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0100 GREEN DUNES DRIVE - Health
100 GREEN DUNES DRV. a <: CENTERVILLE A = 11/! • UPC 12534 ' 2.153L R � HAIM",UN .... COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAI AFFAIRS John Graci DEPARTMENT OF ENVIRONMENTAL PROTECTION DEP Title V Septic Inspector ONE WINTER STREET BOSTON MA 02108(617)292-3500 P.O.Box 2119 TeaTicket,Ma. (508)564-6813 TRUDY COXE Secretary ARGEO PAUL CELLUCCI DAVID B.STRUHS Governor Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION /d0 Property Address: 100 GREEN DUNES RD. HYANNIS S ' �'56' ar Name of Owner GEORGIA WELCH / 11` ' IVEO V! Address of Owner: 301 BERKELY ST.BOSTON MA.02116 Date of Inspection: 918/99 S EP 2 4 �999 a. 114 Name of Inspector:(Please Print)JOHN GRACI TOIVf10F n I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000) S yFQqDE pr F 4 Company Name: n/a A Mailing Address: n/a Telephone Number: nla E 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 inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.The system: X Passes The inpection is based on criteria defined in Title V Conditionally Passes code 310 CMR 15.303.My findings are of how the system Is _ Needs Further Evaluation By the Local Approving Authority performing at the time of the inspection.My inspection does Fails not imply any warranty or guarantee of the longgevity of the septic system and any of its components useful life. Inspector's Signature: / Date:9/21/99 The System Inspector shall bmit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 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. NOTES AND COMMENTS THE SYSTEM PASSES TITLE V INSPECTION.RECOMMEND PUMPING SYSTEM NOW AND THEN MAINTAINING EVERY ONE TWO YEARS.THE PIPE COMING IN TO THE PIT HAS A SLIGHT BEND IN IT. revised 9/2198 Page 1 of 11 I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 100 GREEN DUNES RD.HYANNIS Owner: GEORGIA WELCH Date of Inspection:9/8/99 INSPECTION SUMMARY: Check A, B, C, or D: A. SYSTEM PASSES: I I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist.Any failure criteria not evaluated are indicated below. COMMENTS: System passes Title V inspection B. SYSTEM CONDITIONALLY PASSES: nLa 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 b the Board of Health will ass. P P PP Y P Indicate yes,no,or not determined(Y,N,or ND).Describe basis of determination in all instances.If"not determined",explain why not. nta The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection;or the septic tank,whether or not metal,is cracked,structurally unsound,shows substantial infiltration or exfiltration,or tank failure is imminent.The system will pass inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. nLa 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). broken pipe(s)are replaced obstruction is removed _ distribution box is levelled or replaced Wa 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 revised 9/2/98 Page 2 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 100 GREEN DUNES RD.HYANNIS Owner: GEORGIA WELCH Date of Inspection:9/8/99 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 HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 15.303(1)(b)THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT ThE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: _ Cesspool or privy is within 50 feet of 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 AND SAFETY AND THE 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 soil absorption system and the SAS is within a Zone I of a public water supply well. _ The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well, The system has a septic tank and soil absorption system and the SAS 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 free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,Method used to determine distance nl& (approximation not valid). 3) OTHER n/a revised 9/2/98 Page 3 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 100 GREEN DUNES RD.HYANNIS Owner: GEORGIA WELCH Date of Inspection:9/8/99 D. SYSTEM FAILS: You must indicate either"Yes"or"No"to each of the following: I have determined that one or more of the following failure conditions exist as described 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. Yes No X Backup of sewage into facility or system component due to an 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 nta. X Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. X Any portion of a 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 I 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.If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic ompounds, ammonia nitrogen and nitrate nitrogen. X The liquid level in the SAS is over the invert pipe,is in Hydraulic Failure. E. LARGE SYSTEM FAILS: 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: _ The system serves a facility with a design flow of 10,000 gpd 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: Yes No X the system is within 400 feet of a surface drinking water supply X the system