p '��" ;W46't' -6 Last date of occupancy: iT COMMERCIAUINDUSTRIAL: Type of establishment: ;i ¢ Design flow: �IA allons/day Grease trap present: (yes or no)A)A Industrial Waste Holding Tank present: (yes or no)A/ Non sanitary waste discharged to the Title 5 system: (yes or no)v__'� Water meter readings, if available: d2 _ AM Last date of occupancy:��t OTHER: (Describe) Last date of occupancy: A)14 GENERAL INFORMATION PUMPING RE ORDS nd source of in rma ion: _ System pumped as part of inspection: (yes or no) y If yes, volume pumped: Lb allons / _ Reason for pumping:,��L+/�! .7//h1� ,G11�7G✓!'ff,or TYPE OF SYSTEM _-4--'Septic tank/distribution box/soil absorption system J_ Single cesspool t Overflow cesspool Privy Shared system (yes or no) (if yes, attach previous inspection records, if any) I/A Technol gy etc. Copy of up to date contract? Other /� APPROXIMATE AGE of all components, date installed (if known) and source of information: Sewage odors detected when arriving at the site: (yes or no) (revised 04/25/97) P&y• 5 of 10 it SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 435 Elliot Road Centerville,Mass . Owner: James Sweeney Date of Inspection:3/30/98 BUILDING SEWER: (Locate on site plan) Depth below grade / Material of construction: _ cast iron Z 40 PVC _ other (explain) Distance from, rivate water supply well or suction line AW D ameter #1 Comments: (condition of joints, v nting, evidence f leakage, etc.) SEPTIC TANK:lvllpp"V-5� (locate on site plan) Depth below grader material of construction: /-115oncrete _metal _Fiberglass _Polyethylene _other(explain) if Lank is metal. list age 4 10 Is age confirmed by Cenificate of Compliance 1/ (Yes/No) D,mensi0ns: b � Sludge depth: CJ Distance from top o�udge to bosom of outlet tee or baffle: Scum thickness Distance irom top of scum to top of outlet tee or baffle: Distance from bonom of scum to bonW of outlet tee or baffle._ How dimensions were determined: •i Comments (recommendation for pumping, conditio of inlet and outlet tees or baffles, depth of liquid level in relation to outle. inven, integrity, evidence of leakage, etc.) � ' , r /' C > GREASE TRAP: e— (locate on site plan) Depth below grader Material of con struct ton rL-4concrete,(Al metaliVAFiberglassV4 PolyethyleneiAother(explain) Dimensions: .(I� Scum thickness. Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bosom of outlet tee or baffler Date of last pumping A&4— Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outle. raven, strvc._(�. integrity, evidence of leakage, etc.) — SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORh1ATION (continued) ' Properly Address:435 Elliot Road Centerville,Mass . 02632 O"ne" James Sweeney Date of Inspection: 3/30/98 TIGHT OR HOLDING TANK:Z&y,(Tank must be pumped pnu: to, or at time, of inspection) (lou:e on we plan) Depth glow grade �f1 malenal of construct,orrWAconcrele4/• _metal AFiberglasstAPolyethylene,(/Lother(explain) Ala D1men$1onS .U,4 Capac,^v />A gallons Design ilo- V,* gallons/day Alarm te.el Alarm in working orderAl-4 Date of ore%-ous pumping. _V4 Comments (c Onc,t,cn of nle( tee. condition of alarm and float swathes, etc ) DISTRIBUTION BOX:�� tIOca:e ;,n s,:e plan) Deoln c I c.,d level above outlet invert w'C"V'r 7-0 bO P'-k yd)7-5 lly4 l l � �t�v k c- YYf/ka), Commer:s (note i level and distribution is equal, evidence of solid carryovr evidence of leakage into or out of oox, e;: �' _ i� ,• c' i 06, GZ PUMP CriA.»BER:Akl,"L (loute cn s,:e plan) Pumps r „orking order: (Yes or No)'W-114 Alarms ,n .•orking order (Yes or No)�.41 COmmer..:s (note corc,tion of pump chamber, condition of pumps and appurtenances, etc.) uyl�G•' :�rt�! .�^ 1 fS AJO 7 ,Di`GSP,.