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Home My WebLink About0009 FIVE CORNERS ROAD - Health I Five Corners Road Centerville P 167 029 �� J�QECYC1FpCo UPC 12543 No. 53LOR n.coNS�`�� HASTINGS, MN �60 vv SIX �'ONC. l �f Gp�� FOO.INGS ' N/F DA VID HANSON P L i �69 r A.M. 168-89 F-Y S 17 l 1,e(SL <o\ k-cX-& a-/ o A-f CENTER VILI �.. LOCUS MA1 PLAN REP 554- ls DEED REF.- 19231 o ems_ ZONING: »R�,.1 I FLOOD ZONE.• "C" PANEL NUMBER.- 2500 DATED. 07-G � ss AREA=116,870fS.F. PLOT PLAN 01 LOT 1A �` `��'" LOCATED AT M. 167-29 ti sr3sr�130 9 FI VE CORNER, K " CENTER VILLE, � �+► •'ems PREPARED Ft r2��," h �i•6ost �o°o SHELILA HORA 0WAL TER MCDO] Ak AL AL SEPTEMBER 11, i N/F EDWARD C: WYNNE Hof REV- AL jam" i W A.M. 167-1 � O, O am.aAAA,4a REV. PARCEL IB �� co RFp E��j"ar��sV 4y REV. AIL CSTEJHEN D YANKEE LAND Sb AL , q DOYLE y & CONSUL TA e *." P.O. BOX 26. JIL UNIT 1, 40 INDUSTA JIL ��.E`° a� MARSTONS MILLS, M. rr TEL. 508-428-0055 FAX SHEET 1 OF 1 FYoB 1 GRAPHIC SCALE NORTH 60 0 30 60 120 POND a 0 a 1 inch = 60 fL r WEST POND LOCUS Gp4' F° . BUMPS API CENTER VILLE LOCUS MAP PLAN REF` 554-11 DEED REF- 19237-3 ZONING: "RD-1" (30'-10'--10) "RC" (20'-10'-10) FLOOD ZONE.• "C" PANEL NUMBER.- 250001 0016 D DATED.- 07-02-92 ss9- sr.,-0 PLOT PLAN OF LAND LOCATED AT.• f3o 9 FIVE CORNERS ROAD s . CENTER ,VILLE MA. s3s• PREPARED FOR: SHELILA HORAN & �s3so o WALTER MCDONO UGH SEPTEMBER 11, 2006 WARD C: WYNNE REV Af 167-1 0 ►�A`A AmQ REV.• REV v v�^tea' ,c;_ Sds„ � YANKEE LAND SURVEYORS STEP DG�YLLE EN & CONSULTANTS � � �' P.O. BOX 265 UNIT 1, 40 INDUSTRY ROAD MARSTONS MILLS, MA 02648 f,vv TEL- 508 428 0055 FAX 508 420 5553 SHEET I OF 54117 JF S?' "" �, .o- *�-.<Sks�t'�'�.rce.�,'" ,r•�„�- 7r • �,,. y��,� �s a i y �-• �' �,+ "�'ry'��"`�'�td • a _ � w - �.^�.+, 4''"xA-,y=��t.�TM.S-r�"i Jt "i7 �. �i _- r,.. .aij ,•�i y+'�f �,�y.,� � �� i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) SKETCH OF SEWAGE DISPOSAL SYSTEM: Include ties to atleast two.permanent references,landmarks or benchmarks. Locate all wells within 100 Feet. �C tt� l3L r 36 1V 12 DEPTH TO GROUNDWATER: Depth to groundwater: 7i Feet Method of Deterininatio or Approximation: r�xindhY rn�7 ref, 5, �' �a , a s � I No.�.��--�11� Fee--��----------- BOARD OF HEALTH TOWN OF BARNSTABLE FL ZipplicationforWell Conotruction Permit Application is hereby made for a permit to Construct (✓), Alter ( ), or Repa' ( )an individual Well at: Location — Address Assessors Map and Parcel Owner Address Installer — Driller 4-- -- Address Type of Building J Dwelling—--- -- -------- -- Other - Type of Building- No. of Persons-- _.__--___ —_—_—_ --- Type of Well Ao y�t► 'PUC- --- Ca acit �A--- `^n--—---- ---- Purpose of Well__��w`; � -------- p y-- - �Q- Agreement: The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The Town of Barnstable Board of Health Private Well Protection Regulation - The undersigned further agrees not to place the well in operation until a Certificate.of Compliance has been issued by the Board of Health. Signed -- ---------- ��date Application Application Approved By s,22_- ---_—__-- 2 ___-- �� t Application Disapproved for the following reasons: r date Permit No. 66J �`�� _-�L�—__—__ Issued--�� _-----__----_-___ --------- date BOARD OF HEALTH TOWN OF BARNSTABLE Certificate Of (Compliance THIS IS TO CERTIFY, That the Individual Well Constructed a), Altered ( ), or Repaired ( ) byD�'' � �ci� �� ---- ----- - - -- ------- ------- ---- n, installer has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private W71V Pection n��2- Regulation as described in the application for Well Construction Permit No.l - Uft Dated- -- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE Inspector----- ---_-_-__-___ 7 a -- BOARD OF HEALTH Fee- ti TOWN OF BARNSTABLE c ZippCication-for Well CongtructiouPermit Application is hereby made for a permit to Construct (1/), Alter ( ), or Repair. ( )an individual Well at: 6_�Z�______________ Location --Address Assessors Map and Parcel t S�e Sa o ca n — ------- ------- �r��IeY�c�eu c�s P r 4 k�\,L, Z Owner Address Installer — Driller Address Type of Building Dwelling - Other - Type of Building-=---___—____ No. of Persons--- __—_______—______.____. Type of Well l l t SGc�t10 !Pd C.- Capacity--��; °='n-—---- ---- Purpose of Agreement:' The undersigned agrees to install the.aforedescribed individual well in accordance with the provisions of The Town of Barnstable Board of Health Private Well Protection Regulation - The undersigned further agrees not to place the well in operation until a Certificate.of Compliance has been issued by the Board of Heeal�th. Signed�v``-'`- -------__— __i1 I11�Z - /� (� date Application Approved By ! _ ___—____ -7 ; --- date Application Disapproved for the following reasons: date Permit No. ��.) Issued I _—� 1 -- � --------- t date BOARD OF HEALTH TOWN ,OF BARNSTABLE (Certificate Of (Compliance THIS IS TO CERTIFY, That the Individual Well Constructed a ), Altered ( ), or Repaired ( ) by -- Installer has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection Regulation as described in the application for Well Construction Permit No.l'+a �_��[ Dated -z�? _-- THE ISSUANCE OF THIS CERTIFICATE SHALUNOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE - — -- Inspector—_----- -- ____ -------- 4 BOARD OF HEALTH ----- , _ TOWN OF BARNSTABLE Well Con$truct ion Permit , r No. ---- Fee --------- Permission is hereby granted to,Construct (✓), Alter ( ), or Repair ( ) an Individual Well at: No. - — T�-Cr r V \�'------ -- --- - ------------------------------- Street as shown on the application for a Well Construction Permit No.