is within 200 feet of a tributary to a surface drinking water supply X 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) The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.30412).Please consult the local regional office of the Department for further information. revised 9/2/98 Page 4 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 100 GREEN DUNES RD.HYANNIS Owner: GEORGIA WELCH Date of Inspection:9/8/99 Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following: Yes No X Pumping information was provided by the owner,occupant,or Board of Health. X 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. X As built plans have been obtained and examined.Note if they are not available with N/A, X The facility or dwelling was inspected for signs of sewage back-up. X The system does not receive non-sanitary or industrial waste flow. X The site was inspected for signs of breakout, X All system components,excluding the Soil Absorption System,have been located on the site. X The septic tank manholes were uncovered,opened,and the interior of the septic tank was inspected 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: X Existing information,For example,Plan at B4O,H, X Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable) [1 5.302(3)(b)) X The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of SubSurface Disposal Systems. revised 9/2/98 Page 5 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 100 GREEN DUNES RD.HYANNIS Owner: GEORGIA WELCH Date of Inspection:9/8/99 FLOW CONDITIONS RESIDENTIAL: Design flow:-Q g.p.d./bedroom Number of bedrooms(design): 3 Number of bedrooms(actual):3 Total DESIGN flow: = Number of current residents:- Garbage grinder(yes or no):NO Laundry(separate system)(yes or no): NO If yes,separate inspection required Laundry system inspected(yes or no):M Seasonal use(yes or no):J%Q Water meter readings,if available(last two year's usage(gpd): Wa Sump Pump(yes or no): NO Last date of occupancy: nLa COMMERCIAL/INDUSTRIAL Type of establishment: Wa Design flow: n&gpd(Based on 15.203) Basis of design flow: nLa Grease trap present:(yes or no):JLQ Industrial Waste Holding Tank present:(yes or no): NQ Non-sanitary waste discharged to the Title 5 system:(yes or no):NO Water meter readings.if available:Wa Last date of occupancy: n& OTHER: (Describe) � I Last date of occupancy: Wa GENERAL INFORMATION PUMPING RECORDS and source of information: THE SYSTEM HAS NOT BEEN PUMPED IN TWO YEARS. System pumped as part of inspection:(yes or no):NO If yes,volume pumped nLa_ gallons Reason for pumping: Wa TYPE OF SYSTEM X Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no)(if yes.attach previous inspection records,if any) I/A Technology etc.Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other: n& APPROXIMATE AGE of all components,date installed(if known)and source of information: THE SYSTEM IS 17 YEARS OLD. Sewage odors detected when arriving at the site:(yes or no): NQ revised 9/2/98 Page 6 of 11 r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 100 GREEN DUNES RD.HYANNIS Owner: GEORGIA WELCH Date of Inspection:9/8199 BUILDING SEWER: (Locate on site plan) Depth below grade: V Material of construction:_ cast iron X 40 PVC _ other(explain) Distance from private water supply well or suction line: TOWN Diameter: nLa Comments: (condition of joints,venting,evidence of leakage,etc.) nLa SEPTIC TANK: X (locate on site plan) Depth below grade: 2" Material of construction:X concrete_ metal_ Fiberglass _ Polyethylene _ other(explain) n& If tank is metal,list age Is age confirmed by Certificate of Compliance(Yes/No): NQ D& Dimensions: L 8'6"H 5'7"W 4'10" Sludge depth: r Distance from top of sludge to bottom of outlet tee or baffle: .3 Scum thickness:2 Distance from top of scum to top of outlet tee or baffle: 6" Distance from bottom of scum to bottom of outlet tee or baffle: 1f'_ How dimensions were determined: MEASURED 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.) SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY v SOUND RECOMMEND PUMPING NOW AND THEN MAINTAINED EVERY TWO YEARS. GREASE TRAP: (locate on site plan) Depth below grade: Material of construction:_concrete_ metal_ Fiberglass _ Polyethylene_other(explain) DLa Dimensions: Wa Scum thickness: nta Distance from top of scum to top of outlet tee or baffle:iiLa Distance from bottom of scum to bottom of outlet tee or baffle nLa Date of last pumping: nta 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.) nLa revised 912/98 Page 7 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 100 GREEN DUNES RD.HYANNIS Owner: GEORGIA WELCH Date of Inspection:9/8/99 TIGHT OR HOLDING TANK: NQ (Tank must be pumped prior to,or at time of,inspection) (locate on site plan) Depth below grade: nLa Material of construction:_ concrete_ metal_ Fiberglass _Polyethylene_ other(explain) DIA Dimensions: nta Capacity: nLa gallons Design flow: nLa gallons/day Alarm present: UQ Alarm level:jila- Alarm in working order:Yes_No_: NO Date of previous pumping: nta Comments: (condition