HomeMy WebLinkAbout0025 HI-ONA HILL ROAD - Health (2) � L25Hi-ona-hill P
095
Afl
UPC 10259
(1e-
No. H163OR
N�trygr v�
COMMONWEALTH OF MASSACHUSETTS
" .
EXECUTIVE,OFFICE OF;ENVIHONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PR90T F Q
E -
' ?
_ DEC 1 2 2002
TOYMOFBARiNSTABI E:
HEALTH DEPT.
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION qT9 TS;
Property Address: Christine Glines '
25 Hi-Ona-Hill Rd MAP
Owner's Name: _ Centerville PARCEL
Owner's Address:
LOT
Date of Inspection:/ ;2,:.7- 6
Name of Inspector: (please print) William E_ . Robinson Sr.
Company Name: William E. Robinson Septic Service
Mailing Address: P 0 Box 1089
Centerville. MA
Telephone Number: (508) 775-8776 ,
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 aintenance of on site sewage disposal systems.I am a DEP
approved system inspector pursuant to Sectio 15.340 of Title 5(310 CMR 15.000).- The system:
liPasses
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: - v Date:f� - .--(S Z
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Heatth,or
DEP)within 30 days of completing this inspection.If the system is a shared system or bas a design now 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 approxing
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
f
Page 2 of l l
OFFICIAL INSPECTION FORM
—NOT`FOR`VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM.INSPECTION FORM
PART A
CERTIFICATION (continued)'
Property Address: 25 Hi—Ona—
enterville
Owner: C ristine Glines
Date of Inspection: Q��
Inspection Summary':Check A,B,C,D or E/ALWAYS complete.all of Section D
A. sy
stem Passes:
V 1 have not found any information which indicates 01 evaluated e failure
ailu i criteria
described in 310 CM
15.303 or in 310 CMR 15 304 exist.Any failure criteria n
n
Comments: 1 02
B. ystem Conditionally Passes:
One or more system components as described in the"Conditional Pov'ed by section
ithe Board of Health ew will pass.
repair d.The system,upon completion of the replacement or repair,as aPP
Answ yes,no or not determined(Y,N,ND)in the for the following statements.if"not determined"please
expla' .
e septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally
unso d,exhibits substantial infiltration or exfiltration or tank failure is imminent.System will pass inspection if the
exist- g tank is replaced with a complying septic tank as approved l y the Board of Health:'
*Am tal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indic ing that the tank is less than 20 years old is available.
ND a plain:
Observation of sewage backup or break out or high static water level in the distribution box due to-broken or
obs cted pipe(s)or due to a broken,settled or uneven distribution box.System will pass inspection if(with
appro al of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND ex lain:
The system required pumping more than 4 tunes a year due to broken or obstructed pipe(s).The system will
approval of the Board of Health):
e lion if with p
pass p ( P
broken pipe(s)are replaced
obstruction is rnmovod
ND explain:
i
Page 3 of 1 I
OFFICIAL INSPECTION FORM' NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL'SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 25 Hi—Ona hill Rd
Centerville
Owner: Christine Glines
Date of Inspection: / —,7---�e 1'+i
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 fail g to protect public health,safety or the environment.
1. ystem will pass unless Board of Health determines,in accordance with 310 CMR 15.303(1)(b).that the,
stem 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
Z. Syst in will fail unless the Board of Health(and Public Water Supplier,if any)determines.that the
system i functioning io a manner that protects thi public health,safety and environment;
_ he system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a
surf ce water supply or tributary to a surface water supply:
Jppri
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 front a
te water supply well".Method used to determine distance
• This system passes if the well water analysis,performed at"a DEP certified laboratory, for coliform
b cteria and volatile organic compounds indicates that the well is free from pollution from that facility and,
e presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
ailure criteria are triggered.A copy of the analysis must be attached to this form.
