HomeMy WebLinkAbout0083 GOOSE POINT ROAD - Health 83 Goose Point Road
Centerville P
252 081
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SIIII A J�gECYC(f�Co
UPC 12543
No. 5 pR
HASTINGS,MN
Date: �/ze/
TOWN OF BARNSTABLE
TOXIC AND HAZARDOUS MATERIALS REGISTRATION FORM ;
,n 11
NAME OF BUSINESS:
BUSINESS LOCATION: 6-pUs Wd- INVENTORY
MAILING ADDRESS: S A✓U TOTAL AMOUNT-
TELEPHONE NUMBER:
CONTACT PERSON: Cob,M I e-
l�1 �✓r , I
EMERGENCY CONTACT TELEPHONE NUMBER: So S� 7-96 S-c)? ( MSDS ON SITE?
TYPE OF BUSINESS: Pall cl 4i A s
INFORMATION / RECOMMENDATIONS: Fire District:
Waste Transportation: Qu-mQ ( GZtAAI ,�J-� Last shipment of hazardous waste:
Name of Hauler: Destination:
Waste Product: Licensed? Yes No
NOTE: Under the provisions of Ch. 111, Section 31, of the General Laws of MA, hazardous material use,
storage and disposal of 111 gallons or more a month requires a license from the Public Health Division.
LIST OF TOXIC AND HAZARDOUS MATERIALS
The Board of Health and the Public Health Division have determined that the following products exhibit toxic or
hazardous characteristics and must be registered regardless of volume.
Observed / Maximum Observed / Maximum
Antifreeze (for gasoline or coolant systems) Miscellaneous Corrosive
❑ NEW ❑ USED Cesspool cleaners
Automatic transmission fluid Disinfectants
Engine and radiator flushes Road salts (Halite)
Hydraulic fluid (including brake fluid) Refrigerants
Motor Oils ,���� Pesticides
❑ NEW U'USED (insecticides, herbicides, rodenticides)
Gasoline, Jet fuel,Aviation gas
Photochemicals (Fixers)
Diesel Fuel, kerosene, #2 heating oil ❑ NEW ❑ USED
Miscellaneous petroleum products: grease,
Photochemicals (Developer)
lubricants, gear oil ❑ NEW ❑USED
Degreasers for engines and metal Printing ink
Degreasers for driveways&garages Wood preservatives (creosote)
Caulk/Grout Swimming pool chlorine
Battery acid (electrolyte)/Batteries Lye or caustic soda
Rustproofers Miscellaneous Combustible
Car wash detergents Leather dyes
Car waxes and polishes Fertilizers
Pphalt& roofing tar PCB's
,Qaints, varnishes, stains, dyes Other chlorinated hydrocarbons,
v Lacquer thinne s (including carbon tetrachloride)
�� NEW � USED Any other products with "poison" labels
(including chloroform, formaldehyde,
Paint&varnish removers, deglossers hydrochloric acid, other acids)
Miscellaneous. Flammables Other products not listed which you feel
Floor&furniture strippers may be toxic or hazardous (please list):
Metal polishes
Laundry soil &stain removers
(including bleach)
Spot removers&cleaning fluids
(dry cleaners)
Other cleaning solvents
Bug and tar removers
Windshield wash
WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS Applicant's Signature. Staff's Initials
YOU WISH TO OPEN A BUSINESS?
For Your Information: Business certificates (cost$40,00 for 4 years). A business certificate ONLY REGISTERS YOUR NAME in town (which you
must do by M.G.L.-it does not give you permission to operate.) You must first obtain the necessary signatures on this form at 200 Main St., Hyannis.
Take the completed form to the Town Clerk's Office, 1 st FI., 367 Main St., Hyannis, MA 02601 (Town Hall) and get the Business Certificate that is
required by law.
0maW0 DATE: s'25 ���' Fill in please:
APPLICANT'S YOUR NAME/S: ��`^' `'"+ U C
" BUSINESS YOUR HOME ADDRESS; rr 3 G-ua�0
TELEPHONE # Home Telephone Number_ s'o Fr 36
NAME OF CORPORATION: "
NAME OF NEW BUSINESS (DoU Cc a 1-1 4 TYPE OF BUSINESS-
IS THIS A HOME OCCUPATION? YES NO
ADDRESS OF BUSINESS 9L 0 i S ., Y C'�h /�� MAP/PARCEL NUMBER [Assessing)
9)
When starting a new business there are several things you must do in order to be in compliance with the rules and regulations of the Town of
Barnstable. This form is intended to assist you in obtaining the information you may need. You MUST GO TO 200 Main St. - (corner of Yarmouth
Rd. & Main Street) to make sure you have the appro riate permits and licenses required to legally operate our business in this town.
q 9 y P y
,off- � & I MUST 1. BUILDING COtal
SSI ER S OFFICE ����� COMPLY WITH HOME OCCUPATION
This individ e inf of n per it re uirements that pertain to this re of businessRULES AND REGULATIONS. FAIL URE TO
- COMPLY MAY RESULT IN FINES.