of inlet tee,condition of alarm and float switches,etc.) nta DISTRIBUTION BOX: X (locate on site plan) Depth of liquid level above outlet invert:LIQUID LEVEL WITH BOTTOM OF PIPE Comments: (note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.) DISTRIBUTION BOX IS STRUCTURALLY SOUND PUMP CHAMBER: NQ (locate on site plan) Pumps in working order:(Yes or No): MO Alarms in working order(Yes or No): MO Comments: (note condition of pump chamber,condition of pumps and appurtenances.etc.) Wit revised 9/2/98 Page 8 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 100 GREEN DUNES RD.HYANNIS Owner: GEORGIA WELCH Date of Inspection:9/8/99 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,if possible;excavation not required,location may be approximated by non-intrusive methods) If not located,explain: nLa Type: leaching pits,number: 1000 GALLON LEACH PIT leaching chambers,number: _to leaching galleries,number: _nLa leaching trenches,number,length: nta leaching fields,number,dimensions: nLa overflow cesspool,number: Wit Alternative system: nLa Name of Technology: _nLa Comments: (note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.) THE LEACH PIT IS STRUCTURALL SOUND AND FUNTIONING PROPERLY THE PIT WAS 314 AT THE TIME OF THE INSPECTION SYSTEM SHOWS NO SIGNS CESSPOOLS: _ (locate on site plan) Number and configuration: nLa Depth-top of liquid to inlet invert: Wa Depth of solids layer: Wa Depth of scum layer. Wa Dimensions of cesspool: Wa Materials of construction: nLa Indication of groundwater: Wa inflow(cesspool must be pumped as part of inspection)Wa Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) Wa PRIVY: _ (locate on site plan) Materials of construction:nLa Dimensions:Wa Depth of solids: p Wa Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) Wit revised 9/2/98 Page 9 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 100 GREEN DUNES RD.HYANNIS Owner: GEORGIA WELCH Date of Inspection:9/8/99 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100'(Locate where public water supply comes into house) n/a e C � o RA fk R '4 �p ati revised 9/2/98 Page 10 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 100 GREEN DUNES RD.HYANNIS Owner: GEORGIA WELCH Date of Inspection:9/8/99 NRCS Report name: nta Soil Type: nla Typical depth to groundwater: Wa USGS Date website visited: n/a Observation Wells checked: WQ Groundwater depth:Shallow _ Moderate _ Deep _ SITE EXAM _ Slope _ Surface water _ Check Cellar Shallow wells Estimated Depth to Groundwater 12 Feet Please indicate all the methods used to determine High Groundwater Elevation: _ Obtained from Design Plans on record Observed Site(Abutting property,observation hole,basement sump etc.) Determined from local conditions Checked with local Board of health _ Checked FEMA Maps Checked pumping records _ Checked local excavators,installers XUsed USGS Data Describe how you established the High Groundwater Elevation.(Must be completed) USGS MAPS AND CHARTS-12+FEET revised 9/2/98 Page 11 of 11 i COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL DEPARTMENT OF ENVIRONMENTAL PR ONE WINTER STREET, BOSTON MA 02108 (617) e" WILLIAM F.WELD 0R TRUDY COXE Governor . 01 1 Secretary ARGEO PAUL CELLUCCINsr� DAVID B. STRUHS Lt. Governor �FpT c. Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIF 710N Property Address: _-(O6 �¢�,, „, Dv.lL04$et t '.Address of Owner: lVcvN&.--c, k Htt I c=/L. Date of Inspection: o Zj !o (V different) S/ o / 41 e4A Name of Inspector: ti'l.,_v ,,_\ "t�,-Z:�,�\_o yat, a /N i9- Company Name, Address and Telephone Number: �-VI•(>�c� 1J�yt �nsJ.ek� t Mrs. o2t.yq CSurCi� �i77-1V2d 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 inspection. The inspection was performed based on my training and experience in the proper function 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: 44�2ak, Date: The System Inspector 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 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: Check A, B, C, or D: A] SYSTEM PASSES: 1 have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated 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, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain why not. The septic tank is metal, cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 11/03/95) 1 w i� Printed on Recycled Paper r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address:�mo �r^ea ky4/ ",,�o_ r, �y�,,�•^ Owner: Date of Inspection: /, > "'L B] SYSTEM CONDITIONALLY PASSE§(eontinued) Sewage back�p�n�breakout or high static water level observed in the distribution x is due to broken or obstructed pipe(s) or dyerto� broken, settled or uneven distribution box. The system will p s inspection if(with approval of the Board`of ki al..): broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four times a year due to br en 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 HEALT . Conditions exist which require further evaluation by the Bo d of Health in order to determine if the system is failing to protect