3. O er:
3
Page 4 of l I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSTION FORKASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPEC
PART
CERTIFICATION(continued)
25 Hi—Ona—Hill
Property Address:
Rd
enterville
Owner. Christine G1_ines
Date of Inspection:
D. System Failure Criteria applicable to all systems:.
You ust indicate`des"or"no"to each of the following for all inspections:
Yes o
Backup of sewage into facility or systemcomponent-
dace o en ede o nd or surface a waters d e to anoverloaded cesspool or
f th
the surface o gr .. ..
of effluent to ., _... .__ ..... _ .. . . _.. _
_ Discharge or ponding -
clogged SAS or cesspool
_ Static liquid level in the distribution box above outlet invert due to an`overloaded or clogged SAS or
S
cesspool
_ Liquid depth in cesspool is less than 6"below invert or available volume is less than day flow
tructe
Required pumping more than 4 times in the last year NOT due to clogged or obsd 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 7 of a public well.
_ Any,p'rtion 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 f et from a private water'
supply well with no acceptable water quality analysis.[This system passes if the well water analysis,
coliform bacteria,and volatile organic compounds
performed at a DEP certified laboratory,for
indicates that the well is free from pollution from that facility and the presence of ammonia
l to or less than 5 ppm,provided that no other failure criteria
nitrogen and nitrate nitrogen is equa
are triggered.A copy of the analysis must be attached to this form.]
(Yes/No)The system fails.1 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. rge Systems:
must serve a facility with a design now of 10,000 gpd to 15,000
To be considered a large system the system
gpd-
You m st indicate either"yes"or"no"to each of the following:
(The f lowing criteria apply to large systems in addition to the criteria above)
yes n
_ 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 11 of a public water supply well .
If you h e answered"yes"to any question in Section E the system is con sa f d a si ne�e threat, tiered
"yes"in Section D above the large system has failed.The own operas
signific nt threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
15.304. he system owner should contact the appropriate regional office of the Department.
4
Page 5 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAG El'DISP OS' A ' SYSTEM IN. SPECTION'F0RM
, = PARTB
CHECKLIST
Property Address- 25 .Hi—Ona—Hill Rd
Centerville
Owner:
ris ine Ines ,.
Date of Inspection: /,Z_ --6 �--
Check if the following have been done.You must indicate"yes"or"no"as to each of the following:
Yes No
t/Pumping information was provided by the owner,occupant,or Board of Health Y.
_ _c/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 large volumes of water been introduced to the system recently or as part of this inspection.?
✓ — Were as built plans of the system obtained and examined?(If 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
of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum?
_ , Was the facility owner(and occupants if different from owner)provided with information on the proper
maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has been determined based on:
Yes 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)]
5
F
Page 6 of 11
OFFICIAL INSPECTION FORM—A.--NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART G:.
SYSTEM INFORMATION
hill
Property Address: 25 Hi-Ona—
Centerville
Owner:
Christine G ines
Date of Inspection:
FLOW CONDITIONS
RESIDENTIAI.
Number of bedrooms(design): J Number of bedrooms(actual):
DESIGN flow based on 310 C 5.203(for example: 110 gpd x#of b drooms):
Number of current residents:�/
Does residence have a garbag grinder(yes or no)-&!p 4,
— -
Is laundry on a separate sewage system(yes or no)y,•6(1 [if yes separate inspection required]
Laundry system inspected(yes or no):
Seasonal use:(yes or no): �
Water meter readings,if available(last 2 years usage(gpd))" 2 0 0 0 69,00 0: gals
Sump pump(yes or no): 2001 , 0 0 0 gals
Last date of occupancy: rj:=,a.—e"✓
COMM CIAL/INDUSTRIAL
Type of es blishment:
Design flo (based on 310 CMR 15.203): gpd
Basis of design flow(seats/persons/sgft,etc.):
Grease trap resent(yes or no):_
Industrial w ste holding tank present(yes or no):_
Non-sani waste discharged to the Title 5 system(yes or no):_
Water meter readings,if available:
Last date of ccupancy/use:
OTHER(d cribe):
GENERAL INFORMATION
Pumping Records
Source of information:
Was system pumped as part of the inspection(yes or no):
If yes,volume pumped:_gallons--How was quantity pumped determined?