�y7' ___ —__ ) of 10 r • SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 435 Elliot Road Centerville,Mass . Owner: James Sweeney Date of Inspection: 3/3 0/9 8 / SOIL ABSORPTION SYSTEM ;locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: Type: leaching pits, number: leaching chambers, number: leaching galleries, number: a leaching trenches, number,length: leaching fields, number, dimensions: overflow cesspool, number:a Alternative system: I7,d � Name of Technology: 7 M /O e- Comments: (note condition of soil, signs of h draulic failure, level of ponding, con ition of vegetation, etc.) Sn► S SrD a, > C CESSPOOLS: (locate on site plan) Number and configuration: ,IVA r Depth-top of liquid,to inlet inven: A114 Depth of solids layer: A414 Depth of scum layer: AA Dimensions of cesspool: /7'A Materials of construction: Indication of groundwater: /U09 inflow (cesspool must be pumped as part of inspenion) _ G /J S i4l^L .1-S T �/,1y'd sNAv,?' Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) -E'i 3 PRIVY: 4&�tt'� (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.) (r•visod 04/35/97) P4g• 9 of 10 r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORm PART C SYSTEM INFORMATION (continued) Properly Address:435 Elliot Road Centerville,Mass . O»ner: James Sweeney Date of lnsaection: 3/30/98 SKETCH OF SEWAGE DISPOSAL SYSTEM: inc:uoe ties to at least two permanent references landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) i 1 / C- t 0A --- — N / 0 . h' (Y"l." ci/25/97) P.q• 9 of 10 SUBSURFACE SEWAGE DISP, t SYSTEM INSPECTION FORM ✓ SYSTEM INFOI. :iON (continued) ' Property Address: 435 Elliot Road Centerville,Mass . Owner: James Sweeney Date of Inspection: 3/3 O/9 H r Depth to Groundwater Feet Please indicate all the methods used to determine High Groundwate"Elea:ion: Obtained from Design Plans on record I bservation of Site (Abuning property, observation hole, baserrstnhsimp etc.) —�-4etermine it from local conditions Check with local Board of health Check FEMA Maps heck pumping records —'4-- -heck local excavators, installers Use USGS Data Describe in your own words how you established the High Grouncf v/xef-E levation. Must be completed) Used Water Contours Map. Gahrety & Miller Model 12/16/94 (r.vt..e 04/2507) v.5, 1001 10 6 1 ` rs'-e-rr.•-.�ra—s rn-�---T-r.—.— .. 1'..T.,T,�n,,-.--•T-.,�.-n„A.t.,�-,..,+S.,.R!R:•.,,-.,,9.fr,,.-,",T.TR,i,wQ,r•.C...sT', - _- - - '1'OWN OF Barnstable HOARD OF HEALTH 1 SUIISURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART D - CERTIFICATION `- F•••T••,•�••••.♦-T.,1'^.��.7•�n•R.7T,TTST1f]T'.T.T1',r•!.'f�'I,THt��aiR1v1"'TTmR!pT�'C.T+.'1LT1 lsfnnTrmrR SC�Trr+r..r.:-.r r.- r -, -. -TYPE OR PRINT CLEARLY- PROPERTY INSPECTED STREET ADDRESS 435 Elliot Road Centerville,Mass . ASSESSORS MAP , BLOCK AND PARCEL # :9, 7 d�� OWNER' s NAME James Sweebey PART D - CEITIFICATION 1 NAME OF INSPECTOR Joseph P.Macomber Jr. COMPANY NAME J.P.Macomber & Son Inc'.` ' COMPANY ADDRES S Box 66 Centerville Mass . 02632 Street Town or City 5 t a t I t I P_ COMPANY TELEPHONE ( 508 ) 775 - 3338 FAX (508 -490 - 1578 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported is true , accurate , and complete as of the time of :inspection . The inspection was performed and any recommendations regarding upgrade , maintenance , and repair are consistent with my training and experience in the proper function and maintenance of on site sewage disposal systems . Check ne : System PASSED The inspection which I have conducted has not found any information which indicates that the system fails to adequately protect public health or the environment as defined in 310 CMR 15 . 303 . Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form . System FAILED* The inspection which I have conucted has found that the system fails to Protect the public health and the environment in accordance with 'Title 5 , 3.10 CMR 15 , 303 , and as specifically noted o.n PART C - FAILURE CRITERIA of this inspection form . ��jInspector Signature � �t Date One copy of this certification must be provided to the OWNER, the BUYER ( where applicable ) and the BOARD OF 11HAL7'1I. • If the inspection FAILED, the owner or "operator ehall upgrade the ayotem within one year of the date of the inspection , unless allowed or required otherwise as provided in 3.10 CmR 16 . 