- _^_—____ Dated- -- 12 --7/� 3 /�2 — — Board of Health DATE ;f i CERTIFICATE OF ANALYSIS Page: 1 of 1 Barnstable County Health Laboratory (M-MA009) :ssgC��yS!c Report Prepared For: Report Dated: 8/27/2012 Sally Desmond ` Desmond Well Drilling Order No.: G1270701 P O Box 2783 Orleans, MA 02653 Laboratory ID#: 1270701-01 Description: Water-Drinking Water Sample#: Sample Location: 9 Five Corners Rd. Centerville, MA Collected: 08/23/2012 Collected by: Customer Received: 08/23/2012 Routine ` ITEM RESULT UNITS RL MCL METHOD# ANALYST TESTED NOTE Nitrate as Nitrogen 2,3 mg/L 0.10 10 EPA 300.0 LAP 8/23/2012 Copper ND mg/L 0.10 1.3 SM 3111E LAP 8/24/2012 Iron 0.15 mg/L 0.10 0.3 SM 3111E LAP 8/24/2012 r pH 6.3 PH AT.25C NA 6.5-8.5 SM 4500-H-B LAP 8/23/2012 Sodium 29 mg/L 1.0 20 SM 3111E LAP 8/24/2012 Total Coliform Absent P/A 0 0 SM9223 AF 8/23/2012 Conductance 190 umohs/cm 2.0 EPA 120.1 DCB 8/23/2012 Sodium level is above the maxium contaminant level. Those on a low sodium diet may wish to concult a physician. Attached please find the laboratory certified parameter list. Approved By: —I-to"7 (Lab Manager) Fh2-71 Z �a C) LV Ern ND=None Detected RL = Reporting Limit MCL=Maximum Contaminant Level Superior Court House, PO. Box 427, Barnstable, MA 02630 Ph: 508-375-6605 I � 9, CERTIFICATE OF ANALYSIS ' Barnstable County Health Laboratory (M-MA009) Recipient: Sally Desmond Matrix: Water-Drinking Water Desmond Well Drilling Sampled: 08/23/2012 14:00 P 0 Box 2783 Received: 08/23/2012 Orleans, MA 02653 Collection Address: 9 Five Corners Rd.Centerville,MA Order#: G1270701 Sample Location: 1 Description: 2day-9 Five Comers Rd Lab I 701 Date Analyzed: 8/27/2012 @ 15:41 Sample#: Analyst: yn Method: EPA 524.2 Dilution Factor: 1 Comment: Sodium level is above the maxium contaminant level. Those on a low sodium diet may wish to concult a physician. I EPA 524.2 - Volatile Organics by GC/MS Result MCL MD L Result MCL MDL Parameter ug/L ug/L ug/L Parameter ug/L ug/L ug/L Dichlorodifluoromethane ND 0.50 Chloroform ND 80 0.50 Chloromethane ND 0.50 cis-1,2-Dichloroethene ND 70 0.50 Vinyl chloride ND 2.0 0.50 cis-1,3-Dichloropropene ND 0.50 Bromomethane ND 0.50 Dibromochloromethane ND 0.50 1,1,1,2-Tetrachloroethane ND 0.50 Dibromomethane ND 0.50 1,1,1-Trichloroethane ND 200 0.50 Ethylbenzene ND 700 0.50 1,1,2,2-Tetrachloroethane ND 0.50 Hexachlorobutadiene ND 0.50 1,1,2-Trichloroethane ND 5.0 0.50 Isopropylbenzene ND 0.50 1,1-Dichloroethane ND 0.50 Methylene chloride ND 5.0 0.50 1,1-Dichloroethene ND 7.0 0.50 Methyl-tert-butyl ether ND 0.50 1,1-Dichloropropene ND 0.50 Naphthalene ND 0.50 1,2,3-Trichlorobenzene ND 0.50 n-Butylbenzene ND 0.50 1,2,3-Tdchloropropane ND 0.50 n-Propylbenzene ND 0.50 1,2,4-Trichlorobenzene ND 70 0.50 p-Isopropyltoluene ND 0.50 1,2,4-Trimethylbenzene ND 0.50 sec-Butylbenzene ND 0.50 1,2-Dibromo-3-chloropropane ND 0.50 Styrene ND 100 0.50 1,2-Dibromoethane(EDB) ND 0.50 tert-Butylbenzene ND 0.50 1,2-Dichlorobenzene ND 600 0.50 Tetrachloroethene ND 5.0 0.50 1,2-Dichloroethane ND 5.0 0.50 Toluene ND 1000 0.50 1,2-Dichloropropane ND 0.50 Total xylenes ND 10000 0.50 1,3,5-Trimethylbenzene ND 0.50 trans-1,2-Dichloroethene ND 100 0.50 1,3-Dichlorobenzene ND 0.50 trans-1,3-Dichloropropene ND 0.50 1,3-Dichloropropane ND 0.50 Trichloroethene ND 5.0 0.50 1,4-Dichlorobenzene ND 5.0 0.50 Trichlorofluoromethane ND 0.50 2,2-Dichloropropane ND 0.50 Surrogates %Recovered QC Limits(%) 2-Chlorotoluene ND 0.50 p-Bromofluorobenzene 98% 70 130 4-Chlorotoluene ND 0.50 1,2-Dichlorobenzene-d4 97% 70 1 130 Benzene ND 5.0 0.50 Bromobenzene ND 0.50 Bromochloromethane ND 0.50 Bromodichloromethane ND 0.50 Bromoform ND 0.50 Carbon tetrachloride ND 5.0 0.50 Chlorobenzene ND 100 0.50 Chloroethane ND 0.50 I Attached please find the laboratory certified parameter list. Approved By: (Lab Director) 7// ND=None Detected RL = Reporting Limit MCL=Maximum Contaminant Level Superior Court House, PO. Box 427, Barnstable, MA 02630 Ph: 508-375-6605 Page 1 of 1 it Massachusetts Department of Environmental Protection �j Bureau of Resource Protection WELL DRILLER Please specify work performed: Address at well location: New Well D Street Number: Street Name: --� FIVE CORNERS ROAD Please specify well type: Building Lot#: Assessor's Map#: Domestic E- Assessor's Lot#: ZIP Code: Number Of Wells: 102632 —� City/rown: Well Location BARNSTABLE In public right-of-way: GPS North: West: 141.64779 � 70.37257 Subdivision/Property/Description: Mailing Address: ti click here if same as well location addres Property Owner: Street Number: Street Name: HORAN 9 --7 FIVE CORNERS ROAD City/Town: State: fEngineering —Finn: I&MINSTABL_E �� MASSACHUSETTS I ZIP Code: 02632 Board of health permit obtained: +Yes I k Not Required Permit Number: Date Issued: W2012 019 7/23/2012 -1 Y _ r_ - wj Massachusetts Department of Environmental Protection j Bureau of Resource Protection—Well Driller Program Well Completion Reporis(General) ttS,,,� Well Driller - General Well Form DRILLING METHOD Overburden Bedrock Auger --Choose Bedrock WELL LOG OVERBURDEN LITHOLOGY From To(ft) Code Color Comment Drop In Extra fast or slow Loss or addition of (it) drill stem drill rate fluid P207, Medium Sand Brown Ye I cji Fast r.ja Slow c)1 Loss +Addition F267 25 Silty Sand Brown e Ye iJ:,Fast TJ1 Slow iJ,.Loss z)m Addition 25 31 Fine To Coarse Sand Brown , Ye 7)1 Fast rJR Slow iJ,i Loss poi Addition WELL LOG BEDROCK LITHOLOGY Visible Extra From Drop In Extra fast or slow Loss or addition of To(ft) Code Comment Rust Large (it) drill stem drill rate fluid Staining Chips Choose Code e Ye d),Fast iJ1 Slow IJI Loss 03 Addition Ye Ye ADDITIONAL WELL INFORMATION Developed ,Ji Yes 1J,No Disinfected Yes ,J,W Total Well Depth 31 Depth to Bedrock Fracture ------- Surface Seal Type None Enhancement iJ+Yes ri No CASING IS Is Casing above ground. From: 11 To: 10 1 From To Type Thickness Diameter Driveshoe 0� 28 Polyvinyl Chloride !Schedule 40 0 Ye SCREEN e— No Scree From To Type Slot Size Diameter 28 31 Stainless Steel Well Point 0.012 WATER-BEARING ZONES c DRY WELL From To Yield(gpm) 17 31 12 PERMANENT PUMP(IF AVAILABLE) 2 Wire Constan t Speed Pump Description Horsepower Submersible 1/2 Pump Intake Depth(ft) 127 1 Nominal Pump Capacity(gpm) 110 f � Massachusetts Department of Environmental Protection Bureau of Resource Protection—Well Driller Program Well Completion Reports(General) ANNULAR SEAL/FILTER PACK From To Material 1 Weight Material 2 Weight Water Batches Method Of Placement (gal) Choose Material Choose Material --Choose One-� WELL TEST DATA Time Pumping Time To Date Method Yield (gpm) Pumped Level (it Recover Recovery (it (HH:MM) BGS) (HH:MM) BGS) e 8/30/2012 - 1 Constant Rate Pump 112 130 1 122 0:01 17 WATER LEVEL Date Measured Static Depth BGS (it) Flowing Rate (gpm) 8/30/2012 17 COMMENTS WELL DRILLERS STATEMENT This well was drilled or altered under my direct supervision,according