Reason for pumping:
TYP F SYSTEM
eptic tank,distribution box,soil absorption system
_Single cesspool
_Overflow cesspool
—Privy
_Shared system(yes or no)(if yes,attach previous inspection records,if any)
_Innovative/Altemative 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:
r^
Were sewage odors detected when arriving at the site(yes or no)k(J
6
` Page 7 of I I
OFFICIAL INSPECTION FORM NOT-FOR VOLUNTARY ASSESSMENTS
SUBSURFACE'SEWAGE DISPOSAL SYSTEM IN FORM
PART C
SYSTEM INFORMATION.(continued):
Property Address: 25 Hi—Ona—Hill Rd
Centerville
Owner: Christine Gl •nes_. ...
Date of Inspection:
BUILIkNG SEWER(locate'on site plan)
Depth b ow grade
Material of construction: cast icon._°'40 PVC, ._other(explain):
Distanc from private water supply well or suction line:
Comme is(on condition of joints,venting,evidence of leakage,etc.): '
SEPTIC TANK.Zoocate on site plan)....
Depth below grade:
Material of construction: concrete_metal_fiberglass_polyethylene
_othcr(explain)
If tank is metal list age:_ Is age confirmed-by a Certificate of Compliance(yes or no):_(attach a copy of
certificate) +r 7
Dimensions: a
Sludge depth: /— 4
Distance from top of sludge to bottom of outlet tee or baffle: 7 6
Scum thickness: 3
Distance from top of scum to top of outlet tee or baffle: 7 , +
Distance from bottom of scum to bottom outlet tee or baffle:/
How were dimensions determined: d ' ��}- t,4,
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of.leakage,etc.):
GRE E TRAP:_(locate on site plan)
Depth be ow grade:
Material f construction:_concrete_metal_fiberglass_polyethylene_other
(explain):
Dimensio :
Scum thic ess:
Distance fr m top of scum to top of outlet tee or baffle:
Distance fr a m bottom of scum to bottom of outlet tee or baffle:
Date of las pumping:
Comment110
(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related outlet invert,evidence of leakage,etc.):
Page 8 ofAEN 11
INSPECTION FORM SSESR
'NOT FOR VOL, ION FORM pTS
SUBSURFACE
SEWAGE DISPOSAL`SYSTEM INSPE
OFFICIAL CT
PART C
SYSTEM:JNFORAVIATION(continued)',�'.. <
Property Address: 25 Hi ill Rd
CeritPrv; 11
Owner: Chri ��,n.e Glines m..
Date of Inspection: f
-� y
'f'or HOLDING TANK: _(�must be pumped at time
of inspection)(locate on site plan)
T1CH
Depth bSe w grade: — 1 fiberglass__polyethylene other(explatn);;
p concrete meta ;
Material f construction:
Dimensio s:
allons
Capacity: gallons/day
Design Flow:
Alarm pre ent(yes or no): working es or no
Alarm lev l: _ Alarm in orkin order(y ):
Date of la t pumping:
Comment (condition of alarm and float switches,etc.):
if resent must be opened)(locate on site plan)
DISTRIBUTION BOX: P
Depth of liquid level above outlet invert:
evidence of solids carryover,
Comments(note if box is level and distribution t any evidence of _
o outlets equal,any
leakage into or out of box,etc.): l
pUMp CHA BER: (locate on site plan)
pumps in wor ing order(yes or no):
Alarms in wo king order(yes or no):
Comments( ote 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 p., 34
SYSTEM INFORMATION(continued),
Property Address: 25 Hi-Ona_Hill Rd
Centervil- l- e
ris ine Ines
Owner:
Date of Inspection: 4-1—
SOIL
SOIL ABSORPTION SYSTEM(SAS): V(locate on site plan,excavation not required)
If SAS not located explain why:
Type/ D
ching 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.): 'f
*77 —�i✓�
CE SPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan)
Numb r and configuration:
Depth top of liquid to inlet invert:
Depth o solids layer: .