305 . partd . doc t 11 Q ti S byy 31�v THE CON MONWEALTH OF MA.SSA.CIMSETTS DEPARTMILi NT OF ENVIRONNIENTAL PROTECTION BE IT KNOWN THAT Joseph P. Macomber, Jr. Has satisfied the Department's qualificatigns as required and is hereby authorized to use the title CERT 1 < D TITLE 5 SYSTEM INSPECTOR as provided in 310 CMR 15 .340 and Section 13 of Chapter 21 A of the- General Laws _ Issued by The Depart-ment of Environmenmi Protection . A( tiny{ l)itct(m u( the l (tl wil Uf %V11ci ( ulllinii ( unliul r *vt?v9 7/��G/o8 I; SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Address of property qZ.5 �l.X�� d4&h li, 0A4- 2 Owner's name it Date of Inspection PART A CHECKLIST 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 flow rates during that period . Large volumes of water have not been introduced into the system recently or as part of this inspection. _-k�'As built plans have been obtained and examined. Note if they are not available with N/A. je01*,1rhe facility or dwelli,..; was inspected for signs of sewage back-up. !/ The site was inspected for signs of breakout. _ All system components, excluding the SAS, have been located on the site . VO/The septic tank manholes were uncovered, opened, and the interior bf the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. * Gem AAL AT4aj 0441" f ccAt Y 1he size and location of the SAS on the site has been dete , ined based on existing information cr. approximated by non-intrusive methods. The facility owner (and occupants, if different from owner) were prov_ :.ied with information on the proper maintenance of SSDS. 9 ' � 199v 8 s SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM P7.RT B SYSTEM INFORMATION FLOW CONDITIONS If residential number of bedrooms number of current residents -Al_ garbage grinder, yes or no Xj,S laundry connected to system, yes or no —hfLL seasonal use, yes or no If nonresidential , calculated flow: r Water meter readings, if available: Last date of occupancy GENERAL INFORMATION Pumping e ords a d source of information: qo ri i! g v Z _ System pumped as part of inspection, yes or no if yes , volume pumped_ Reason for pumping: Type of system --- Septic tank/d4sti- `g"*i^^ 'Rem/soil absorption. system Single cesspool m Overflow cesspool Privy Shared system (yes or no) (if yes, attach previous inspection records, if any) Other (e`xplain) Approx?ma5te age'f all components. Date installed, if known. Source of information &yere o IVA NO Sewage odors/detected when arriving at the site, yes or no < O . ra :F SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION continued SEPTIC TANK: �A-Aiia•v-S (locate on site plan) / depth below grade: I f& �J�$ TifZ/VK" G ���, ,c� �iGlL material of construction: concrete metal FRP other(explain) dimensions: X c_S i� X S' 7 4 di{�V /LSU u,l,(,{,i„U y sludge depth -- distance from top of sludge to bottom of outlet tee or baffle scum thickness EK distance from top of scum to top of outlet. tee or baffle CST1,W.4-Tf,0 f distance from bottom of scum to bottom of outlet tee or baffle X Comments: �C O u t•Q f'6 Ctlttit�l. /ns i4 cc�s J/b/E (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leak ge., reco endations or reps}rs, etc. ) ��r�tJ e0.0 DISTRIBUTION BOX: (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, recommendation for repairs, etc. ) PUMP CHAMBER:--NQ (locate on site plan) pumps in working order, yes or no Comments: (note condition of pump chamber, condition of pumps and appurtenances, recommendations for maintenance or repairs,etc. ) '^ 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION continued SOIL ABSORPTION SYSTEM (SAS) :��v ?'