Aut oriz i
MMENTS
0 t - T.
2. BOARDfFF H LTH a)a_ AIr �--
This individual has been i d of he permit requirements that pertain to this type of business. (,�.c�rylQ.yJ
Auth d Signa MUST COMPLYINITH ALA:.
COMMENTS: Calf 'HAZARDOUS MATERIALS REGULATIONS-
3. CONSUMER AFFAIRS (LICENSING AUTHORITY)
This individual has been informed of the licensing requirements that pertain to this type of business.
Authorized Signature*
COMMENTS:
Hazardous Materials Inventory Sheet Checklist
Y 3 Date
Z Physical Street Address-Check database to ensure it exists
Working Phone Number
Actual Amounts -( ie. gas being used to fuel machines., thinner to
+; clean brushes all count as hazardous materials-no blanks)
Storage Information -location of storage, how long is storage for?
If none, rote that.
_�6isposal information where and who? If none, note that.
4- --Applicant Signature - understand what is listed and noted
Staff Initial -any questions, know who to ask
Vehicle.Washing/Rinsing? -give a vehicle washing policy and
e plain it
Attach the Business Certificate with your sign off and comments
*'tThe.inventory form should explain what the business consists of and the procedures
they are doing. Notes need to be left to explain what you discussed with them.
YOU WISH TO OPEN A BUSINESS? ' �
For Your Information: Business certificates (cost$40 00 for 4 inPss certificate ONLY REGISTERS YOUR NAME in town (which you
'must do by M.G.L.-it does not give you perrnission'to operate.) You must first obtain the necessary signatures on this form at 200 1-Aain St.., Hyannis.
Takes the completed form to the [own Clerk's Office, 1 st. FL, 367 Main St., Hyannis, MA 02001 (T own Hall:) and get the Business Certificate that is
required by law.
DATE. wl Fill in please: .
t APPLICANT'S YOUR NAME/S: "^v"
BUSINESS YOUR HOME ADDRESS:_ 8 3 6-ev>c 'Po .,i V r
h G + 4P }eX✓) L v✓l dt O L
r
TELEPHONE # Home Telephone Number Sn S' 36
NAME OF CORPORATION: �tJn )o J c e, e: D ►`F
NAME OF NEWBUSINESS TYPE OF BUSINESS
IS THIS-A HOME OCCUPATION? L� YES NO 1 J
ADDRESS OF BUSINESS R 3 (- .�o� Po .� (- rG! r�.Y ! �/c. �1 4 MAP/PARCEL NUMBER (Assessing]
When starting a new business there are several things you must do in order to be in compliance with the rules and regulations of the Town of
Barnstable. This form is intended to.assist you in obtaining the information you may need. You MUST GO TO 200 Main St. - (corner of Yarmouth
Rd. & Main Street) to make sure you have the appropriate permits and licenses required to legally operate your business in this town.
1. BUILDING COMMISSIONER'S OFFICE
This individual has been informed of any permit requirements that pertain to this type of business.
Authorized Signature*
COMMENTS:
2. BOARD OF HEALTH
This individual een inf d o the pp rmit re.Wirements that pertain to this type of business.
Authorized gnature**
COMMENTS:
3. CONSUMER AFFAIRS(LICENSING AUTHORITY)
This individual has been informed of.the licensing requirements that pertain to this type of business.
Authorized Signature**
COMMENTS:
Date: y / IF-
TOWN OF BARNSTABLE P S; I n
TOXIC AND HAZARDOUS MATERIALS ON-SITE I
NAME OF BUSINESS: �o (� A0re-
BUSINESS LOCATION: F 3 (took. ;o,A rd to^4rA ll<. wV1 Gz6sa INVENTORY
MAILING ADDRESS: S o w,e. TOTAL AMOUNT:
TELEPHONE NUMBER: Sow 7G _> /S�6
CONTACT PERSON: <<" n n, V n o r-rl
EMERGENCY CONTACT TELEPHONE NUMBER: C/61 ,1i9t, 9�9 9��, MSDS ON SITE?
