Loading...
HomeMy WebLinkAbout0076 LONG BEACH ROAD - Health } 76 Long Beach Road Centerville P •- - 206 009 i C X t �1 a a down cape engineering, inc.SIEVE SOILS ANALYSIS 76 LONG BEACH RD CENTERVILLE, MA.xlsx DATE OF REPORT: 4/21/2021 JOB : GRAIN SIZE AN TEST SITE: 76 LONG BEACH ROAD, CENTERVILLE LOCATION: DCE TEST HOLE SIEVE ANALYSIS Weight Sample(Grams): 154.3 SIZE ;WEIGHT RETAINED % RETAINED % PASSED (sum ) --------------r-------------------------- -------------------- ------------------ 1" 0.0: 0.0%: 100.0% ------------------------------------- - ----------------------------------------- 3/4" 0.0 ------------- 0 0%`---------100.0% -------------r - A- 1 0.0: 0.0%: 100.0% 3/8"---------;------------------------.�r---------------0.0% ---------100.0% .-------------;..........--...........-•_.r--------------------- ------------------ #4 0.0: 0.0%: 100.0% # ---1--0---------I--------•--------------13.---8:---------------8----9%-->:...__.------9- -1.1%--- . #20 58 ------------ ------. #40 110.8: 71.8%: 28.2% --------------11------------------- .---------------------,------------- ---- #50 1----- 85.4%; 14.6% #80 143.0: 92.7%: 7.3% -------------- -------------------- •---------------------•--•-----........-- #100 145.4 94.2%: 5.8% ------------ ---------------------------%--------------------- ------------------ #200 148.2: 96.0%: 4.0% _------------•.i-••----•----------------•-••-----'---------------i------------------ PAN: 149.0; 100.0 0 0.0% c -------------:-------------------------- ---------------------------------------- SAMPLE: 154.3 NOTE:TEST ON PASSING#4 ONLY, 5.2% RETAINED ON#4 <45% O.K. RESULTS: SOIL CLASSIFIED AS AASHTO A-1-b(GRAVEL AND SAND) (UNCOMPACTED) PERCENTAGE OF MATERIAL PASSING#4 SIEVE : #4 100% (TEST ONLY MATERIAL PASSING#4) OK #5010%-100% OK #100 0%-20% OK #200 0%-5% OK SAMPLE MEETS TITLE 5 FILL SPECIFICATION >96% SAND y ,- t Amy �`� z RESULTS: PERMEABLE MATERIAL-CLASS 1 <2 MINJIN. MATERIAL a ' NONCOMPACTED SOIL DESCRIPTION: MEDIUM/COARSE SAND : E ;f f v f o COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A o�G CERTIFICATION Property Address: 76 Lone Beach Road Centerville, MA 02632 .. Owner's Name: Mike Fitzgerald c� Owner's Address: Date of Inspection: December 1. 2006 ry Name of Inspector: (Please Print) James M. Ford zm Company Name: James M. Ford Mailing Address: P.O.Box 49 Osterville,MA 02655-0049 r-.� r- Telephone Number: (508)862-9400 UN M 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 perfonned based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ✓ Passes Conditionally Passes eds Further Evaluation by the Local Approving Authority Fa is Inspector's Signature: f ffiv MA6 Date: December 6, 2006 The system inspector shall sub t a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 Page 2 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 76 Loniz Beach Road Centerville, MA Owner: Mike Fitzgerald Date of Inspection: December 1. 2006 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: ✓ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined",please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: 2 I Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 76 LonQ Beach Road Centerville, MA Owner: Mike Fitzgerald Date of Inspection: December 1. 2006 C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: 3 Page 4 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 76 Long Beach Road Centerville, MA Owner: Mike Fitzgerald Date of Inspection: December 1, 2006 D. System Failure Criteria applicable to all systems: You must indicate either"yes"or"no"to each of the following for all inspections: Yes No ✓ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ✓ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ✓ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ✓ Liquid depth in cesspool is less than 6"below invert or available volume is less than'h day flow ✓ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped— ✓ Any portion of the SAS,cesspool or privy is below high ground water elevation. ✓ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ✓ Any portion of a cesspool or privy is within a Zone 1 of a public well. _ ✓ Any portion of a cesspool or privy is within 50 feet of a private water supply well. ✓ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] No (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large System: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd• You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) Yes No the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes"in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 4 L 1J -Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 76 Lowz Beach Road Centerville, MA Owner: Mike Fitzgerald Date of Inspection: December 1, 2006 Check if the following have been done: You must indicate"yes or"no"as to each of the following: Yes No ✓ _ Pumping information was provided by the owner,occupant, or Board of Health ✓ Were any of the system components pumped out in the previous two weeks? ✓ Has the system received normal flows in the previous two week period? ✓ Have 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 'Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 76 Lonk Beach Road Centerville, MA Owner: Mike Fitzgerald Date of Inspection: December 1, 2006 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Number of current residents: 0 Does residence have a garbage grinder(yes or no): n/a Is laundry on a separate sewage system(yes or no): No [if yes separate inspection required] Laundry system inspected(yes or no): No