to the applicable rules and regulations,and this report is complete a knowledge. Driller I PATRICKDESMOND Registration# 1877 Monitoring[M] ❑ Supervising Drill Firm DESMOND WELL DRI Rig Permit# 1024 Date Job Compl NOTE:Well Completion Reports must be filed by the registered well driller within 30 days of well completion. f CERTIFICATE OF ANALYSIS g Pa e: 1 Barnstable County Health Laboratory �9CshCK� r Report Prepared For: Report Dated: 12/7/2006 Sheila W.Horan Order No.: G0638921 9 Five Corners Road Centerville, MA 02632 Laboratory ID#: 0638921-01 Description: Water- ri7Rd. ter, - Sample#: Samplin ocation 9 Five Cornenterville,MA Collected: 12/4/2006 Collected by: W.M. Map 167 Pa Received: 12/4/2006 Routine ITEM RESULT UNITS RL MCL Method 4 Tested Nitrate as Nitrogen BRL mg/L 0.10 10 EPA 300.0 12/4/2006 Copper BRL mg/L 0.10 1.3 SM 3111B 12/7/2006 Iron BRL mg/L 0.10 0.3 SM 311113 12/7/2006 Sodium 30 mg/L , 1.0 20 SM3111B 12/7/2006 Total Coliform Absent P/A 0 0 SM9223 12/4/2006 Conductance 120 umohs/cm 2.0 EPA 120.1 12/4/2006 pH 7.7 pH-units 0 EPA 150.1 12/4/2006 Sodium level is above the maximum contaminant level. Tit iie oit a[ow sodium diet may wish'to cottsult'a physician Approved By:- (L irector) N .- C� Q M _ W c� —v .. as w r _.t r+m MCL=Maximum Contaminant Level RL = Reporting Limit Superior Court House, PO.Box 427, Barnstable, MA 02630 Ph: 508-375-6605 -k UF.i{hR`ttr, CERTIFICATE OF ANALYSIS Page: 1 i Barnstable County Health Laboratory Report Dated: 10/22/2004 Report Prepared For: Pernille Monto Order No.: G0428294 Buyer Brokerage of Osterville P O Box 27 Osterville, MA 02655 Laboratory ID#: 0428294-01 Description: Water-Drinking Water Sample#: 28294 Sampling Location 9 Five Corners Road Centerville MA Collected: 10/13/2004 Collected by: P Monto Map 167 Parcel 029 Received: 10/13/2004 Routine ITEM RESULT UNITS RL MCL Method# Tested LAB: Inorganics Nitrate as Nitrogen BRL mg/L 0.1 10 EPA 300.0 10/13/2004 LAB: Metals Copper BRL mg/L 0.1 1.3 SM 31 11 B 10/20/2004 Iron BRL mg/L 0.1 0.3 SM 31 1 1 B 10/20/2004 Sodium 30 mg/L 1.0 20 SM 3111 B 10/20/2004 LAB: Microbiology Total Coliform Absent P/A 0 Absent 307 10/13/2004 LAB: Physical Chemistry Conductance 130 umohs/cm 1 EPA 120.1 10/13/2004 pH 7.5 pH-units 0 EPA 150.1 10/13/2004 Sample has higher than average levels of Sodium.Those on a low Sodium diet may want to consult a physician. Approved By. ( Director) 6Z RL = Reporting Limit �-1 �1 i C.i`' a !'1 Q . MCL=Maximum Contaminant Level Superior Court House, PO.Box 427, Barnstable, MA 02630 Ph: 508-375-6605 ST- COMMONWEALTH OF MASSACHUSF ------------ EXECUTIVE OFFICE 60EI&RONMENTAL AFFAIRS DEPARTMENT OF Eft IR®NMFN4T�A1< ROTECTION r W TITLE 5 LOT A OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION RECEIVED Property Address: � kwJ � 1�VIi..L� ` MBA aSFp• 1 4 2004 Owner's Name: TQbS;I�OF < Owner's Address: �� PjY f/('y HEALTH DEPT. VJSABLE avS Date of Inspection:kje j"x-gr S! Name of Inspector: please print) Company Name: - c,�e�l)'s • . Mailing Address: Telephone Number: ( "-7'7/ 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 pursuantry to Section 15.340 of Title 5(310 CMR 15.000). The system: V Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority a is l Inspector's Signature: /A Date: 7 4°j The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. 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. Title 5 Inspection Form 6/15/2000 page I r Page 2of]1 , OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART.A . CERTIFICATION (continued) Property Address: Owner: Date of Inspection: _ Z�)DCVV Inspection Summary: Check A,B,C,D or E./ALWAYS complete all of Section D A. System Passes: I have not found any information which indicates that any of the failure criteria described in.310 CMR 15.303 or in 3.10 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system, upon completion of the replacement or repair as approved by the Board of Health,Will,pass., Answer yes,no or not determined(Y,N,ND)in the for the following statements..If"not determined"please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally. unsound,.exhibits substantial infiltration or exfiltration or tank failure is imminent:System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: 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 ND explain: The system required pumping more than'4 times a year due to broken or obstructed pipe(s).The system.will pass inspection.if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is.removed ND explain: 2 t Pape 3 of 1 I OFFICIAL INSPECTION FORM - NOT. FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE ]DISPOSAL SYSTEM INSPECTION FORM' PART A CERTIFICATION(continued) Property Address: Owner: Date of Inspection: C. Further Evaluation is Required by the Board.of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: _ Cesspool or privy is within 50 feet of a surface water _ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier, if any).determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of'a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone l of a public water supply. _ The system has aseptic 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.ifthe well water analysis,perf6nred:at.a.DEP certified,laboratory, for_colifornn 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: Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE I3ISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: a0J A, Z1 Owner: Date of Inspection: D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No/ ✓/Backup of sewage into facility.or system component due to overloaded:or clogged SAS.or.cesspool V Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool Static liquid level in the distribution box above outlet invert due to an overloaded or.clogged SAS or cesspool, Liquid depth in cesspool is less than 6"below invert or available volume is less than '/z day flow Required pumping more than 4 times in the last year NOT due to.clogged or obstructed pipe(s).Number /of times pumped �✓ Any portion of the SAS, cesspool or privy is below high ground water elevation. Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface / water supply. Any portion of a cesspool.or privy is within.a Zone I of&public well. Any portion of a cesspool or privy is within.50 feet of a.private water supply well. Any portion of a.cesspool or privy is less than 100.feet but greater than 50 feet from,a private water supply well with no acceptable water quality analysis. [This system passes,if the well water analysis, performed at a DEP certified laboratory, for 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.] (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large:Systems: To be considered a large system the system must serve a.facility with a design flow of:10;000 gpd to 15,000 gpd• 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—I WPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any questibn in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section.D shall upgrade the system in accordance with 310 CMR 15:304.The system owner should contact the appropriate regional office of the Department 4 Pase 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: l"o� Owner:. - — Date of Inspection: Check if the followinz have been done. You must indicate."yes"or"no"as to each of the followins: Yes No Pumping.information was provided by the owner,occupant, or Board of Health ✓Were any of the system components pumped out in the previous two weeks? ✓ /Has the system received normal flows in the previous two week period ? .Have laree volumes of water been introduced to the system recently or as part of this inspection ? Were as built plans of the system obtained and examined? (If they were not available note as N/A) Was the facility or dwelling inspected for signs of sewage back up Was the site inspected for signs of break out? Were all system components, excluding the SAS, located on site ? Were the septic tank manholes uncovered, opened,and the interior of the tank inspected for the condition oI the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? _V_ 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 no Existing information. For example,a plan.at the Board of Health. Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)] S r x Page 6 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE.SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: cam. r baw A Owner: Date of Inspection: ZVA C FLOW CONDITIONS RESIDENTIAL. Number of bedrooms(design): Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203 (for example: 11.0 gpd x#of bedrooms):_- Number of current residents: , 99!� Does residence have a garbage grinder(yes or no):/N Is laundry on a separate sewage system(yes or no):;E0 .[if yes separate inspection required] Laundry system inspected(yes.or. •AW Seasonal use: (yes or no): &2� y Water meter readings, if available(last 2 years usage(gpd)): OZ Sump pump(yes or no): Last date of occupancy: Ye'd, COMMERCIAL/INDUSTRIA� Type of establishment` Design flow(based on 310 CMR 15203): gpd Basis of design flow(seats/persons/sgft,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 occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information:Was system pumped as part of th inspection(ye or no)- If yes, volume pumped: gallons--How was quantity pumped determined? Reason for pumping: - TYP OF SYSTEM septic tank,distribution box,soili 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 ace of all components,date inns ailed(if known)and source of information. 0 Were sewage odors detected when arriving at the site(yes or no) 6 Paae 7 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM-INFORMATION(continued) Property A dress: Cf ¢� Owner: , � Date of nspection: BUILDING SEWER(locate on site plan)A& Depth below.grade: Materials of construction:_cast.iron _40 PVC_other(explain): Distance from private water supply well or suction line: Comments (on condition of joints, venting, evidence of leakage, etc.): SEPTIC TANK: (locate on site plan) Depth below grade: Al -`--- Material of constructron: . 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) r Dimensions: Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: �l .Scum thickness: Distance from top of scum to top of outlet tee or baffle: 5 // Distance from bottom of scum to ottoin of outlet tees or baffle: How were dimensions determine Comments(on pumping recomm ndation , inlet and outlet tee or baffle condition, structural integrity, liquid levels related to outlet invert, evidence of leakage tc.): r 1�r , /p GREASE TRAP/ AJ(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.): 7 Page 8 of l 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued). Property dress: ;)VVLW Owner: Date of Inspection: TIGHT or HOLDING TANK./2L�(tank.must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass_polyethylene other(explain):. Dimensions:' Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches, etc.): DISTRIBUTION BOX: r/(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert:. Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of r-teakne into or ou of bo i PUMP CHAMBER (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): _ Comments (note condition of pump chamber,condition of pumps and appurtenances, etc.): 8 L Page 9 of 11 OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: G' C� Owner: _ Date of Inspection. r '' SOIL ABSORPTION SYSTEM (SAS): lzoocate 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 failure, level of ponding, damp soil, condition of vegetation, etc). : CO rX ie l i CESSPOOLS:/:341*esspool must be pumped as part of inspection)(locate on site plan) /6 Number and configuration: Depth—top of liquid to inlet invert: Depth of solids laver: 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: (locate on site plan) Ma rials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation, etc.): o Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM,INSPECTION FORM PART C SYSTEM.INFORMATION(continued) Property Address: Owner: Date of Inspec ion. ,��J �� C-)` SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate al ells within 10.0 feet. Locate where public water supply enters the building. r t i 0 10 Page 11 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) . Property.Address: - mod Owner: Date of Inspection. ,�C�0 SITE EXAM Slope Surface water "Check cellar Shallow-wells 7 Estimated depth to ground water I 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 hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with local excavators, installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: i 11 Permit Number: Date: Completed by: � . HIGH GROUND-WATER LEVEL COMPUTATION Site Location: C `~ llC Lot No. Owner: Z Address:Contractor: Address: ��"� Notes: STEP 1 Measure depth to water table z tonearest 1110 ft. .............................................................................. .Date l� month/day/Year STEP 2 Using Water-Level Range Zone and Index Well Map locate site and determiner (A Appropriate index well.................................................... OB Water-level range zone ..................................................... STEP 3 Using monthly report "Current Water Resources Conditions" determine current depth to water level for index well ........................... month!