TYPE OF BUSINESS: Pa. 1.,41 s%
INFORMATION/RECOMMENDATION Fire District:
Waste Transportation: Last shipment of hazardous waste:
Name of Hauler: Destination:
Waste Product: &14dl - NAza w.. kraL a pcensed? Yes No
NOTE: Under the provisions of Ch. 111, Section 31, of the General Laws of MA, hazardous material use,
storage and disposal of 111 gallons or more a month requires a license from the Public Health Division.
LIST OF TOXIC AND HAZARDOUS MATERIALS
The board of health and the Public Health Division have determined that the following products exhibit toxic or
hazardous characteristics and must be registered regardless of volume.
Observed / Maximum Observed / Maximum
Antifreeze (for gasoline or coolant systems) Miscellaneous Corrosive
❑ NEW ❑ USED Cesspool cleaners
Automatic transmission fluid Disinfectants
Engine and radiator flushes Road salts (Halite)
Hydraulic fluid (including brake fluid) Refrigerants
Motor Oils Pesticides
❑ NEW ❑ USED (insecticides, herbicides, rodenticides)
Gasoline, Jet fuel,Aviation gas Photochemicals (Fixers)
Diesel Fuel, kerosene, #2 heating oil ❑ NEW ❑ USED
Miscellaneous petroleum products: grease, Photochemicals (Developer)
lubricants, gear oil ❑ NEW ❑ USED
Degreasers for engines and metal Printing ink
Degreasers for driveways&garages Wood preservatives (creosote)
Caulk/Grout Swimming pool chlorine
Battery acid (electrolyte)/Batteries Lye or caustic soda
Rustproofers Miscellaneous Combustible
Car wash detergents Leather dyes
Car waxes and polishes Fertilizers
Asphalt& roofing tar PCB's
Pints, v?rnishes, stains, dyes Other chlorinated hydrocarbons,
`i•�1 S ' " (including carbon tetrachloride)
Lacquer thinners
Any other products with "poison" labels
❑ NEW BUSED
(including chloroform, formaldehyde,
Paint&varnish removers, deglossers hydrochloric acid, other acids)
Miscellaneous. Flammables Other products not listed which you feel
Floor&furniture strippers may be toxic or hazardous (please list):
Metal polishes
Laundry soil &stain removers
(including bleach)
Spot removers &cleaning fluids
(dry cleaners)
Other cleaning solvents
Bug and tar removers
Windshield wash
WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS Applicant's Signature Staff's Initials L
ECOJECH ��IAR
Environmental PARCEL • ®96 1
www.eco-tech.us LOT
THIS FORM IS A FACSIMILE OF THE STANDARD SEPTIC INSPECTION FORM ISSUED BY THE MASSACHUSETTS DEPARTMENT
OF ENVIRONMENTAL PROTECTION(revised 6/15/2000)
TITLE 5
OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 83 Goose Point Road
Centerville
Owner's Name: James Haines, George Haines,Laurie O'Brien,Lois Kelly &John Haines
Owner's Address: 815 Treasure Road
Venice,FL 34293 � a
Date of Inspection: September 30, 2004
Name of Inspector: (Please Print) David D. Coughanowr,R.S.
Company Name: Eco-Tech Environmental ?
Mailing Address: 43 Triangle Circle
Centerville,MA 02563
Telephone Number: (508)364-0894 1r1l
CERTIFICATION STATEMENT:
I certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my
training and experience in the proper function and maintenance of on-site sewage disposal systems. I am a DEP
approved system inspector pursuant to section 15.340 of Title 5(310 CMR 15.000). The system:
X Passes
Conditionally Passes
Needs Further Evaluation By the Local Approving Authority
Fails
Inspector's Signature �b K,�� G �s Date: see& 301 10
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
I_nspector's Note==> A septic system is deemed to pass this Real Estate Transfer Inspection if it does not trigger
any of the failure criteria listed below. The septic system has been evaluated according to the conditions observed
on the day it was inspected. No estimate or guarantee of system longevity is made or implied by a passing determination.