Depth o scum layer:
Dimensi ns of cesspool:
Material of construction:
Indicatio of groundwater inflow(yes or no):
Comm en (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
PRIVY: (locate on site plan)
Materials f construction:
Dimensio s:
Depth of olids:
Comme is(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
9
Page 10 of 1 l
OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION'FORM
PART C:
SYSTEM INFORMATION(continued)
Property Address: 25 Hi—Ona—Hill Rd
Centerville
Owner: Christine Glines _._..._
Date of Inspection:)�Z-2 --0 ?-
-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 feet.Locate where public water supply enters the building. -
i
Nil
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: 25 Hi—Ona—Hill Rd
en ervi e
Owner: Gar; dine Glines
Date of Inspection:_� —,A-0-2—
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
otr
Estimated depth to groundwater 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 wit in 150 feet of SAS)
Checked with local Board of Health-explain: -rD d ,W
Checked with local excavators,installers-(attach documentation)
Accessed USGS database-explain:
You mustdesc ib$how you established the high gro nd wate elevation:
11
7
SUBSURFACE SEWAGE DISPOSAL BY B EM INSPECTI ON`IyORM '
Address of property
R�C�oy�p
Owner's name ° boh
Date of Inspection
PART A /N
CHECKLIST
Check if the following have been done: a
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 site was inspected for signs of breakout.
y V All system components, excluding the SAS, 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 SAS on the site has been determined based
on existing information or approximated by non-intrusive methods.
:1✓`,6 The facility owner (and occupants, if different from owner) were
provided with information on the proper maintenance of SSDS.'
t'
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION
FLOW CONDITIONS
If residential
3 number of bedrooms
number of current- residents
garbage grinder, yes or no
laundry connected to system, yes or no
,ate seasonal use, yes or no
If nonresidential, calculated flow:
Water meter readings, if available:
Last date of occupancy
GENERAL INFORMATION
Pumping records and source of information:
/ System Y pumped as part of inspection, yes or no
if yes, volume pumped l' o
Reason for pumping;
TYPE' of system
VV 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. Source of
information:
�U Sewage odors detected when arriving at the site yes or no
1
I
C!'
9
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION continued
SEPTIC TANK:
(locate on site plan)
depth below grade: '
material of construction: V Concrete metal FRP other(explain)
,i % V
dimensions:
sludge depth
distance from top of sludge to bottom of outlet tee or baffle
'I " scum thickness
41 , distance from top of scum to top of outlet tee or baffle
S` ' 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, recommendations for repairs, etc. )
DISTRIBUTION BOX:
(locate on site plan) _
i(/11q depth of liquid level above outlet invert
Comments:
(note if level and distribution is equal, evidence of solids carryover,
evidence of leakage into or out of box, recommendation for repairs, etc. )
L
PUMP CHAMBER:
(locate on sit pan)
pumps in working order, yes or no
Comments:
(note condition of pump chamber, condition of pumps and appurtenances, .
recommendations for maintenance or repairs,etc. )
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION continued
SEPTIC TANK:
(locate on site plan)
depth below grade:
material of construction: concrete metal FRP other(explair.
dimensions:— t V 1 6 v O r
sludge depth
�! distance from top of sludge to bottom of outlet tee or baffle
l " scum thickness
__!jj_! distance from top of scum to top of outlet tee or baffle
AL 1' 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, recommendations for repairs, etc. )
17 S ri.� b Q 4 r'
DISTRIBUTION BOX:
(locate on site plan)
depth of liquid level -above outlet invert
Comments:
(note if level and distribution is equal , evidence of solids carryover,
evidence of leakage into or out of box, recommendation for repairs, etc. )
l
V ti
PUMP CHAMBER:
(locate on sit pan)
pumps in working order, yes or no
Comments:
(note condition of pump chamber, condition of pumps and appurtenances,
recommendations for maintenance or repairs,etc. )
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION continued
SOIL ABSORPTION SYSTEM (SAS) :
(locate on site plan, if possible; excavation not required, but ma
approximated by non-intrusive methods) y be
If not determined to be present, explain:
---------------
Type.