the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH D ERMINES THAT THE SYSTEM 15 NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AN SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of a rface water Cesspool or privy is within 50 feet of bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD PF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A NER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic ta*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 nk and soil absorption system and is within a Zone I of a public water supply well. _ The system has a septi tank and soil absorption system and is within 50 feet of a private water supply well. _ The system has a se p is tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water supply well, unless well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollutio from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm• 3) OTHER (revised 1 03/95) 2 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 400 Owner: P, /Y E!2/L_. Date of Inspection: o / S D] SYSTEM FAILS: L I have determined that the system violates one or more of the following failure criteri as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted o determine what will be necessary to correct the failure. Backup of sewage into facility or system component due to an overloa ed or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or su ce waters due to an overloaded or clogged SAS or cesspool. Static liquid level in the distribution box above outlet invert d to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6" below invert or ava'able 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 _. Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. g Any portion of a cesspool or privy is within 100 et of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a one I of a public well. Any portion of a cesspool or privy is withi 50 feet of a private water supply well. Any portion of a cesspool or privy is les than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If th well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic co pounds, ammonia nitrogen and nitrate nitrogen. E] LARGE SYSTEM FAILS: The following criteria apply to large sys ms in addition to the criteria above: The system serves a facility with a d ign flow of 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety and the en ironment because one or more of the following conditions exist: the/and ithin 4 feet of a surface drinking water supply theithin 00 feet of a tributary to a surface drinking water supply theo ed in a nitrogen sensitive area (Interim Wellhead Protection Area (IWPA) or a mapped Zone II of a pubu ply well) The owner or operatorh system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 Cnd 6.00. Please consult the local regional office of the Department for further information. (revised 11/03/95) 3 C SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: -ea c GKe ✓ J) Owner: Date of Inspection: 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. 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, excluding 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 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 b non-intrusive methods. PP Y The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of Sub- Surface Disposal System. (revised 11/03/95) 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: —Coo G �► �+�..d_ r . �y 4 Owner: A,, Date of Inspection: 4 51- FLOW CONDITIONS RESIDENTIAL: Design flow: '�330gallons Number of bedrooms:PZ> Number of current residents: Garbage grinder (yes or no): t2.0 Laundry connected to system (yes or no):-�-S Seasonal use (yes or no):41110 Water meter readings, if available:_tj a. Low v Last date of occupancy: COMMERCIAUINDUSTRIAL: Type of establishment: Design flow: gallons/day 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: OTHER: (Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: _ "<Rvr�DI)��� TXWjS �ti\�n.S &,P in Al&T� IN OW1►�4"C& Taaw�Ou�tr�e System pumped as part of inspection: (yes or no)_ If yes, volume pumped: Gallons Reason for pumping: TYPE OF SYSTEM X Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system (yes or no) (if yes, attach previous inspection records, if any) Other (explain) 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 11/03/95) 5 s K i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: . ?ap e? G vie Owner: b • K&!'eZ/Z_ Date of Inspection: 4 SEPTIC TANK: (locate on site plan) Depth below grade:JL Material of construction: A_concrete _metal _FRP —other(explain) Dimensions: N' Sludge depth: t)' 7 Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: 611 Distance from top of scum to top of outlet tee or baffle: IU't Distance from bottom of scum to bottom of outlet tee or baffle:_ Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation too t invert, structural integrity, evidence of leakage, etc.) W GREASE TRAP:A9 (locate on site plan) 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: Distance from bottom of scum to bottom 