****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 1
Page 2 of 11
OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 83 Goose Point Road
Centerville
Owner: James Haines, George Haines,Laurie O'Brien,Lois Kelly, &John Haines
Date of Inspection: September 30, 2004
INSPECTION SUMMARY: Check A,B,C,D or E/ALWAYS complete all of section D:
A] System Passes:
Yes I have not found any information which indicates that any of the failure criteria described in 310 CMR
5.303 or in 310 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,or 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 breakout or high static water level 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 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 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
ND explain
2
Page 3 of 11
OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 83 Goose Point Road
Centerville
Owner: James Haines, George Haines,Laurie O'Brien,Lois Kelly, &John Haines
Date of Inspection: September 30,2004
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 and 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 1 of a public water supply.
The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a
private water supply well". Method used to determine distance
"This system passes if the well water analysis, performed by a DEP certified laboratory, for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
failure criteria are triggered. A copy of the analysis must be attached to this form
3) OTHER
3
Page 4 of 11
OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 83 Goose Point Road
Centerville
Owner: James Haines, George Haines,Laurie O'Brien,Lois Kelly, &John Haines
Date of Inspection: September 30,2004
D) System Failure Criteria applicable to all systems:
You must indicate either"yes" or"no" to each of the following for all inspections:
I have determined that one or more of the following failure conditions exist as described in 310 CUR 15.303.
The basis for this determination is identified below. The Board of Health should be contacted to determine what
will be necessary to correct the failure.
yes no
X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool.
X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool.
X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool.
X Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow.
X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number
of times pumped
X Any portion of the SAS,cesspool or privy is below high groundwater elevation.
X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
X Any portion of a cesspool or privy is within a Zone 1 of a public well
X Any portion of a cesspool or privy is within 50 feet of a private water supply well
X 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 by 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)
No (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-IWPA)or a mapped
Zone II of a public water supply well.
If you have answered"yes" to any question in Section E the system is considered a significant 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 CUR
15.304.The system owner should contact the appropriate regional office of the Department.
4
Page 5 of 11
OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 83 Goose Point Road
Centerville
Owner: James Haines, George Haines,Laurie O'Brien,Lois Kelly, &John Haines
Date of Inspection: September 30,2004
Check if the following have been done: You must indicate either"Yes" or"No"as to each of the following:
Yes No
Y Pumping information was provided by the owner,occupant or Board of Health.
N Were any of the system components pumped out in the last two weeks?
Y _ Has the system received normal flows in the previous two week period?
N Have large volumes of water been introduced to the system recently or as part of this inspection?
n/a _ Were as built plans of the system obtained and examined?(If they were not available as N/A)
Y _ Was the facility or dwelling inspected for signs of sewage back-up?
Y _ Was the site inspected for signs of breakout?
including
Y _ Were all system components,exeludin the SAS. located on site?
Y _ Were the septic tank manholes uncovered, opened;and the interior of the septic tank inspected for
the condition of the baffles or tees, material of construction,dimensions,depth of liquid, depth of sludge and depth of
scum.?
Y _ Was the facility owner(and occupants,if different from owner)provided with information on the proper
maintenance of subsurface disposal systems?
For information on the proper maintenance of subsurface disposal systems please go to:
WWW.ECO-TECH.US
The size and location of the Soil Absorption System(SAS)on the site has been determined based on:
N Existing information. For example,Plan at the Board of Health.
Y 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)]
5
Page 6 of 11
OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 83 Goose Point Road
Centerville
Owner: James Haines, George Haines,Laurie O'Brien,Lois Kelly, &John Haines
Date of Inspection: September 30, 2004
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): n/a Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): n/a—No plan on file at Health Dept.
Number of current residents 1
Does the residence have a garbage grinder(yes or no): yes—removal of grinder is strongly recommended
Is laundry on a separate sewage system(yes or no): no :(If yes, separate inspection required)
Laundry system inspected (yes or no): n/a
Seasonal use(yes or no): no
Water meter readings, if available(last two year's usage(gpd): 76 gpd
Sump Pump(yes or no)` no
Last date of occupancy: current
COMMERCIAL/INDUSTRIAL:
Type of establishment:
Design flow(based on 310 CMR 15.203):: gpd
Basis of design flow(seats/persons/sqft/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: System not pumped in recent past(Owner)
Was system pumped as part of the inspection: (yes or no) No
If yes,volume pumped: gallons--How was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM:
X Septic tank,fox, soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system(yes or no) (if yes, attach previous inspection records,if any)
Innovative/Alternate technology. Attach a copy of the current operation and maintenance contract(to be
obtained from system owner)"
Tight Tank Attach a copy of the DEP approval
Other(describe)
APPROXIMATE AGE of all components,date installed(if known)and source of information:
Age: 30 years. System is assumed to have been installed at time of dwelling's construction in 1974
Were sewage odors detected when arriving at the site: (yes or no) no
6
Page 7 of 11
OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 83 Goose Point Road
Centerville
Owner: James Haines, George Haines,Laurie O'Brien,Lois Kelly, &John Haines
Date of Inspection: September 30,2004
BUILDING SEWER_(Locate on site plan)
Depth below grade: 2 ft
Material of construction: X cast iron _40 PVC_other(explain)
Distance from private water supply well or suction line 20+
Comments: (on condition of joints,venting, evidence of leakage, etc.) .