/year STEP 4 Using Table of Water-level Adjustments for index well (STEP 2A),.current depth to water level for index well (STEP 3), and water-level zone (STEP 2B) determine water-level adjustment ......................................................................... . STEP 5 Estimate depth to High water by subtracting the water- level adjustment (STEP 4) from measured depth'to water levelat site (STEP 1) ............................................................................................................. Figure 13.--Reproducible computation form. 15 . � ��r ��;�1. ��:li,;� I...1 -• � -did j� i I BORTOLOTTI CONSTRUCTION, INC. TWP 45 INDUSTRY ROAD, MARS'CONS MILLS, MA 02648 508-771-9399 508-428-8926 FAX: 508-428-9399 SUBSURFACE SEWAGI? DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: /" � a ,t" L.,� 0 Date Of Inspection Inspector's Name: O v er's Na ne an Address: CERTIFICATION STATEMENT: I Certify that I have personally Inspected the Sewage Disposal System at this address and that the informa- tion reported below is true, accurate and complete as of the time of Inspection. The Inspection was perform- ed based on my Training and Experience in the Proper Function and Maintenance of On-Site Sewage Dis- posal Systems ie system: Passes Conditionally Y. s Needs Furt r alu do y the Local Approving Authority Failure Inspector's Signature Date: The System Inspector shall submit a copy of this Inspection Report to the Approving Authority with Thirty (30) Days of completing this Inspection. If the System is a Shared System or has a Design Flow of 10,000 gpd or greater, the Inspector and the System Owner shall submit the Report to the appropriate Regional Office of the Department of Environmental Protection. The Original should be sent to the System Owner and copies suit to the Buyer,if applicable and the Approving Authority. INSPECTION SUMMARY: A) SYSTEI PASSES: I have not found any Information which indicates that the System violates any of the fail- ure criteria as defined in 310 CMR 15.303. Any Failure Criteria not evaluated are indi- cated below. B) 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. Indicate yes, nor,or not determined (Y,N,OR ND). Describe bases of determination in all instances. if"not determined",explain why not. The Septic Tank is Metal,Cracked,Structurally Unsound,shows Substantial Infiltration or exfil- tration,or Tank Failure is imminent. Tile System will Pass Inspection if Existing Septic Tank is Replaced with a conforming Septic Tank as Approved by the Board Of Health. Sewage Backup or Breakout or High Static Water-Level observed in the Distribution Box is clue to broken or obstructed pipe(s)or due to a broken,settled or uneven Distribution Box. The System will pass Inspection if(With Approval of the Board Of Health): - I - SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A • CERTIFICATION (continued) Broken pipe(s) replaced Obstruction is removed Distribution Box is leveled or replaced 'rite System required pumping more than four times a year due to broken or obstructed pipe(s). The System will pass inspection if(with approval of'I'he Board Of Health): Broken pipe(s)are replaced Obstruction is removed. C) FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board Of Health in order to determine if the System is failing to protect the Public Health,Safety and the Environment. 1)SYSTEM WILL PASS UNLESS BOARD OF HELATH DETERMINES THAT THE SYSTEM 1S NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or Privy is within 50 Feet of a Surface Water Cesspool or Privy is within 50 Feet of a bordering Vegetated Wetland or a Salt Marsh. 2) SYSTEM WILL FAIL UNLESS THE BOAR.) OF HEALTH (AND PUBLIC WATER SUPPLIER,IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTION- ING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has.a Septic Tank and Soil Absorption System and is within 100 Feet to a Surface Water Supply or Tributary to a Surface Water Supply. The System has a Septic Tank and Soil Absorption,System and is with a Zone 1 of a Public Water Supply Well. The System has a Septic Tank and Soil Absorption System and is within 50 Feet of a Private Water Supply Well. The System has a Septic Tank and Soil Absorption System and is less than100.Feet but 50 Feet or more from a Private Water Supply Well, unless a Well Water Analysis for coliform bacteria and volatile organic compounds indicates that the Well is from pollution from the facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. D)SYSTEM FAILS: I have determined that the System violates one or more of the following Failure Criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Backup of sewage into facility or system component due to an overload or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to all overloaded or clogged SAS or cesspool. Static liquid level in the distribution box above outlet invert due to an overloaded or clog- ged SAS or cesspool. Liquid depth in cesspool is less than G" below invert or available volume is less than 1/2 day flow. Required pumping more than 4 times in the last year N( due to clogged or obstructed pipe(s). Number of times pumped - 2 - 1 SUBSURFACE SEWAGE DISPOSAL.SYS•1'LM INSPECTION FORM PART A CERTIFICATION (c)ntinued) Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 Feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone 1 of a Public Well. Any portion of a cesspool or jhrivy is within 50 Feet of a private water supply well. Any portion of a cesspool or privy is less than 100 Feet but-greater than 50 Feet from a private water supply well with no acceptable water quality analysis. if the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E) LARGE SYSTEM FAILS: The following criteria apply to a large system in addition to the criteria above: The design flow of a system is 10,000 ggd or greater(Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: 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 ll of a public water supply well. The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 315 CIVIR 5.00 and 6.00. Please consult the local regional office of the Department for further information. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PARTS CHECKLIST Check if the following have been done: Pumping informaition was requested of the owner,occupant, and Board of Health. _'None of the system components have been pumped for atleast two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. As-built plans have been obtained and examined. Note if they are not available with N/A. t/The facility or dwelling was inspected for signs of sewage back-up. The system does not receive non-sanitary or industrial waste flow. L/The site was inspected for signs of breakout. --&-/—All system components,excluding the Soil Absorption System, have been located on site. _,4The septic tank manholes were uncovered,opened,and the interior of the septic tank was in- spected for condition of baffles or tees,material of construction,dimensions,depth of liquid, depth of sludge,depth of scum. (�/ ` The size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods. - 3 - SUBSURFACE SEWAGE DISPOSAL SYSTEM^ INSPECTION FORM PART B CHECKLIST(continued) 1 � f.. .:1:{ r!n•.l n ..tn :f ....'rentant fr v.. w-� f rv1:a 2i.1 With .i ."Gr i■aaiv . oil the proper maintenance of Subsurface Disposal System. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION FLOW CONDITIONS RESIDENTIAL: Design Flow:_` gallons Number of Bedrooms: N m er of Current Residents: Garbage Grinder:_ Laundry Connected To System: Seasonal Use: Water Meter din a le• Readings,gs, i a ila b Last Date of Occupancy - COMMERCI LAND ST IAL• /l10 Type of Establishment: Design Flow: gallons/day Grease Trap Present: (yes or no) Industrial Waste Holding Tank Present: Non-Sanitary Waste Discharged To The Title V System: Water Meter Readings, If Available: Last Date of Occupancy: OTHER: (Describe) Last Date of Occupancy: GENERAL OILMATION PUMPING RECORDS any source of information: 99 System Pumped as part of inspection: volume pumped: _ gallons Reason for Pumping: TYPE OF SYSTEM: ✓Septic Tank/Distribution Box/Soil Absorption System Single Cesspool Overflow Cesspool Privy Shared System(If yes,attach previous inspection records, if any) Other(explain): AP ROXIMATE AGE all components,date installed (if nown) and source of information: _ Sewage odors detected w en arriving at the e: -4- n" SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C GENERAL INFORMATION (continued) CCDT i!`TA NY. .qua aaa. ae-aia Depth below grader n Material of Construction: concrete metal FRP Other (explain) Dimensions: /0.5'x(p' .1' S' Sludge Depth: Co " Scum Thickness: / " Distance from top of sludge to bottom of outlet tee or baffle: 32. 11 Distance from bottom of scum to bottom of outlet tee or baffle: /> " Comments: (recommendation for pumping,conditioin of inlet and outlet s or baffles,depth of liquid level in relation to outleAmvert,structural ii tegrity�evide ce of leakage,etc: ' GREASE TRAP: Depth Below Grade: Material of Construction: concrete metal FRP Other (explain): Dimensions: Scum Thickness: Distance from top of scum to top of outlet tee or baffle: Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage,etc.) TIGHT OR HOLDING TANK: Depth Below Grade: Material of Construction: concrete metal FRP Other (explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm Level: Comments: (condition of inlet tee,condition of alarm and float switches,etc.) DISTRIBUTION BOX: Depth of liquid level above outlet invert:/J t a" �I Comments: (note'f level.and distribution is equal,evid , of solids carryover,evide ice of 1 aka e 'it ur out of box,etc.) G (� PUMP CHAMBER: A-){� Pump is in working order: Comments: (note condition of pump chamber,condition of pumps and appurtenances,etc.) - 5 - SUBSURFACE SEWAGE -DISPOSAL SYSTEM,INSPECTION FORM PART C SYSTEM INFOII-MA'rION (contiuuetl) SOIL ABSORPTION SYSTEM(SAS): t/ (Locate on site plan,if possible; excavation not required, but may be approximately by non-intrusive methods) If not determined to be present,explain: Type: Leaching pits,number: Leaching chambers, number: Leaching galleries,number: Leacahing trenches,number,length: Leaching fields, number,dimensions: Overflow cesspool, number: Co invents: (note conidtion of soil,signs of hydraulic failure level f'ponding,condition of vegetation,etc.)_ G sO � CESSPOOLS:�Q Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of Cesspool: Materials of construction: Indication of groundwater: Inflow(cesspool must be pumped as part of inspection) Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation, etc.) PRIVY• /Vd - Materials of construction: Dimensions: Depth of Solids: Comments: (note condition of soil,signs of hyddraulic failure,level of ponding;condition"of vegetation, etc.) - 6 - a '�.ys wt SUBSURFACE SEWAGE DISPOSAL SYSTEM. INSPECTION FORM PART C SYSTEM INFORMATION (continued) e SKETCH OF SEWAGE DISPOSAL SYSTEM: e Include ties to atleast two permanent references,landmarks or benchmarks. s Locate all wells within 100 Feet. eC ( �3 ll� 13L i3b l24 iZ DEPTH TO GROUNDWATER: Depth to groundwater: 7i Feet Method of Determinatio or Approximation: �XiM 1r 4 roar �l, 5, e yv Zf �® E` 7 _ e i i t Cj a /> BORTOLOTTI' CONSTRUCTION,ANC. 45 INDUSTRY=ROAD, MARST.ONS MILLS, M*02648 � 568-711-9394 '508-428-8926 FAX: 508-428-9399, ��al BT SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: Date Of Inspection Ins ec is Name: O er's Na a an Address: CERTIFICATION STATEMENT: I Certify that I have personally Inspected the Sewage Disposal System at this address and that the infornia- tion reported below is true,accurate and complete