�U�V (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: "dy�.F�C. .,.t,6� � �• r ' Srt2a.PiC.e• Type leaching pits and number k �o G lead ' ers number cS f er ]tea r-}i j ryn t ranch„ pib r. ,:gth le ns overflow esspoo,_1 Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation., recommendations for maintenance .or repairs,etc. ) CESSPOOLS (locate on site plan) : number and configuration depth-top of liquid to inlet invert depth of solids layer depth of scum layer dimensions of cesspool materials of construction indication of groundwater inflow (cesspool must be pumped as part of inspection) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, recommendations for maintenance or repairs,etc. ) PRIVY : (locate on site plan) materials of construction dimensions depth of solids Comments: ' knote condition of soil , signs of hydraulic failure, level of ponding, condition of vegetation, recommendations for maintenance or repairs,etc. ) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION continued SKETCH OF SEWAGE DISPOSAL SYSTEM: NO kAQ.&4J LPTA6 WIM00 Ems+ include tie s to at least two permanent references landmarks or benchmarks locate all wel ls within 100' 41 <TOIL C l DEPTH TO GROUNDWATER depth to groundwater method. of determination or approximation: i,. 12�, SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM, PART C FAILURE CRITERIA Indicate yes, no, or not determined (Y, N, or ND) . Describe basis of determination in all instances. If !'not determined", explain why not) Backup of sewage into facility? Discharge or ponding of effluent to the surface of the ground or surface waters? 'y0� ic liquid level in the distribution-'box above outlet invert? Liquid depth in c77 esspool++<6" bel'ow invert pr ava'ilable volume< 1 2 da flow? , / Y N Required pumping 4 times or more -in the last year? number of times pumped IV Septic tank is metal? cracked? structurally unsound? substantial infiltration? substantial exfiltration? tank failure imminent? ' (' Is any portion of the SAS,, cesspool or privy:' fV below the high groundwater elevation? ' ts within 50 feet of a surface water? within . 100 feet of a surface water supply or tributary to a surface water supply? within a' Zone' I of a public well? within 50 feet of a bordering vegetated wetland or salt marsh (cesspools and privies only, not the SAS) ? within 50 feet of a private water supply well? 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 coliforr bacteria, volatile organ corpounds, ammonia nitrogen and nitrate nitrogen. 13 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART D CERTIFICATION Name of Inspector Ralpb Ojala Company Name Down Cape Consulting Company Address 939 Route 6A, Yarmoutbport, MA 02675 Certification Statement I certify that I have personally inspected the sewage disposal system at this .address and that the information reported is true, accurate and complete as of the time of inspection. The inspection was performed and any recommendations regarding upgrade, maintenance and repair are ` consistent with my training and experience in the proper function and mzar,tenance of on-site sewage disposal systems. Chec one: I have not found any information which indicates that the system fails to adequately protect public health or the environment as defined in 310 CMR 15. 303. Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form. I have determined that the system .fails to protect public health and the environment as defined in 310 CMR 15. 303 . The basis for this determination is provided in the FAILURE CRITERIA section of this form. &_ (j?� Inspector ' s Sign ture Date ��_g Original to system owner Copies to: Buyer (if applicable) Approving authority �A 1 No.................. --1�., �• FRic............................... ' TF1E COMMONWEALTH OF�MASSACHUSETTS . . BOARD... OF: HEALTH ation -fur 43hipouttl-AVorks Tonstrurtiun Vrrntit Application is hereby'made for a Permit to Construct ( _ or Repair ( ) an Individual Sewage Disposal System at: u Location-Address or Lot No. ow /�/ Address Installer Address U g ...... .......................