leaching pits and number
leaching chambers and number
leaching galleries and number
leaching trenches, number, length
leaching fields, number, dimensions
overflow cesspool, number
Comments:
(note condition of soil, signs of hydraulic failure, level of ondi
or maintenance or re pairs
,etc. )
ng,
condition of vegetation, recommendations f
60 Q �
P ,etc. )
CESSPOOLS (locate on site plan) :
number and configuration J
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,condition of vegetation, signs of hydraulic failure
, levrecommendations for maintenanceeoro ponding,
re ai
p rs,etc. )
PRIVY:
(locate on site plan)
materials of construction
dimensions
depth of solids
Comments:
(note condition of soil,condition of vegetation, signs of hydraulic failure Of
{
recommendations for maintenance or. P etc. )
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION continued
SKETCH OF SEWAGE r'SPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100'
01
DEPTH TO GROUNDWATER
depth to groundwater
method of determination or approximation:
y
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
FAILURE CRITERIA
Indicate yes, no, or not determined (Y, N, or ND
determination in all instances. If "not determined",
Describe basis of
etermined", explain why not)
Backup of sewage into facility? .
Discharge or ponding of effluent to the s surface waters? urface of the ground or
_IV- Static liquid level in the distribution box above outlet invert?
Liquid depth in cesspool <6" below invert or available volume< 1 2
flow? / dad
Required pumping 4 times or more in the last
number of times pumped Year.
Septic tank is metal? cracked? structural) u
infiltration? substantial exfiltration? tank failure imminent?al
Is any portion of the SAS, cesspool or privy:
below the high groundwater elevation?
within 50 feet of a surface water?
within 100 feet of a surface water su v water supply? PPl, or tributary to a surface
l.
A within a Zone I of a u
p blic well?
IV- within 5o feet of a bordering vegetated wetland or
V (cesspools and privies only, not the SAS) ? salt marsh
within 50 feet of a private water supply well?
less than 100 feet but greater than 5o feet from a
supply well with no acceptable water Private water
has been analyzed to be acceptable, attach copy
Of
If the well
siL
. for coliform bacteria, volatile organic compounds s well water awell
and nitrate nitrogen. g compounds, If
nitrogen
f
t
13
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART D
CERTIFICATION
ame of Inspector
ompany Name
ompany Address Ox 10 Sq
ct/\fcrv,l-le. rY►ri e�6 3�
ertification Statement
certify that I have personally inspected the sewage disposal system at
his address and that the information reported is true, accurate and
omplete as of the time of inspection. The inspection was performed and
ny recommendations regarding upgrade, maintenance and repair are
onsistent with my training and experience in the proper function and
anitenance of on-site sewage disposal systems.
:'ieck one:
I have not found any information which indicates that the system fails
to adequately protect public health or the environment as defined in
310 CMR 15. 303 . Any failure criteria not evaluated are as stated in
the FAILURE CRITERIA section of this form.
I have determined that the system fails to protect public health and
the environment as defined in 310 CMR 15. 303 . The basis for this
determination is provided in the FAILURE CRITERIA section of this
form.
ispector's Signature
ite
•iginal to system owner
pies to:
uyer (if applicable)
pproving authority
fj t)f
SUBSURFACE SEWAGE DISPOSAL
�QSYSTEM INSPECTION FORM
Address of property ,,Z�., l'Y� "'Z
owner's name T410 AQ, ltl /p
Date of Inspection
PART A
CHECKLIST
Check if the following have been done:
Pumping information was requested of the owner, occupant, and Board of
Health.
None of the system components have been pumped for at least two weeks
and the system has been receiving normal flow rates during that
period. Large volumes of water have not been introduced into the
system recently or as part of this inspection.
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 site was inspected for signs of breakout.
,y y All system components, excluding the SAS, 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 SAS on the site has been determined based
on existing information or approximated by non-intrusive methods.
The facility owner (and occupants, if different from owner) were
provided with information on the proper maintenance of SSDS.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION
FLOW CONDITIONS
If residential
number of bedrooms
�J3_ number of current residents
J� garbage grinder, yes or no
_ laundry connected to system, yes or no
seasonal use, yes or no
If nonresidential, calculated flow:
Water meter readings, if available:
Last date of occupancy
• I
GENERAL INFORMATION
Pumping records and source of information:
System pumped as art o
P f inspection, yes or no
if yes, volume pumped Vic)
Reason for pumping,-
Type' of system
Septic tank/distribution box/soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system (yes or no)' (if yes, attach previous inspection
records, if any) '
Other (explain)
Approximate age of all components. Date installed, if known. Source of
information: ,
Sewage odors detected when arriving at the site, yes or no
J •
9
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION continued.
