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HomeMy WebLinkAbout0033 HIGH NOON DRIVE - Health 33 HIGH NOON RD. , CENTERVILLE A= 193. 229 cIII � �J�R�CYC�o�a� UPC 12534 No. 2 1 53LO R �°oST•CONSVR- HASTINGS, MN TOWN OF BARNSTABLE LOCATION " I SEWAGE # VILLAGE a �`D ��P ASSESSOR'S MAP& LOT INSTALLER'S NAME&PHONE NO. i SEPTIC TANK CAPACITY S®O v� LEACHING FACILITY: (type) k (size) 1W0 S W NO.OF BEDROOMS Lk _ BUILDER OR OWNER :-> vi1TDATE: I?,®t,r, COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the �' Feet •a 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 D o t \ D \ t � O � 1�3- poi 03- ti° Ks— g5— \31 C-y- \s C)L\- � CO�j.v0N\\"EALTH OF NL-%SSACHL_S—_TTS E}iECL'TI\ E OFFICE OF E\-VIRON'.'ENT,-%L AFF:M411' DEPARTMENT OF ENVIRONMENT.�L PItOTE ON ONE WINTER STREET. BOSTON >L4 0210c 29?-b:?u _f r4 TRIAL COX- 3 f $ •retan ARGEO PA L'L CELLliCCI "f[I,y 1D�AgID B, S RUHS Governor C�. sooner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: z' ��� tJc76i� ` Name of Owner l �Q_UAA`\f, Address of Owner: sfm a - Date of Inspection: �+ Name of Inspector:(Please Print)/ [ C/ I cf '%� Ee!�U I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.0001 Company Name: _19_ r? �k c.�.`r.—��. �...r t.' cE 19 ZC�t c7 "wf Mailing Address::.,i 2 Telephone Number: —4 3;z /4 j- • �o CERTIFICATION STATEMENT 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 2 Inspector's Signature: ti t t l l Date: J The System Inspector shall submit 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 3/ revised 9/2/98 Ppgc:Y of 11 PimttA on Rtq W Pam 4091 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (contirwed) `roperty Address: 33 Jwner: Date of Inspection: INSPECTION SUMMARY: Check A, B, C, Or D: A. SYSTEM PASSES: 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: 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. 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, 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. _ 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 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.2a[tt SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Propefty Address: Owner: Date of Inspection: C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of Health in order to determine if a system is failing to protect the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 0 CMR 15.303 (1)(b)THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND AFETY 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 s t marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBL WATER SUPPLIER,IF ANY)DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC H TH AND SAFETY AND THE ENVIRONMENT: _ The system has a septic tank and soil absorption sy am(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 ystem and the SAS is within a Zone I of a public water supply well. _ The system has a septic tank and soil absorptio system and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and soil absorpt' n system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well wat analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility nd the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine stance (approximation not valid). 3) OTHER i revised 9/2/98 Page 3of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continuedi property Address: Owner: Date of Inspection: 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 C 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what w' be necessary to correct the failure. Yes No Backup of sewage into facility or system component due to an overloaded or clogg d SAS or cesspool. _ Discharge or ponding of effluent to the surface of the ground or surface waters a to an overloaded or clogged SAS or cesspool. Static liquid level in the distribution box above outlet invert due to an overlo ded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6" below invert or available volume i less than 112 day flow. _ Required pumping more than 4 times in the last year NOT due to clog d or obstructed pipe(s). Number of times pumped_. Any portion of the Soil Absorption System, cesspool or privy is be w the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surfa water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I of a pu c well. Any portion of a cesspool or privy is within 50 feet of a p vate water supply well _ Any portion of a cesspool or privy is less-than 100 fee but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has be analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, amm nia nitrogen and nitrate nitrogen. E. LARGE SYSTEM FAILS: Ybu must indicate either "Yes" or "No" to each of the