as of the time of Inspection. The Inspection was perform- ed based on my Training and Experience in the Proper Function and Maintenance of On-Site Sewage Dis- posal Systems ie system: Passes Conditionally P s Needs Furt r: alu ti y the Local Approving Authority Failure Inspector's Signature Date:j �Ud —T— The System Inspector shall submit a copy of this Inspection Report to the Approving Authority with Thirty (30)Days of completing this Inspection. If the System is a Shared System or has a Design Flow of 10,000 gpd or greater,the Inspector and the System Owner shall submit the Report to the appropriate Regional Office of the Department of Environmental Protection. The Original should be sent to the System Owner and copies sent to the Buyer,if applicable and the Approving Authority. INSPECTION SUMMARY: A) SYSTEI PASSES: I have not found any Information which indicates that the System violates any of the fail- ure criteria as defined in 310 CMR 15.303. Any Failure Criteria not evaluated are indi- cated below. B) 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. Indicate yes,nor,or not determined(Y,N,OR ND). Describe bases of determination in all instances. If"not determined",explain why not. The Septic Tank is Metal,Cracked,Structurally Unsound,shows Substantial Infiltration or exfil- tration,or Tank Failure is imminent. The System will Pass Inspection if Existing Septic Tank is Replaced with a conforming Septic Tank as Approved by the Board Of Health. Sewage Backup or Breakout or High Static Water Level observed in the Distribution Box is due to broken or obstructed pipe(s)or due to a broken,settled or uneven Distribution Box: The System will pass Inspection if(With Approval of the Board Of Health): - i - ltrw � 'l � SUBSURFACE SEWAGE �DISPOSAL SYSTEIVI"'INSPECTION FORM PART A CERTIFICATION(continued) Broken pipe(s)replaced Obstruction is removed Distribution Box is leveled or replaced 'File System required pumping more than four times a year due to broken or obstructed pipe(s). The System will pass inspection if(with approval of The Board Of Health): Broken pipe(s)are replaced Obstruction is removed. C) FURTHER EVALUATION.IS REQUIRED BY THE BOARD OF HEALTH: Conditions - Conditions exist which require further evaluation by the Board Of Health in order to determine if the System is failing to protect the Public Health,Safety and the Environment. 1)SYSTEM WILL PASS UNLESS BOARD OF HELATH DETERMINES THAT THE SYSTEM 1S NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or Privy is within 50 Feet of a Surface Water Cesspool or Privy is within 50 Feet of a bordering Vegetated Wetland or a Salt Marsh. 2)SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER,IF APPROPRIATE)DETERMINES THAT THE SYSTEM IS FUNCTION- ING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ;ENVIRONMENT: The system has.a Septic,Tauk and Soil;Absorption'-System'and is within 100 Feet to a Surface Water Supply or Tributary to a Surface Water Supply.'., The System has a Septic Tank and Soil_Absorption System and is with a Zone 1 of a Public Water Supply Well. The System has a Septic Tank and Soil Absorption System and is within 50 Feet of a Private Water Supply Well. The System has a Septic Tank and Soil Absorption System and is less than 100 Feet but 50 Feet or more from a Private Water Supply Well,unless a Well Water Analysis for coliform bacteria and volatile organic compounds indicates that the Well is from pollution from the facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. D)SYSTEM FAILS: ;.- I have determined that the System violates one or more of the following Failure Criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Backup of sewage into facility or system component due to an overload or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. Static liquid level in the distribution box above outlet invert due to an overloaded or clog- ged SAS or cesspool. Liquid depth in cesspool is less than-G" below invert or available volume is less than 1/2 day flow. Required pumping more than 4 times ill the last year'N01'due to clogged or obstructed pipe(s). Number of times pumped ' - 2 - r Y s� - SUBSURFACE.SEWAGE, DISPOSAL_�SYS;I,14:M'•-IN$VECTION,'FORM •` 'PA11T A CEJZ'I'IFICAI-ION(continue(l) Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 Feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone 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. If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic compounds,ammonia nitrogen and nitrate nitrogen. E) LARGE SYSTEM FAILS: € The following criteria apply to a large system in addition to the criteria above: s The design flow of a system is 10,000 ggd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: 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--mappeti Zone;J1 ofo-publicwater;supplywelh, The owner or operator of any such systenrshall'.bring the system and facility into full'compliance with the groundwater treatment program requirements oF315'CMR 5.00 acid 6.00. Please consult the local regional office of the Department for further information. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B 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 atleast two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. As-built plans have been obtained and examined. Note if they are not available with N/A. V The facility or dwelling was inspected for signs of sewage back-up. The system does not receive non-sanitary or industrial waste flow. _ The site was inspected for signs of breakout. _All.system components,excluding the Soil Absorption System,have been located on site. _ The septic tank manholes were uncovered,opened,and.the.interior of the septic tank was in- spected for condition,of baffles or tees,material of,.construction,dimensions,depth of liquid, (Xdepth of sludge,depth of scum. he size and.location of.the Soil Absorption.System.on-the.,site has been determined based on existing information or approximated by non-intrusive methods. - 3 - 4 N Rntiyk04k 'SUBSURFACE SEWAGE''DISPOSAL: SYSTEM,;INSPECTION FORM PART B CHECKLIST(continued):.:: be facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of Subsurface Disposal System. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION / FLOW'CONDITIONS V RESIDENTIAL: Design Flow: gallons Number of Bedrooms: N mPer of Current Residents: Garbage Grinder: 106 Laundry Connected To System: Seasonal Use: Water Meter Readings,i ailable: Last Date of Occupancy COMM .R 1 L/INDUSTRIAL: Type of Establishment:' Design Flow: gallons/day..Grease Trap Present: (yes or'no) ` Industrial Waste HoldingTank Present: . . Non-SanitaryWaste Discharged To The Title V System: g Y Water Meter Readings,If Available: Last Date of.Occupancy: OTHER: (Describe) Last Date of Occupancy: GENERAL ORMA'I'ION PUMPING RECORDS any source of information: �% System Pumped as part of inspection:_ If yes,volume pumped: gallons Reason for Pumping: TYPE OF SYSTEM: ✓Septic Tank/Distribution Box/Soil Absorption System Single Cesspool Overflow Cesspool Privy Shared System(If yes,attach previous inspection records,if any) Other(explain): AJPVROXIMATE AGF, all components,date installed (if nown)and source of information: And Sewage odors detected wifen arriving at the e:'/ -4- }.- SUBSURFACE-§SEWAGVDISPOSAL°S:VS'ITEM¢ INSPECTION FORM .'PART C GENERAL INFORMATION (continued) SEPTIC TANK: ' Depth below grade: Material of Construction: V' concrete metal FRP Other (explain) Dimensions: /D.5'X fin'A'S' Sludge Depth: ' ScumThickness: / Distance from top of sludge to bottom of outlet tee or baffle: 32_ Distance from bottom of scum to bottom of outlet tee or baffle: /> " Comments: (recommendation for pumping,conditioin of inlet and outlet s or baffles,depth of liquid level in relation to outl invert,structural i tegrity,_evide ce of leakage,etc. ' ii i t GREASE TRAP: Depth Below Grade: Material of Construction: concrete-metal-FRP Other (explain): Dimensions: Scum'Thickness: Distance from top of scum to top of outlet tee or baffle: Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level; in relation to outlet invert,structural integrity,evidence of.leakage,etc.) TIGHT OR HOLDING TANK: Depth Below Grade: Material of Construction: concrete metal FRP Other (explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm Level: Comments:(condition of inlet tee,condition of alarm and float switches,etc.) DISTRIBUTION BOX: Depth of liquid level above outlet invert: Comments:(note'f level and distribution is equal,evid ee of solids carryover,evid ce of I aka e wto or �out of box,etc. PUMP CHAMBER: Sy Pump is in working order _. m Conunents: (mote condition of pump chamber,condition of pumps and appurtenances,etc.) 5. - 5 - -' r SUBSURFACE -SEWAGE:DISPOSAL''SYSTEM:INSPECTION FORM PART C SYSTEM 'INFORMATION(continued) SOIL ABSORPTION SYSTEM(SAS): (Locate on site plan,if possible;excavation not required,but may be approximately by non-intrusive methods) If not determined to be present,explain: Type: Leaching pits,number: Leaching chambers,number: Leaching galleries,number: Leacahing trenches,number,length: Leaching Gelds,number,dimensions: Overflow cesspool,number: Co meats: (note conidtion of soil,signs of hydraulic failure level f ponding,condition of vegetation,etc.)_ y0 -Y- - N CESSPOOLS: I�Q Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of Cesspool: Materials of construction: Indication of groundwater: Inflow(cesspool must be.pumped as part of inspection) Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation, etc.) PRIVY: Nd Materials of construction: Dimensions: Depth of Solids: Comments: (note condition of soil,signs of hyddraulic failure,level of ponding,condition of vegetation, etc.) A i - 6 - <�- t #��...-..:r f '" k :�.. ''J '6i. •. J �. ,.y sw. s/ 3;fi?C,A S f+'N h' ��.r�•.. }a.�-4!.++� '� R"r^' � `�� r+ "5��4,�a,M,'3+ � � F .,t�A f ,� z'E. ��i^r, �.1 t> S ,�� •w. v .�a. ° ! � *:4'� SUBSURFACEaiSEWAGE'DISPOSAL-,SYSTEM INSPECTION FORM PART C SYSTEM.INF.ORMATION(continued) SKETCH OF SEWAGE DISPOSAL SYSTEM: Include ties to atleast two permanent references,landmarks or benchmarks. Locate all wells within 100 Feet. cC t r 131 12 DEPTH TO GROUNDWATER: Depth to groundwater: .2,I Feet Method of Determinatio or Approximation: �eximarW ro'+l U,5, A 1�,y - 7 - TOWN OF BARNSTABLE LOCATION ( Lt V G Ctrr hA.. 3 &a-o,, SEWAGE # sf VILLAGE (3:_lly v (t`Q ASSESSOR'S MAP & LOT a INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) Lca_ 4 {_J (size) NO.OF BEDROOMS BUILDER O � PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility//) Feet Furnished by �`v ? r � .� S �� , i � N� -� rye �. ^�j 5 � _ _� � � � ,� ` ` .e \ r ��`� ' �` r � - � .. .o- ....+�^` �C MASSACHUSETTS `�W AUDUBON SOCIETY a� o •03 �6� SIX CONC. FOOTINGS 9�; N/F DA VID HANSON r A.M. 168-89 „ al,. ALI ". Q �_ 1 AREA=116,870.f-S.F. LOT IA aL A.M. 167-29 Alk I IL ti i �o AL AL AIL ssy_ Ilk AL LI ram. o A .b del• tO 11.L al A` N/1 JAI. � . all. p alp. all. Tl�. ali. I:4 IL . PARCEL IB all. o All i O Ab If i,• du L al,, ail. ,i,. jJ6�uv SIX CONC. N1 � - F007sINGS Gp4' yF,P �6. N/F DA YID HANSON � AM. 168-89 FP � 3! IV 7- � / °``4 .O. CENTER VIL. LOCUS MA rs PLAN REF 554- r' DEED REF 1923 s- ZONING: 'RD-. "RC" FLOOD ZONE- "C" PANEL NUMBER.- 2501 0S" DATED.- 07-1 AREA=116,870-t F t sr 1.1- LOT 1A �zF� PLOT PLAN O, A.M. 167-29 S's9. LOCATED AT �3��,}0 � 9 FI VE CORNEh �co AL CENTER VILLE PREPARED Ft AL f�� h 4� ' 0 , sSHELILA � HORS co 3s- a oA I WALTER MCDOJ SEPTEMBER Il, i N/F EDWARD C; WMNE �ofT�+ , i W A.M 167-1 REV (L A, AAAAA REV- PARCEL IB O R*p °'II-" Qa REV ,i 9LG v AL < 17 STEPHEN ; YANKEE LAND SL � a DOYLE ;� s & CONSUL TA ,� '�, a '� �" • P.O. BOX 26.' oil. i, •� `~' '` E`O a�� MARSTDNS MLLS,SM. TEL 508-428-0055 FAX* ' AL IL it-- _ - .`. s'�_,x -;n,u„,... ,.. . -. ....,,. .., - <. n.:. ..._ ..i.ieEsr•. .-..:.+ zs.:: ,e.:r":'r...-..,..a. .._,:_.:._ .1—,- tts BIRCH PLY&SCREE RECESS AROUND FULL RIMETER 9 FRAMES 47.6 CILL BOARD [0,"17 I 1 r-iao 19 b [0 ob m to m rt Z a o SCREEN z 44��/J/ PPP n w SCREENS AT 4 OPENING SASHES K. TOWN CouNTRY C o n s e r v a t o r i e s GSJNT1AI8IsMmAw CMAW LB1613 . T�TI3�81-121� G�c Trl2B1$s 676 1311 1311 664 - v � i.. Frame Plan " G *,L1-1 — Scale:1:20 ...-- HOUSING GUIDE RAIL REVISION REM DATE HO tU` HORAN ORANGERY Sire Address 19 FIVE CORNERS ROAD, C TER I L e N V L A /1 02632 °� �� Dra✓viny Tiile x { IIY ( PLAN SCREENS Date Scale 05/27/ 1:2c&1.C •,+Ora ,oy checeed�y. YeC:ed on Motatim Nmber Drawing Number l L 17/05/20119 09 Z 4 J