SEPTIC TANK:
(locate on site plan)
depth below grade:
—
material of construction: t concrete metal FRP other(explain)
dimensions: 10 `V "� ( A � '
sludge depth
distance from top of sludge to bottom of outlet tee or baffle
'I " scum thickness
< distance from top of scum to top of outlet tee or baffle
A` ' 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, recommendations for repairs, etc. )
DISTRIBUTION BOX:
(locate on site plan)
depth of liquid level above outlet invert
Comments:
(note if level and distribution is equal, evidence of solids carryover,
evidence of leakage into or out of box, recommendation for repairs, etc.)
v--
PUMP CHAMBER: ;
(locate on si p an)
pumps in working order, yes or no
Comments:
(note condition of pump chamber, condition of pumps and appurtenances,
recommendations for maintenance or repairs,etc. )
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION continued
SOIL ABSORPTION SYSTEM (SAS) :
(locate on site plan, if possible; excavation not required, but may be
approximated by non-intrusive methods)
If not determined to be present, explain:
Type.
leaching pits and number i y
leaching chambers and number / ��C9-B S low
leaching galleries and number
leaching trenches, number, length
leaching fields, number, dimensions
overflow cesspool, number
Comments:
(note condition of soil , signs of hydraulic failure, level of ponding,
condition of vegetation, recommendations for maintenance or repairs,etc. )
11
L.
CESSPOOLS (locate on site plan) .
number and configuration
depth-top of liquid to inlet invert
depth of solids layer
depth of scum layer
dimensions of cesspool
materials of construction
indication of groundwater
inflow (cesspool must be pumped as
part of inspection)
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding,
condition of vegetation, recommendations for maintenance or repairs,etc. )
PRIVY:
(locate on site plan.)
materials of construction
dimensions 'v
m
depth of solids
Comments:
(note condition of. soil, signs of hydraulic failure, level of ponding, `
condition of vegetation, recommendations for maintenance. or repairs,etc. )
r
11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION continued
SKETCH OF SEWAGE L_SPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100'
b� 2
/ b6d
/ao 0
DEPTH TO GROUNDWATER
+ depth to groundwater
method of determination or approximation: i
J6 w ti I?
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
FAILURE CRITERIA
Indicate yes, no, or not determined (Y, N, or ND) . Describe basis of
determination in all instances. If' "not determined", explain why not)
Al Backup of sewage into facility? .
Discharge or ponding of effluent to the surface of the ground or
surface waters?
_Al' Static liquid level in the distribution box above outlet invert?
�L Liquid depth in cesspool <6" below invert or av
flow? allable volume< 1/2 da
Required pumping 4. times or more in the last ear?
number of times pumped y
Septic tank is metal? cracked? structural ly unsou
infiltration? substantial exfiltration? tank failure imminent?al
Is any portion of the SAS, cesspool or privy:
below the high groundwater elevation?
within 50 feet of a surface water?
within 100 feet of a surface water supply or tributary to a surface
water supply?
within a Zone I of a public well?
. within 50 feet of a bordering vegetated wetland or salt marsh
(cesspools and privies only, not the SAS) ?
within 50 feet of a private water supply well?
2�less than 100 feet but greater than 50 feet from a private w
supply well with no acceptable water water
has been analyzed to be acceptable, attach co, If the well
for colnitrate
bacteria, volatile organic compounds, ammoniatnitrogeer nsi!
and nitrate nitrogen.
13
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART D
CERTIFICATION
.me of Inspector (�j Fjm i20b��1SD r1 SRC
Impany Name Qo����Sa�1 Sep+Yc Sep��i c e
,mpany Address Q�K 0 89
�e�tc�u►lle h1 R e�63� .
!rtification Statement
certify that I have personally inspected the sewage disposal system at
.is address and that the information reported is true, accurate and
mplete as of the time of inspection. The inspection was performed and
y recommendations regarding upgrade, maintenance and repair are
nsistent with my training and experience in the proper function and
nitenance of on-site sewage disposal systems.
e one:
=: I have not found any information which indicates that the system fails
to adequately protect public health or the environment as defined in
310 CMR 15. 303 . Any failure criteria not evaluated are as stated in
the FAILURE CRITERIA section of this form.