following: The following criteria apply to large systems in additio to the criteria above: The system serves a facility with a design flow of 1 ,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because o or more of the following conditions exist: Yes No the system is within 400 feet of a urface drinking water supply the system is within 200 feet o a tributary to a surface drinking water supply the system is located in a nit gen 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 s all upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional office of the Department for further inform ion. revised 9/2/98 pags.4orit SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 33 "N Owner: Date of Inspection: Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Yes No Pumping information was provided by the owner, occupant, or Board of Health. None of the system components have been pumped for at least two weeks and-the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. A- bi-61 pens have been obtained and examined. Note if they are not available with NIA. 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: X _ Existing information. For example, Plan at B.O.H. Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable) t [15.302(3)(b)) The facility owner (and occupants,if different from owner) were provided with information on the proper maintenaac+a of SubSurface Disposal Systems. revised 9/2/98 pager.orit SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM. PART C SYSTEM INFORMATION Iroperty Address: 3.3 �h � Owner: 1 Date of Inspection: FLOW CONDITIONS RESIDENTIAL: Design flow: Cj•p d.fbedroom. Number of bedrooms (design):_6� Number of bedrooms (actual):d� Total DESIGN flow SSCj Number of current residents:�i r Garbage grinder(yes or no):,b. Laundry(separate system) ( es or no ) ; If yes, separate inspection required Laundry system inspected yes or no) Seasonal use (yes or no):� Water meter readings, if available (last two year's usage (gpd): Sump Pump(yes or no): ►J Last date of occupancy:. COMMERCIAL/INDUSTRIAL: Type of establishment: Design flow: npd ( Based on 15.203) Basis of design flow 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: o - ­0 Y 0%- >a A` System pumped as part of inspection: or no)_ If yes, volume pumped: gallons Reason for pumping: TYPE OF SYSTEM Septic tank ldistribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no) (if yes, attach previous inspection records,if any) IIA Technology etc. Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other APPROXIMATE AGE of all components, date installed lif known)and source of information: ��5 cy, Sewage odors detected when arriving at the site: (yes or no) revised 9./2/98 Page 6ofIt SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) vroperty Address:�� ��t tikk7tJ Owner: Date of Inspection: BUILDING SEWER: (Locate on site plan) 1 Depth below grader Material of construction: _cast iron 40 PVC _ other (explain) Distance from private water supply well or suction line ;­1 Nam--t— Diameter—LV Comments: (condition.of joints, venting, evidence of leakage,-etc.) SEPTIC TANK:&S flocate on site pla ) Depth below grade: a� Material of construction: concrete_metal_Fiberglass _Polyethylene_other(explain) If tank is metal,list age_ Is age confirmed by Certificate of Compliance_(Yes/No) Dimensions: ksw_�� Sludge depth: A" �l Distance from top of sludge to bottom of outlet tee or baffle: 31— Scum thickness: fJi'l Distance from top of scum to top of outlet tee or baffle:--1 �1 Distance from bottom of scum to bottom of outlet tee or baffle:_ How dimensions were determined: "911 aA&N— 6 'omments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrit evidence of leakage,et C, v.� S GREASE TRAP: fW ,pocate on site plan) Depth below grade: Material of construction:_concrete_metal_Fiberglass _Polyethylene_other(ezplain) 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: (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 9/2/98 Page 7or11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (contirwed) 'ropeny Address: -53 �k\ Own,*: Date of Inspection: TIGHT OR HOLDING TANK: Vn (Tank must be pumped prior to, or 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 Alarm level: Alarm in working order. Yes _ No Date of previous pumping: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX: (locate on site plan) L ��6vZaT T.