Sewer is vented through roof and appears structurally sound with no evidence of leakage or backup into dwelling
SEPTIC TANK: Yes (locate on site plan)
Depth below grade: 12 inches
Material of construction: X concrete_metal_fiberglass_polyethylene
other(explain)
If tank is metal,list age_ Is age confirmed by Certificate of Compliance_(yes or no):_(attach a copy of
certificate)
Dimensions: 8.5 ft x 5 ft x 5 ft(1000 gallon)
Sludge depth: 4 in
Distance from top of sludge to bottom of outlet tee or baffle: 30 in
Scum thickness: 1 in
Distance from top of scum to top of outlet tee or baffle: 9 in
Distance from bottom of scum to bottom of outlet tee or baffle: 14 in
How dimensions were determined: Probe to top of tank
Comments: (on pumping recommendations,inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert,evidence of leakage, etc.):
Pumping not required at this time but maintenance pumping is recommended within and every 2 years. Liquid level at
outlet invert.Tank and tees appear structurally sound and functioning as intended. No evidence of leakage in or out.
GREASE TRAP: none (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
f
Page 8 of 11
OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 83 Goose Point Road
Centerville
Owner: James Haines, George Haines,Laurie O'Brien,Lois Kelly, &John Haines
Date of Inspection: September 30, 2004
TIGHT OR HOLDING TANK: none (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 inlet tee, condition of alarm and float switches,etc.)
DISTRIBUTION BOX: none (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 is equal,any evidence of solids carryover,any evidence of
leakage into or out of box, etc.)
PUMP CHAMBER: none (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
Page 9 of 11
OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 83 Goose Point Road
Centerville
Owner: James Haines, George Haines,Laurie O'Brien,Lois Kelly, &John Haines
Date of Inspection: September 30,2004
SOIL ABSORPTION SYSTEM(SAS): Yes (locate on site plan;excavation not required)
If SAS not located, explain why:
Type:
X leaching pits,number 1
_leaching chambers,number
_leaching galleries,number
_leaching trenches, number, length
_leaching fields,number,dimensions
_overflow cesspool, number
—innovative/alternate system Type/name of Technology
Comments: (note condition of soil, signs of hydraulic failure, level of ponding,damp soil,condition of vegetation, etc.)
Soils above leaching pit appeared unsaturated.No evidence of surface ponding breakout lush vegetation or
other evidence of hydraulic failure was observed. An observation hole was dug into leach pit stone and no
effluent contact staining was observed. No level of standing effluent was observed in top 2 feet of stone
CESSPOOLS: none (cesspool must be pumped at time of inspection)(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(yes or no):
Comments: (note condition of soil, signs of hydraulic failure,level of ponding,condition of vegetation,
etc.):
PRIVY:none (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.):
9 �
Page 10 of 11
OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 83 Goose Point Road
Centerville
Owner: James Haines, George Haines,Laurie O'Brien,Lois Kelly, &John Haines
Date of Inspection: September 30,2004
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 all wells within 100'(Locate where public water supply enters the building)
LEACH LOCATIONS
O PIT
A B
I 24 f t 24.5 It
2 2 28 Ft 27 It
SEPTIC 3 34.5 It 33.5 It
TANK M
A 6
EXISTING
DWELLING
# 83
W
Z
J
C
W
3
I
GOOSE POINT ROAD NOT TO SCALE
10
Page 11 of 11
OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 83 Goose Point Road
Centerville
Owner: James Haines, George Haines,Laurie O'Brien,Lois Kelly,&John Haines
Date of Inspection: September 30,2004
SITE EXAM
Slope
Surface water
Check Cellar
Shallow wells
Estimated Depth to ground water: 30+ feet
Please indicate(check)all methods used to determine 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 local excavators,installers-attach documentation)
X Accessed USGS database
You must describe how you established the high ground water elevation.
Comparison of USGS topography maps and surface water elevation shows property is over 30 feet above
nearby Shallow Pond.
11