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.) (revised 11/03/95) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: f 6, Owner: Al. /Y p Date of Inspection: TIGHT OR HOLDING TANKA (locate on site plan) 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:�1 ,� (locate on site plan) 1 Depth of liquid level above outlet invert: '601a7TNle4 Comments: (note if level aV�nd tribu o is equal, evidence of solids carryover, evidence of leakage into or ut of box, etc.)J PUMP CHAMBER: (locate on site plan) Pumps in working order:(yes or no) Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) (revised 11/03/95) 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: N . K�-�•� 2 j Date of Inspection: SOIL ABSORPTION SYSTEM (SAS): (locate on site plan, if possible; excav tion not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: i Type: leaching pits, number:_ leaching chambers, number:_ leaching galleries, number: leaching trenches, number,length: leaching fields, number, dimensions: overflow cesspool, number: Comments: (note condition of soil, signs o hydraulic ilpre, I vel p�ponding n � t�onditiP .of v getation,etc.) n � 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, etc.) PRIVY: (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.) (revised 11/03/95) 8 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: m p Owner: N. t._t �r�er.� ✓�_.a� f�y a ..I L.,ti Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' a t O C� y �w1151U NS DEPTH TO GROUNDWATER 1 Sig Depth to groundwater'-11 feet method of determination or approximation: -kOGe t{,yr n 3 }a wa4ua. %R,170 .. ,( ► l 3'S' S� z,C)N (revised 11/03/95) 9 No...8!.'. Fps....�®.. THE COMMONWEALTH OF MASSACHUSETTS I�i ' BOAR® OF HEALTH . ....... o Appl ration for Dhivoii al i0orkii Tong rurtiun jhrutit Application is hereby made for a Permit to Construct (1,/4 Repair ( ) an Individual Sewage Disposal System at: ��/ �. ... r� 41E......... ........... ......!5�� ................................................. Locatiyn-Address or Lot No. ............. t .... -------------- ................................_. ............------.........................._ ner Address Installer Address Type of Building Size Lo - 1 ...Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic ( ) arbage Grinder ( ) Pk Other—Type of Building ............................ No. of persons........4............... Showers ( ) — Cafeteria ( ) Q' Other 'fixtures -----••------------------------•-- W Design Flow................4_47.................gallons per person e`day. Total daily flow............. a Q................_galls. WSeptic Tank—Liquid'capacity�MP.gallons Length__... Widths .. Diameter________________ Depth 5". x Disposal Trench—No..................... Width----s............... Total Length.....................Total leaching area....................sq. ft.Seepage Pit No.......�__........ Diameter..,/Z.......... Depth below inlet...Z.47 .... Total leaching area-_,.'YSr..sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed A_�!4 MOC,. Date.........OA_21 -1-.. Test Pit No. 1....�- .minutes per inch Depth of Test Pit_.�r� ._.__. Depth to ground water/rl.NVE..600'y LT4 Test Pit No. 2Z7-L—minutes per inch Depth of Test Pit./l<1..... Depth to ground water.tiP�.P--y-140 O io....�:� d ---- ------------------------------------••-----e......---....-�i._-----....-----•-•---••-------------------------•--••---•----••••-- Description of Soil �`1 1� - ��?w�B.. Z o A .- '`°® D w sT` c?fE_-7`c�_. ref et, '� - ��v __. _. � �� UNature of Repairs or Alterations—Answer when applicable............................................................................................... -----------•----------------•--------------•--•-••-•----....---.....----------------........------..-1.....----••----------------------------•--•-----------------------------...---------------......._. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of iITL LE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has beenAsurd by the board 1 ealth. Signed------•...111-14 Date Application Approved By..... !---------•.. ... .................... .:!.------------... ... V ate Application Disapproved for the following reasons:..........................................------------------•--------------•-................................. .................................................................................................................................................................................. Date PermitNo....................................................... Issued-........................................ ............... Date xo............G2.Z. . F�$.....3.°..�� ....... gf THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ............0 Appliration for DhiposFai Vorkri Tontruriion ramit Application is hereby made for a Permit to Construct (tor Repair ( } an Individual Sewage Disposal System at: .............. --_...._ .... ...................... .................... .................................................... Location-Address or Lot No. ............. . .. x............