I have determined that the system fails td protect public health and
the environment as defined in 310 CMR 15. 303. The basis for this
determination is provided in the FAILURE CRITERIA section of this
form. ��ff ����
Spector' s Signature �i(��Lo%wn���OUvw��
to
iginal to system owner
pies to:
uyer (if applicable)
pproving authority
[ ] [R207 095. ]
LOC10025 HI-ONA-HILL CTY]10 TDS] 300 CO KEY] 12568
--MAILING ADDRESS------- PCA] 1011 PCS]00 YR]00 PARENT]
TWOHIG, WILLIAM & HELEN MAP] AREA]49BC JV]288156 MTG]0000
3200 BINNACLE DR APT H-3 SP1]UT1 UT21 .26 SQSFT] 936
NAPLES FL 33940 AYB] 1949 EYB]1975 OBS] CONST]
1492 LAND 25200 IMP 57300 OTHER 360
----LEGAL DESCRIPTION---- TRUE MKT 86100 REA CLASSIFIED
#LAND 1 25,200 ASD LND 25200 ASD IMP 57300 ASD OTH 360
#BLDG(S)-CARD-1 1 57,300 DESCRIPTION TAX YR CURRENT EXEMPT TAXABI
#OTHER FEATURE 1 3,600 TAX EXEMPT
#PL 25 HI-ONA-HILL RESIDENT'L 91200 86100 8610
#DL LOT UNNUMB OPEN SPACE
#S1 11/80 21 $00042500 I COMMERCIAL
#RR 0696 0105 INDUSTRIAL
EXEMPTIONS
SALE]00/00 PRICE] ORB]3188/28 AFD]
LAST ACTIVITY]12/17/93 PCR]Y
ASSESSORS MAP NO:
N1?-:f 7B PARCEL NO:
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
`'AW........................OF... tS�TS'I iB ...
Appliration for Disposal larks Tomitrurtiun ramit
Application is hereby made for a Permit to Construct ( ) or Repair ( } an Individual Sewage Disposal
System at:
- SH ' ..Q LL...1JQAP _QFMI RY_ILLE
-----...----•-......-•-------------------•---•-------....--•-•-----------------------•
Location-Address or Lot No.
....I� Jam..:�1 QJ
Ae---------------------•--...----••------... ............................................. ................................................
Owner Address
a .__lR..__!t_.__ P 1VIac qm--a r---•-------------------------------------------------------- ----------•--•----------------•-•--•--------......---------•-------------•----•----------....-----
Installer Address
UType of Building Size Lot............................Sq. feet
�-, Dwellings No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
N.� Other—T e of Builditi
a YP g ---------------------------- No. of persons............................ Showers ( ) — Cafeteria-(---->-
Otherfixtures -----------------•--------------------•----•-----------••••--•---------•••---•••-------------------•---•-•------.--
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
W Septic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth._._:___.___._..
x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area_--___-__-----_•-•-sq. ft.
Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area........_.........sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by --------------'•----- Date
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water--...._-_____-_---__--_.
Gz, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water-------.................
............................................................................................................................................................
Description of Soil_......_.�and_gnd_._Eravel:-
x ....................................-..........................................................................................
V -------------------•---------------------------•----•---------------------------...----.......-----•-----•----------•-•--
x •-----------• ---------------------------•-•--•-•-••----•--•----•-•-•-•-------------•••-------••••••-------•-------•-•---•----------•---------••-----••-----------------•-•-••----------._...._.._------
V Nature of Repairs or Alterations—Answer when a licable...............................................................................................
1 1000_._Fallon� tanic 1: 1OU gallon leach. Pit,.
--------------------•-• ............--_-•---
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of iiTi ; of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has bee issued by th bo r of health
Si ned ..
_....
Application Approved By..................... •.............................:
e
.........S�7................