__.__.Ex ansion Attic Garbage Grinder et Dwelling—No. of Bedrooms__.____ p ( ) g d Type,of Building Size Lot..�.Cf1. S feel H Other—Type of Building ............................ No. of persons___-------..:_.---_----_-- Showers ( ) — Cafeteria Other fixtures ---------------------- - - . W Design Flow.y...�v`�---_-___. _ __ allons per person pet day. Total dai� flow............. ...................gallon WSeptic Tank—Liquid capacitytilons Length '. Width_. .��. Diameter---------------- Depth,___. --- x Disposal Trench—No- -------------------- Width ----------------- Total Length.................... Total leaching -area.......-------------sq..ft. Seepage Pit No......./--------- Diameter/2-_-_ .____ Depth below inlet..... Total leaching area.-2/-C� - ' z Othef. Distribution box ( Dosing tank � Percolation Test Results Performed-by._._�_,��5._:-/�:���_�-�..1�%F�... Date_t�/,_.F/2f Test Pit No. 1____--_____?minutes per inch Depth of Test Pit...... . _ Depth to ground water._!- ._...... r14 Test Pit No. 2__�_�_minutes per-0 inch Depth of Test Pit_Z!5-0.��. ... Depth to ground water__�51�--_._.. -.---------•--------------- O Description of Soil-------671/_ l0--`*'2 4 ��-' ----------------- �d tom' 27> .•a�,`a_--------------------- ../G i uh...._t�cJ ,C.e 1r-. U Nature of Repairs or Alterations—Answer when applicable''.__,__-_---. s ______________________________________________________________ -----•--•------------------------ -----------------------------------------•--------•---•------------------------------••---------------•----- -•-------•----------------- --------------------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article \I of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Signed...................................................................................... -------------------------------- Date Application Approved By---` J `l� J- ---------- -------------- Application Disapproved for the following reasons:.------------ ------.___-- _--_-- _ _- _ ..-------_----------------------------------------------- r ............ ................ --------•-•------------------------------ ------•---- Permit No. Issued••- . - T ��-r.4 -------------- - -- --: -ate (1 - wd No..---.._'..�-- S� _- t Fmic...�-'..-,.....W....... THE COMMONWEALTH OF"MASSACHUSETTS BOARD OF HEALTH Appliration -for Bhipoml Norbi Tomitrurtion Prrmit Application is hereby'made for a Permit to Construct ( !iJ'`or Repair ( ) an Individual Sewage Disposal System at: , / r Location_Address or fLot No. ... ---- ---- •--------•-------•• -- ..................... r Address. Installer Address ., . r , U Type of Building y,1 y Size Lot..-= 171_ 1;7_�_Sq. f��efft Dwelling—No. of Bedrooms__._--___.__�e_____________________________Expansion Attic ( ) Garbage Grinder (/V� Other—Type of Building ____________________________ No. of persons---------------------------- Showers ( ) — Cafeteria ( ) Q' Other fixtures ....... W Design Flow_____ ?__.______ Mons per person per Py Total daily flow---------- ! __..... _..gallon '- WSeptic Tank Liquid capacity� allons Length Width Width._ Diameter................ Depth:»J�';_... x Disposal Trench—No_ ____________________ Width_-_____- ____:____ Total Length------------_------ Total leaching area.._.--_-__-_--______sq. ft. 1-7 Seepage Pit No--------/--_______ Diameter,�_G�_"_�'_____ Depth below inlet____�_.._..___ Total leaching area.-, _� ' z Other Distribution box ((�)' Dosing tank ( ) i � ��i� .%� '-' Percolation Test Results Perfor'med"'b*. �'�� :�__.../I'_--" <. .. 't`j��__ Date.:/a, Test Pit No. I...nt'M__ ninutes•per inch Depth of Test Depth to ground water...! !Z f—I f� Test Pit No. 2___:�"="_��_minutes per inch Depth of Test Pit../41'"'. Depth to ground water_.