•......................... ..........--...................................................................................... 0 ner Address Installer Address dType of Building Size Lot_?�.__7- 0--- feet F Dwelling—No. of Bedrooms..........'.................................Expansion Attic ( ) .Garbage Grinder ( ) `04 4 Other—T e of Building No. of persons........ ................ Showers — Cafeteria Q' Other fixtures -----------------------------••••- W Design Flow..................•.......... ...._..___....gallons per person er�ay. Total daily flow__........_�, 3 C-%...........•.....gallons. WSeptic Tank—Liquid capacit o�o.gallons Length.-----.._. Width:t�...... Diameter............... Depth-�...=t.... x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No.......Z.......... Diameter—/ .......... Depth below inlet....3_.5- .... Total leaching area.2.!' .-___sq. ft. Z Other Distribution box ( ) Dosing tank ( ) '-' Percolation Test Results Performed bat, ?.:___ ___ .............................` �� Date........ /..Z.?.. J_..... !Ylo:.iN �! ,aa Test Pit No. L-__�Z_minutes per inch Depth of Test Pit.-/ Depth to ground Test Pit No. 2Z.� minutes per inch Depth of Test Pit./ ....... Depth to ground water.!�t''___ --- --- -•-- ............... 0 Description es ption of Soil ��:�`- --'`- JS Soi L. • �Z�`7 Co�`�=�C ���`'� . -------------- ---- -- - ---••••. c., 9.. cc �'j ` .� �r= /� tad! = =-5-'�R=� -......... W � sr/�OvG .............................� ` 1� ``' --17. rs i..k, 5?. ............................Q_c_i_..... ..)------ UNature of Repairs or Alterations—Answer when applicable___________________ ________ ____________________ _________ ............_....... ----------------------------•---............----•-•-------------------•-------------------------------------------------------------•---------•--------------------....----------------•--•-----•--•_.. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE; 5 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.....................................••--•-•••-•...••... Application Approved B �.... j5�0_W ---- . � ,� . Application Disapproved for the following reasons-------------------------------------------------------------------------------------••--- Date -----•---••-. --•--•----•----------•----....-•-----------------------------------------------------------------••----------••-••-••............•------•--............................................................ Date PermitNo.......................................................... Issued_....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS _ BOARD OF HEALTH ./............O `1. `.. /_5...1.4...�J: `'5�.- .................. Murr#ifiratr of TuntpfiFatta THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed (L./or Repaired ( ) by------------- .........2-> - ----•-----•---Installer•------------------------.-------------- .............. .-.........•------------------ -------- � at__... ,.c ,.yam.......7 has been installed in accordance with the provisions of TIT�he State Sanitary Code as described in the application for Disposal Works Construction Permit �'o.._�t,1r.�!..$,, ......... dated__........__________________________________•--- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE............................................ ..� :� ....... Inspector---•---v . ` ................................................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEA TH ............... ." No......� - ,�L .- FEE..... ........... �i��ro��1 ork� �on�#rttr�ion rrnti# . Permission is hereby granted........... �2 . -•••-••.......-•---•--••--•--•••-••-••••-•••-•...............•-•-....•. to Construct or Repair ( ) an Indivi ual Sewage Disposal System at No. . ............�r,�.. �------... ------- � r loin arG Street as shown on the application for Disposal Works Construction Permit No......................D Dated....... _. .........................:_:,_.. / of Health DATE................................................. ..1�!/w . FORM 1255 HOBBS & WARREN. INC., PUBLISHERS r n _ �C� �c P TOWN OF W LWATION (1 S SE AGE # VILLAGE ASSESSOR'S MAP &LOT INSTALLER'S NAME&PRONE NO. _SEPTIC TANK CAPACITY -7660 LEACHING FACILITY: ( pe) /�Z� (size) ` 6 NO.OF BEDROOMS BUILDER OR OWNER . 0 PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the 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 77 AA d- AC a� A0 31 A as � r TOWN OF BARNSTABLE LOCATION' r� ,�,`'1� ��� SEWAGE VILLAGE W= 11�-T— _ASSESSOR'S MAP &LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY "o C+IP1 l LEACHING FACILITY: (type)T (size) x NO.OF BEDROOMS BUILDER OR OWNER PERMTTDATE: 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 r A 30 A3 4�y-37�' g�-�� J/ LO AT ION /' SEWAGE PERMIT NO• VILLA-GE INSTA LLER'S NAME i ADDRESS 6UILDE111 0R OWNER DATE PERMIT ISS_U E 0 D-kT E C0M-PLIAN-CE ISSUED �. / s�� }.. - p -�.�...�r.�z�,.�..�--•ems . 3 r� t I '-7s;;' ,�'*•t,',.r..� * yr... 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