��1 LN��S Depth of liquid level above outlet invert: Comments: (note if level an``d--distribution is equal, evidence of solids carryover, evidence of leaka�e into or out of box, etc.) PsOJI PUMP CHAMBER:_1W (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.) revised 9/2/98 Page 8of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) 'roperty Address: Owner: Date of Inspection: SOIL ABSORPTION SYSTEM (SAS): (locate on site plan, if possible: excav tion not required, location may be approximated by non-intrusive methods) If not located, explain: Type: leaching pits, number: a\(ak(o leaching chambers, number:_ leaching galleries, number:_ leaching trenches, number, length: leaching fields, number, dimensions: overflow cesspool, number:_ Alternative system: Name of Technology: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegeta ion, tc.) N CESSPOOLS: ;gyp (locate on site pan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: )epth 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 9/2/98 rare 9orli SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) 'roperty Address: :�,5 tiX.Ci Jwner: Date of Inspection: 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) * Ott hr roQ �f St'wt+a.a �.r 4r.,�h A'k 1 1 3 •z � t��TeF Z �Z �Zl bar QjjZ� �O�b�t cy- \s' �y- ►yt revised 9/2/98 page tooru SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) ;opefty Address: -33 ow t4 , Owner: Date of Inspection: NRCS Report nameKl -- Soil Type_ --- Typical depth to groundwater_____ USGS Date website visited f'V Observation Wells checked Groundwater depth: Shallow Moderate Deep SITE EXAI.: Slope p.)C) Surface water Nb Check Cellar b" Shallow wellsw-�w. � i Estimated Depth to Groundwater" 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 Used USGS Data Describe how h Groundwater Elevation. (Must be completed) you established the High Y V.S. CgA-o\0C?g% Sao-vQ� �-ya�lnO�o�� TN�eS�t�lartGv�S ��A ��iZ r revised 9/2/98 Page 11of11 L CO1MMONWEALTH OF MASSACHUSETTS � _ _- Fj E�iECUTIVE OFFICE OF E?NTVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PRO CTION /ff 4.:- J►� - ONE W TER STREET. BOSTON :ALA 02108 (61 o 292-550 i� �fry[0 � '0k!►►oF s 199AU OXF c etan ARGEO PALL CELLUCCI A DAB 1 RUHS Governor Co ' sio;er SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ti lot 3 PART A I�EJ �; 1 CERTIFICATION 1 ��l!,,__ � � Name of Owner , u Property Address: 33 �'V"` � Jk ko Address of Owner: -.— Date of Inspection: a��3`�� / Name of Inspector:(Please Print) D ELK/a I am a DEP approved system inspector pursuant to Section 15.1/340 of Trde 5(310 CMR 15.000) Company Name: t!9#C4._�r �k N r'r� i.. .... r r.+I..- F Marling Address:_?� 140,1- � g4• N ON f��[_ I 1 �Z �f-� Telephone Number: 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: XV Passes Conditionally Passes Needs Further Evaluation By the Local Approving Authority _ Fails Inspector's Signature: L°` Date: l The System Inspector shall submit 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 t C-� fS � �{� Q,w I� ol-l� Jr✓J 1*7 revised 9/2/98 Page I of II iPrinted on Recycled Paper '�' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A � CERTIFICATION (continued) �'roperty Address: 9J (4,1 h 0"V Date of Inspection: INSPECTION SUMMARY: Check A, A C, or D: A: • SYSTEM PASSES: rt ha�e`not�found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist. Any failure -ciitena 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. 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, 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. _ 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 _ 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 2of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Owner: Date of Inspection: C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: / Conditions exist which require further evaluation by the Board of Health in order to determine if h�system is failing to protect the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITHl310 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 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 a orption 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 so' absorption system and the SAS is within a Zone I of a public water supply well. The system has a septic tank and oil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank an soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unle s a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution fr that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used o determine distance (approximation not valid). 