Date
Application Disapproved for the following reasons:-------•-------••--•----•---•---------------------------------------------------------------------------------_
--•--------------------•--------------------•--•---•--------....-•-------•-------------......--••---------------•----•.....----------••••---•--------------•••-•-••------------------------•-•---•--•---
Date
Permit No............. � �-17S
---- ------------------ Issued.......................................................
Date
i
n �vr VV
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF.............................,............................................................
IirFation for Bi_gpaa al Marks C anstrortioat Vrrmit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at: 1'
...: ........_...._:- ...,............. - -............................... . .... ...........••••._.._...--------•-•-•-------- •--- --•--..........------...........---.....•---•-
Location-Address _ or Lot No.
•_______•t-____••__ .. .......................................... ........................................... . ..............................................
w'ner Address
Installer Address
UType of Building Size Lot...........................Sq. feet
Dwelling,—No, of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
e of Building a Other'—T YP g ---------------------------- No. of persons............................ Showers ( ) — Cafeteria ( )
d Other fixtures
Wn Design Flow.............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................
x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No------------------_ Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by.......................................................................... Date------------------•---------------------
Test Pit No. 1________________minutes per inch 'Depth of Test Pit.................... Depth to ground water----__--______-_-----__.
fZ, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
•------•----------------------------------------•-•--------......---......--••-............--.-•----........................................................
Description of Soil. =-'•---•.==._------- ....
x .�-.==......--•--•--------••-•----•--------------------•------------------------••-----------------------------------•-----
U ---•----------•-------------------------------------------------------•-••--------...-------•----------••---------------•-•------------------------------------------------••---•-•-----•-••--•--•--••-
W
U Nature 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 i T'L✓ 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..... =.:. =- .......................................... ' °f/ --- ---
i i Date l
Application Approved BY---•-......--••••. _`�` Wit•= ` +' '== - �r:
- Date
Application Disapproved for the following reasons:----------•----•----------------------------•.......................................
---------------•-•-----...----•-••••-•-----•-••--•---- ...
Date
Permit No.................x :.2.....tJ-------= ---- Issued_.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
or
......::..,....: ........................OF. .....:..,....:........:.....................................................
Trrtif irFatr of (SompfiFattrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( }
b
Y = ----------••---------------------•--•------.--------------------__-.-----••--------•------------------•----•-•-------------•-------------•---------------------
Installer
at
i rt ,
........
r .r -----------------------•----------- ---------
a._ _•. l Y 1.�
has been installed in accordance with the provisions of�Tii. 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No...::::7__-- ...... dated....._._'' .:_:_%'�;=� _____________
THE ISSUANCE. OF THIS .CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUAR"TEE THAT YHE
SYSTEM. WILL FUNCTION SATISFACTORY.
DATE------------------�ar.-_.�6__"_ ..?...-•••••......-•--••-••••----_.. Inspector
----------------
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
q .
• _..� .. .................. .. .. .............._...........................__......................................_..
fro:._-'�fr p° OF FEE.: Z�C► { '
,' �i��o��a� ork� �oata�tr�rtion rrmit
Permission is hereby granted .-� -----•------•--------------•------•-----•---•----------------- ----------------,..................
to Construct ( ) or Repair - ) an Individual Sewage Disposal System
atN ---- ----•-----------------------
Street
as shown on the application for Disposal Works Construction Permit .......... •Dated.....'-' � `I_....
DATE...
f i r '` Board�oi 1-Iealth ,`.
•----------.........
FORM 1255 HOBBS & WARREN. INC., PUBLISHERS
TOWN OF BARNSTABLE
LOCATION 2-3- 12r,�SEWAGE #
VILLAGE CL IJ / I(. ASSESSOR'S MAP & LOT o20
INSTALLER'S NAME & PHONE NO. P 1"G C C/"het-
SEPTIC TANK CAPACITY l oo p L
LEACHING FACILITY:(type) (size) 00 0 C
NO. OF BEDROOMS, ii PRIVATE WELL OR PUBLIC WATER
BUILDER OR OWNER 1 i l i� glk.� � 0 1 ,C,_
DATE PERMIT ISSUED:
DATE .COMPLIANCE ISSUED: ^ —If 7
VARIANCE GRANTED: Yes No �, !�
Ir
�1
r
Zoe
°g