•'_�✓-_L�....... •------------------------- --------------------------•-•---- ..............:..............•-------................................. ----------- O . Description of Soilc 7 ,=/_� _ f� -- } d - 45. { w f ------------ ------- ----- -,1'7�.��0--i-. �*-1 --�.�Z,4 'tt-- !__�+___..i = �' ��---`-----•- -•------------- t V Nature of Repairs or Alterations—Answer when applcable..___ __ - ---- ---------------------------------------- ------------- ---------- Agreement: The,.undersigned.-agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article NI of the State.Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Sid-------------------------------------------------------------------------------------- ----•-••-••--•------------------ Date Application Approved By...... ��. ------------------------------- -------------------------•---------------••------•---•--------------------- Date Application Disapproved for the following reasons______________ - ---------____ --=-----•----•-----------•-------------- ------__-•-------------•-•-------___---•--•--•-•-•----•---------•---------------•-----•-•- --•----------------•-•- ? iF Date PermitNo.......................................................... Issued........................................................ 4' a R Date r THECOMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH - . r r (9rrtifirotr� of fI'omtpfiattrr � :�,, THIS T CER"lI , Th he n vidual.Sewage s osal System constructed ( �) or Repaired ( ) by "" F • ---------••••--•••- / Installer J -•- --------- has been installed in accordance with the provisions of Ar I of The State Sanitary Code as described in 'the application for Disposal Works Construction Permit No.... ._, �► 7 .......... - •--�-----•--- dated-�----�---��...... T14E ISSUANCE OF THIS (CERTIFICATE SHALL, NOT BE CONSTRUED AS A GUARANTEE THAT,THE SYSTEM WILL FUNCTION SATISFACTORY. DATE '--- -------- •------------- Inspector THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 7 J.7_.r • ... ,.:....c'`..<<.4"./.tom+..... 0F'....,/ ,.�.,3'-/i rtrr1 K'/.�",.��.:�.�.2..�..1`"y""...... /t+V ..s N o. ai ;t ,. - •..._..__. •----•• a+.• FEE rk .5tru'tt . t Permission is hereby granted_______ . _ ......... ............ _ _______________ to Construct ( e),,.mf'-Repair ( ) an Individual Sewage Disposal stem I t . .. � - ' as shown on the application for Disposat-Works Construction Perrriit� 0 14ited .; ' ---------'7,f......... _-: DATE. .....,�_r".-f...•. oard of Health T . FORM 12HOBBS & WARREN;-INC_.PUBLISHERS EVERETT H . HINCKLEY V 42 STANDISH WAY WEST YARMOUTH, MASSACHUSETTS 775-4979 REGISTERED LAIC: SURVEYOR --�.rT. !� REGISTERED PROFESSIONAL ENGINEER Sept. 21 1979 Town of Barnstable, Health Department Re.-Alvan B. Hirsburg property47$-265) Gentlmen;,� I have inspected the disposal system at the above-location and find that it satisfies bhe: requirement of the state; tytle 5 Yours t Everett H. Hinckley P.E. I h f LOCAf _ a� cTION SE7.AGE PERMIT NO. Ll �✓ VILLAGE e 1NSTA LLER'S NAME i A0DRES_Sgj ® U I L D E R OR OWNER DATE PERMIT - ISSUED „�� _� , DAT E COMPLIA lit E 'ISSUED -/ 7 �. ��. v�� �� �� ���� � �� ��<� a� �� � � • 7c�S-��s�' R.r Noisddddyvv , 03 3 8 -3/77 N0I1VAa3SN®3 �,�,�� ��{c9i la �� 7 ue— IV 319 e?' „ . \ � f � . /` r r o . ;. S� OC> O r' D O.E'OYC ATZ s / p--. SG�i ytO �1f / /6? �!/6�'� e,'' /.S,� f .%>�2 -- ,le� //�f4� � �/,ly� �, r.1 L7 •.�:� r _ f�•'�. ,-- ——a— -__. / p 6AGLO�S 6 L ,+qLL A*Ae 7 uj syTE/�✓1 .d:).e��oSOEG,��S (S,491 /04 Y I, f 41--70AZS`Ti!?ZlC7"/0�f T© eE4019 c'Y- �i ` t^ 7-fir �-"rz.. SITE PLAN SHOWING PROPOSED CONSTRUCTION a` F O R �G �'� ': f / '.�3 A P P R O V E D 1 9 7 9 SCALE . �'' " `�� � DATE: * ' '��' - ' t � BOARD OF HEALTH R E F.E R E N C E A3 >/-/G� ..c T" - �` DATE A G E N T / " ' ' off/—•`r f%cam ,` «' '�./ '/'"'' ... //.,,y'� s P <4'LJ Cl o MONAHAN,19. 13660 S. -;t;' / �..�:-� {l t�5,t+�;,!1.:�.k tb i •#'\i! -;�. �' >> >R>�:'� �ie }s+ef a�. ,1.. ::u � �� .