3) OTHER revised 9/2/98 Page 3ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Owner: Date of Inspection: 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 at CMR 1 will be necessary The basis for this determination is identified below. The Board of Health should be contacted to determine hat ary to correct the failure. Yes No _ Backup of sewage into facility or system component due to an overloaded r clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surfac waters due to an overloaded or clogged SAS or cesspool. Static liquid level in the distribution box above outlet invert due t an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6" below invert or availa a volume is less than 1l2 day flow. Required pumping more than 4 times in the last year NOT ue to clogged or obstructed pipe(s). Number of times pumped Any portion of the Soil Absorption System, cesspool privy is below the high groundwater elevation.. _ Any portion of a cesspool or privy is within 100 f t of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Z ne I of a public well. r Any portion of a cesspool or privy is within 0 feet of a private water supply well. Any of a cesspool or privy is les han 100 feet but greater than 50 feet from a private water supply well with no _ •_ t acceptable water quality analysis. If t well has been analyzed to be acceptable, attach copy of well water analysis for coliforni bacteria, volatile organic co ounds, ammonia nitrogen and nitrate nitrogen. E. LAR GE SYSTEM FAILS: You must indicate either "Yes" or "No" to each o the following: The following criteria apply to large sys ems in addition to the criteria above: The system serves a facility with a sign flow of 10,000 gpd or greater(Large System) and the system is a significant threat to public health and safety and the environ nt because one or more of the following conditions exist: Yes No the system is with' 400 feet of a surface drinking water supply the system is w hin 200 feet of a tributary to a surface drinking water supply the system i located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPAI or a mapped Zone II of a public water sup p well) The owner or operator of a y such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional office of the Department r further information. revised 9/2/98 Page 4of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: Owner: Date of Inspection: Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Yes No _ Pumping information was provided by the owner, occupant, or Board of Health. None of the system components have been pumped for at least two weeks and-the system has been-receiving ntrmal 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. Y _ The system does not receive non-sanitary or industrial waste flow. The site was inspected for signs of breakout. X _ 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. For example, Plan at B.O.H. Determined in the field (if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable) [15.302(3)(b)) _ The facility owner(and occupants,if different from owner) were provided with information on the properinaintenaaca-0f Subsurface Disposal Systems. revised 9/2/98 Page 5ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C 2 2 (j'y�,� SYSTEM INFORMATION 33'roperty Address: (-b lh 1U0 Owner: Date of Inspection: FLOW CONDITIONS RESIDENTIAL: Design flow: ,;30 g.p.d./bedroom. Number of bedrooms (design):G-�, Number of bedrooms (actual):_ Total DESIGN flow-Z3 Cj_ Number of current residents:, Garbage grinder(yes or no):—P Laundry(separate system) (yes or ol'_; If yes, separate inspection required Laundry system inspected &or no) Seasonal use (yes or no):IJ Water meter readings, if available (last two year's usage (gpd):K--) Sump Pump(yes or no):—LjJ Last date of occupancy: v-s� COMMERCIAL/INDUSTRIAL: Type of establishment: Design flow: 9pd ( Based on 15.203) Basis of design flow 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: -\!:sfS - System pumped as part of inspection: (yes or no)_ If yes, volume pumped: gallons Reason for pumping: TYPE OF SYSTEM Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system(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 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 9/2/98 Page 6(if ll SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 'roperty Address: -�3 f Ndf7cti-3 Owner: Date of Inspection: BUILDING SEWER: (Locate on site plan) Depth below grade:' Material of construction: _cast iron X-40 PVC_other (explain) Distance from private water supply well or suction line TCx.ua U -9� Diameter— Comments: (condition of joints, venting, evidence of leakage,-etc.) SEPTIC TANK:� (locate on site an)Pm 1 Depth below grader Material of construction:4concrete_metal_Fiberglass _Polyethylene_other(explain) If tank is metal, list age_ Is.age confirmed by Certificate of Compliance_(Yes/No) Dimensions: If700 el � Sludge depth:! ll Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: Ot% II Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee baffler_ How dimensions were determined:,MgGp=to 42 'omments: (recommendation for pumpin , condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet inve t, structur integrity) evidence of leakage, etc.) t V GREASE TRAP:_J�� (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: (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 9/2/98 Page 7ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART SYSTEM INFORMATION (contirwed) 'roperty Address: Owner: Date of Inspection: TIGHT OR HOLDING TANK: (Tank must be pumped prior to, or 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 Alarm level: Alarm in working order:Yes _ No_ Date of previous pumping: Comments: (condition of inlet tee, condition of alarm and float switches,etc.) DISTRIBUTION BOX: S (locate on site plan) S/� ��(� rl/ O TZ2� .2.�C. Depth of liquid level above outlet invert: i VL v Comments: - (note if level and istribu ' n's e �ITv_idence of solids carryover, evi ce of leaka a into`r out of box, etc.) v PUMP CHAMBERMa (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.) revised 9/2/98 Page 8of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) J 'roperty Address: Owner: Date of Inspection: SOIL ABSORPTION SYSTEM(SAS): (locate on site plan, if possible: excav on not required, location may be approximated by non-intrusive methods) If not located, explain: Type: leaching pits, number:�(rX(o leaching chambers, number:_ leaching galleries, number:_ leaching trenches, number, length: leaching fields, number, dimensions: overflow cesspool, number:_ Alternative system: Name of Technology: Comments: (note condition of soil, signs of hydraulic failure, level of ponding damp soil, ndition f ve tation, etc.) CESSPOOLS: (locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: 9epth of solids layer: )epth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater: inflow (cesspool must be pumped as part of inspection) I 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.) 9 revised 9/2/98 Page 9ofII Y SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) 'roperty Address: )weer: J Date of Inspection: 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) � 5S V� revised 9/2/98 Page 10of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) roperty Address: 33 $e�,M®v,� Owner: Date of Inspection: NRCS Report name Soil Type_ Typical depth to groundwater USGS Date website visited t4O Observation Wells checked Groundwater depth: Shallow Moderate Deep SITE EXAM Slope Surface water h+2oo fov\ Check Cellar 0 L u Shallow wells wIP► Estimated Depth to Groundwater —3(1 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 Used USGS Data Describe how you established the High Groundwater Elevation. (Must be completed) &V4�"1 revised 9/2/98 Page 11of11 ASSESSOR'S MAP NO. i c 3 PARCEL L0CAT10N ^:gjr�`�'{� SE,-WAGE PERMIT NO. v1iLACE �5_9 . INSTA LLER'S NAME i ADDRESS z5q C� /V 7-& S U I L D E R OR OWNER DATE PERMIT ISSUED DATE COMPLIANCE ISSUED, - -.-" L© \ r00q- QC . 0� 0 Ly Ck �s 8�' ASSESSOR'S MAP NO. PARCEL -9 LOCATION 'S ' SE;WAGE PERMIT NO. V I L L A G E 7-����G I N S T A LLER'S NAME i ' ADDRESS S U I L D E R OR OWNER �` G � w IV 6 - &117-L D A T E P,ERMIT ISSUED DATE COMPLIANCE ISSUED J-7 Lek \� ®Ur Qr 2 Ck�o FL .............. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 7dM< ....................oF..... .!9:.:•vs.... .r ................................................ Appliration for Biiipaaal Hijarkii Towitrurti n ramit Application is hereby made for a Permit to Construct (L-l'or Repair ( ) an Individual Sewage Disposal System at: ......•z.GT" �9 11....................................................... ,a. Locati-ngg-Address /9r Lot No ✓ J' ��( ocat'i ?lc/S r F'� iv .......................................vi it ........_.. - Owner Address Os 4C Installer Address �� Type of Building Size Lot-_l_._✓.................Sq. feet U Dwelling— No. of Bedrooms.............................___ .Expansion Attic ( ) Garbage Grinder �td Other—Type of Building No. of persons............................ Showers ( ) Cafeteria a4 Other fixtures ............................... . . W Design Flow...................:Y!Y -_.1/�2......gallons per person per day. Total daily flow.___.........___.._yy G..___.........gallons. R: Septic Tank—Liquid capacity------------gallons Length................ Width................ Diameter................ Depth................ W Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area_.................sq. ft. x Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box Dosing tank ( ) ~" Percolation Test Results Performed by...... . ...................... Date... Test Pit No. 1________________minutes per inch Depth of Test Pit______ ........ Depth to ground water..._c'_�__-_______--___--- fi, Test Pit No. 2.......a.....minutes per inch Depth of Test Pit-------------------- Depth to ground water........................ P4 ----•------•-----------•---------------•---••-•--•--•-•--•--•---•-------•-•-----.........---•-•---•.....----•--•------•---•-----•-•-•--•--•--•-----•-•------ 0 Description of Soil.........L ..........._�flc ` G < _ ? " �'•Le S� —Z`t-` - U •------••-•------------•---•••----••••-- - - ----- -- ------------------ v9 � suesue` .. 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 TITLE 5 of the State Sanitary Code—.The undersigned further agrees not to place the system in operation until a Certificate of Compliance h been issued by the board of health. Signed:. --•----• --•-•--.....-•--..........G2 �..— Date ApplicationApproved By•-••--•-•-•------•-••-•••-------•-•------•......................•-.._....----•................... ........................................ Date Application Disapproved for the following reasons:.............................................................................................................. ......................................--.....------••-----•----••-------••---•--.....-----•---...---•••------•---------------------•--•-------•-----------------------•--...----------------------..... Date PermitNo.. .......................................... Issued....................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH , R ..........I...........OF..... .ws7 � Cam' Appliratiun for Bispusal Works Tunstrurtiun prrufit Application is hereby made for a Permit to Construct (t—y' or Repair ( ) an Individual Sewage Disposal System at: ...... ......_.0 7- ..........19 ........, .. •-------------------................... ...........-- ...----------........----- ..........._........__..............------ Locatio -Address -....... .. ✓� _ U..L. CZin�� �i�S L Nof� PG C?ti7' '.' - --•---•-•---. - ...._..... r� Owner Address ✓f'J'./�'/.`-.................. d`...T�lv ......�.........-•--•-••-•---•---•............................. Installer Address d Type of Building Size Lot.. `!..................Sq. feet Dwelling—No. of Bedrooms............................_._._.....__....Expansion Attic ( ) Garbage Grinder (`t•C) Other—T e of Building ��''`� No. of persons............................ Showers a YP g --•--•--•------•--•--------- P (----)..— Cafeteria (�)� dOther fixtures ---------------•-------------------•--------------------•-•--•••---------•••--••-----•-•--••------...-•----•- W Design Flow.....................V✓....//......gallons per person per day. Total daily flow...._.._____._..._.y`...G..______...._.gallons. 04 W h Septic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Dept .......•.....__. x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. 3 Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ar Dosing tank ( ) ~' Percolation Test Results Performed by......" ._.............S'u�.:'��.:'...................... Date....9....!..� Test Pit�No. I................minutes per inch Depth of Test Pit..._._.� ....... Depth to ground water------------- -_......... 44 Test Pit No. 2....... ....minutes per inch Depth of Test Pit.................... Depth to ground water........................ a ........................... •-•---•-•-..........•-------••-•-------•---•-----•--••------------------•-----.......------......--•-•.....---••-------........-- O Description of Soil.......... - `f ........... -c:�So -- --------------------•--•------•----•--------------------•-------•-•------------- 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 TITIE 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...D. -� O .�3 Date ApplicationApproved BY.................................................................................................. ........................................ Date Application.Disapproved for the following reasons:-------•-- ----•----•--..._...--•-----------•-------•-•-------•-----•-------------------•-------.......•-•..... -----------------•---••--•---•--.-----------•-•-•----•-•--------••-••------......•--------•--•....------•-------•----------•--•••----------••------•-•---------------•-•---------•------•--•-•---------- r Date PermitNo.... ...............--......v............................. Issued---------.......--------------•---•--••--•••------•-••• Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................OF........w1s-�s r;!8 Co ................................•••-••...........•.... Trrtifiratr of Tampliattrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ✓ror Repaired ( ) by........ - '� '�_..._ ' .�� ,.r .._ - '`r' o,✓ Lf gnstaller at �- �'_ '-...... � v'-�`/t•----•---._...-•----••-------•------------•-. has been installAd in accordanc(5 with the provisions of TITLE 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No.....or g_ ........ dated......../_�, . —t. .............. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONS AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE... � .................... Inspector----------------------------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Cr= (>&P• ...... ...................OF..........- ." r�S 4 t3.. ....................._. ....... F � .. No......................... FEE............_.........-- Disposal Works (gurtstrudiurt f rrutit Permissionis hereby granted.......... c .. ..-•.--•--••----...-••---------•--...---••--•-••-•--•-•--•-••.....-•............................... to Construct ( ) or Repair ( ) an Individuaal Sewage Disposal System atNo...........�=....e..7.--.. 1: .........................................c -••----------•---•-----------•----•--------•--•-•---•--------•........ Street as shown on the application for Disposal Works Construction Permit No _ _ Dated...... ...............................................- Board of Health FORM 1255 A. M. SULKIN, INC., BOSTON 0W 7",4 -Dt,IL / F oto - 70- 6,1,0 Gr�� Bt? ,00 Z I ` 92 t VSt3 ISaD 6AL. , V I ! \> ELzio� q , C ��SPosn� ?ITS LM66AL, 5rOQF Q a5s���� d t--Gw/�,LL. Art-c,- - S-1& Sf= _ 7 poi �aI n 40 i! q rZ N 12 l� _' 58. s F l oo s (s�n�,� t jl / + Of �o(o U Y h I ( Tn N f Y az. � AIL. �-c-ou) 4) o fP TZCo c-AT rr o PQ Ri4T'E u t►.i 2 .Mr N o.sZ LESS , 7-- --- J OF Iq . 1�j►! f ;',� r `� PETERJ. ��•�� i � i �'�,��I O �� �l�, 1 Bea;e. ia ,3Ui IIVaIV a i /.. _. v> 9r•� is�� .. 10,2:. No -29733 --•s. to _. ysp, IAL N4 - 103. 104- - SvZS• /oon v✓./. G.4L. r , G�LW. Box %9 SEPrrG I , P•rS A T.vn�rc Men �v .; ��y J�,� •. 49•Z ¢ 2T/F/E.o PGor' C:71-:4,V WIISHC-D i STo iJ E ;o J,3 a� -� 7'�.--_ G •�'Z�� LoGQT/ors/ _`.� ,; . SCALE LoT yE�Eov GO�+/�GY,S Gt/�T//TiyE .S/0��✓itiE B�Xr�,e ,4/t/O.SETl/�G` ,C�4V/,�'E'kIENTS d� T.'/� ,C�.Ecsisr�,ec'I.�rvo.SU.e�EyoP.S 7 //v el RA1aA,)6rA8L9 Av L ocdr�.o (/✓/T.y/y �",�/.E ,cam�vo�..4/�V L L) /O-B z�35 kt-.4-V ( i ej._> �, .•o T/Zt P4-,d/V /.S A a.7 f3.4fE0 GM 4 V//Y-57,12 r A . iTH EVE 1.AVC Ns, N4 z- 4o'f cj l01' v 3S + 38't 2 19 . 4 IS GI o s.F 48'± Z i 1 o S,ov �,rZ- Lo-TAz� 531.4 l 1,....� e.np'''C'k L LOCATION C C� SCALE bATE 8C PLAN REFERENCE LADT 0 PC.,131L. 3z� PG-• 27 BAXTER ?✓ NYE, INC. 'THIS PLAN IS NOT_ BASED- ON AN REGISTERED LAND SURVEYORS INSTRUMENT S.URV,>=Y AND THE OSTERVILLE^- MASS. OFFSETS SHOWN . SHOULD NOT BE USED TO DETERMINE LOT LINES, APPLICANT TD,-,vil-,�, BAXTER/ & NYE, INC. Registered Land Surveyors and Civil Engineers 7 Parker Road/Osterville,Massachusetts 02655/Tel. (617)428-9131 wItLLIAM c.NYE,RL.S,=President RICHARD A.BAXTER,RL.3.-Vice President PETER SULLIVAN,P.E.-Vice President-Engineering li 4. July 15, 1986 Board of Health ; Town of -Barnstable -` P.O. Box 534 Hyannis,' MA 02601 RE: Lot 19 High Noon Drive, Centerville Dear Board, Attached please find an "As Built" of the septic for Lot 19. Also I have witnessed an ad- ditonal test hole, .the test hole demonstrated that there is four .feet of dry previous material ; beneath the bottom of the leach pit. I trust . this meets your present needs. Very truly yours, l Peter Sullivan, P.E. PS/cas CC David Sauro PtK OF Pi TER o SULLIVAN U H No. 29733 ONA MEMBERS OF CAPE COD SOCIETY OFPROFESSIONAL ENGINEERS AND LAND SURVEYORS/AMERICAN CONGRESS ON SURVEYING AND MAPPING MASSACHUSETTS ASSOCIATION OF LAND SURVEYORS AND CIVIL ENGINEERS BAXTER & NYE, INC. Registered Land Surveyors and Civil Engineers 7 Parker Road/Osterville,Massachusetts 02655/Tel.'(617)428-9131 WILLIAM C.NYE,R.L.S.-President RiCHARD A.BARTER,R.L.S.-Vice President PETER SULLIVAN,P.E.-Vice President-Engineering July 15, 1986 Board of Health Town of Barnstable, P.O. Box 534 -Hyannis, MA 02601 RE: Lot. 19 High Noon Drive, Centerville Dear Board, Attached please find-an "As Buil.t" of .the W septic for Lot 19. Also I have witnessed an ad- ditonal test .hole, the test 'hole demonstrated that there is four feet of dry previous material beneath the bottom of the .leach pit. I trust this meets your present needs . Very -truly yours, Peter• Sullivan, P.E. PS/cas CC: ' 'David Sauro ik Ok MER , SULLIVAN' '� f4o. 29i33 0 Ss�ONA L�N:e MEMBERS OF CAPE COD SOCIETY OF PROFESSIONAL ENGINEERS AND LAND SURVEYORS/AMEMCAN CONGRESS ON SURVEYING AND MAPPING AIASSACHUSE7TS ASSOCIATION OF LAND SURVEYORS AND CIVIL ENGINEERS