Seasonal use(yes or no): No Water meter readings,if available(last 2 years usage(gpd)): Unavailable Sump Pump(yes or no): No Last date of occupancy: Weekend use COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no) Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Unavailable Was system pumped as part of the inspection(yes or no): No If yes, volume pumped: gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM ✓ 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) Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight Tank Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: Installed on 411192-per as built card Were sewage odors detected when arriving at the site(yes or no): No 6 Page 7 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 76 Long Beach Road Centerville, MA Owner: Mike Fitzgerald Date of Inspection: December 1, 2006 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction: _cast iron _40 PVC other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting, evidence of leakage,etc.): SEPTIC TANK: ✓ (locate on site plan) Depth below grade: 12" Material of construction: ✓ concrete _metal _fiberglass polyethylene _other(explain) If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of certificate) Dimensions: 1000 ag 1. Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle: 30" Scum thickness: 3" 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: 10" How were dimensions detennined: Measuring stick Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage,etc.). Tees were present. The liquid level was even with the outlet invert There did not appear to be any suns of leakage GREASE TRAP: None (locate on site plan) Depth below grade: Material of construction: _concrete _metal _fiberglass _polyethylene _other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): 7 R • Page 8 of I 1 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 76 Long Beach Road Centerville, MA Owner: Mike Fitzgerald Date of Inspection: _ December 1, 2006 TIGHT or HOLDING TANK: None (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: _concrete _metal _fiberglass _polyethylene _other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: None (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): PUMP CHAMBER: ✓ (locate on site plan) Pumps in working order(yes or no): Yes Alarms in working order(yes or no) n✓a Conments(note condition of pump chamber,condition of pumps and appurtenances,etc.): I cycled through the pump and it appeared to be working fine. Could not cycle alarm since no one was home to shut it o[f The _liquid was at a normal level. 8 I Page 9 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 76 Long Beach Road Centerville, MA Owner: Mike Fitzgerald Date of Inspection: December 1, 2006 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number: ✓ leaching chambers,number: 3 infcltrators 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.): I dug down in the stone beside the infiltrators and the stone was clean and dry. There did not appear to be an signs igns offailure The top of the infiltrators were 8"below grade. CESSPOOLS: None (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments (note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): PRIVY: None (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil, signs of hydraulic failure,level of ponding,condition of vegetation,etc.): 9 Page 10 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 76 Lonz Beach Road Centerville, MA Owner: Mike Fitzgerald Date of Inspection: December 1, 2006 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. A a 8 1 13 30 AG Ily 10 � j Page llof 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 76 Long Beach Road Centerville, MA Owner: Mike Fitzgerald Date of Inspection: December 1, 2006 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: ✓ Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with local excavators, installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: I hand augered down 4'below the bottom of the SAS to 6'below grade, and no ground water was observed. This report has been prepared only for the septic system and components described herein. This septic system has been inspected and passed as of the date of inspection. This report is not a warranty or guarantee that the system will function properly in the future. There have been no warranties or guarantees, either expressed, written or implied, relating to the septic system, the inspection, this report and/or any components of the septic system which have not been located and inspected. 11 i RECEIVED JAN 0 8 2003 COMMONWEALTH OF MASSACHUSETTS TOWN OF BARNSTABLE HEALTH DEPT. z W EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS m + d DEPARTMENT OF ENVIRONMENTAL PROTECTION A h ti i�qM SV By 350 MAIN STREET WEST YARMOUTH,MA 508-775-2800 TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION MAP 206 PAR 009 Property Address: 76 LONG BEACH ROAD CENTERVILLE,MA 02632 Owner's Name: MWCHELLO,LINDA Owner's Address: 29 AMBER WOOD DRIVE WINCHESTER,MA 01890 Date of Inspection DECEMBER 16,2002 Name of Inspector:(please print) JAMES D.SEARS Company Name: A&B Canco Mailing Address: 350 Main Street West Yannouth,MA 02673 Telephone Number: 508-775-2800 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposals stem at this address and that the information reported Y P below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ✓ Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: ?;off Date: ' 13_a� .42-2, The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent tot he buyer,if applicable,and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 1 Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 76 LONG BEACH ROAD CENTERVILLE,MA 02632 Owner: MINCHELLO,LINDA Date of Inspection: DECEMBER 16,2002 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: ✓ I have not found any infonnation which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: N/A One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined" please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health)" broken pipe(s)are replaced obstruction is removed ND explain: Title 5 Inspection Form 6/15/2000 2 i Page 3 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(CONTINUED) Property Address: 76 LONG BEACH ROAD CENTERVILLE,MA 02632 Owner: MINCHELLO,LINDA Date of Inspection: DECEMBER 16,2002 C. Further Evaluation is Required by the Board of Health: N/A Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety,or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health safety and the environment: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to detennine distance **This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: Title 5 Inspection Form 6/15/2000 3 Page 4 of i l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(CONTINUED) Property Address: 76 LONG BEACH ROAD CENTERVILLE,MA 02632 Owner: MINCHELLO,LINDA Date of Inspection: DECEMBER 16,2002 D. System Failure Criteria applicable to all systems: N/A You must indicate"yes"or"no"to each of the following for all inspections: Yes No ✓ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ✓ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ✓ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ✓ Liquid depth in leaching is less than 6"below invert or available volume is less than%2 day flow ✓ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped ✓ Any portion of the SAS,cesspool or privy is below high ground water elevation N/A Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply N/A Any portion of a cesspool or privy is within a Zone 1 of a public well N/A Any portion of a cesspool or privy is within 50 feet of a private water supply well N/A Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. (This system passes if the well water analysis performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.) NO (Yes/No)The system fails. I have detennined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: N/A To be considered a large system the system must service a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no to each of the following: (The following criteria apply to large systems in addition to the criteria above) Yes No the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone lI of a public water supply well. If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes"in Section D above the large system is failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. Title 5 Inspection Form 6/15/2000 4 Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 76 LONG BEACH ROAD CENTERVILLE,MA 02632 Owner: MINCHELLO,LINDA Date of Inspection: DECEMBER 16,2002 Check if the following have been done. You must indicate"yes"or"no"as to each of the following Yes No ✓ Pumping infonnation was provided by the owner,occupant,or Board of Health ✓ Were any of the system components pumped out in the previous two weeks? ✓ Has the system received nonnal 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 infonnation on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)has been determined based on: Yes No ✓ Existing infonnation. 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)] Title 5 Inspection Form 6/15/2000 P 5 Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 76 LONG BEACH ROAD CENTERVILLE,MA 02632 Owner: MINCHELLO,LINDA Date of Inspection: DECEMBER 16,2002 FLOW CONDITIONS RESIDENTIAL Number of Bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms: 330 Number of current residents: 0 Does residence have a garbage grinder(yes or no): NO Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required] Laundry system inspected(yes or no): YES Seasonal use(yes or no): NO Water meter readings,if available(last 2 years usage(gpd)): N/A Sump pump(yes or no) NO Last date of occupancy: UNKNOWN COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CM 15.203): Basis of design flow(seats/persons/sqft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no): Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: N/A Was system pumped as part of the inspection(yes or no): NO If yes,volume pumped: gallons—How was quantity pumped detennined? 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) Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight tank Attach copy of the DEP approval ✓ Other(describe): PUMP CHAMBER Approximate age of all components,date installed(if known)and source of information: 1992 PERMIT#92-551 Were sewage odors detected when arriving at the site(yes or no): NO Title 5 Inspection Form 6/15/2000 6 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 76 LONG BEACH ROAD CENTERVILLE,MA 02632 Owner: MINCHELLO,LINDA Date of Inspection: DECEMBER 16,2002 BUILDING SEWER(locate on site plan): ✓ Depth below grade: 8" Materials of construction: Cast iron _ 40 PVC _ other(explain) Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK(locate onsite plan): ✓ Depth below grade: I Material of construction: ✓ concrete metal fiberglass polyethylene other(explain) If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of certificate) Dimensions: 1,000 GALLON PRE CAST Sludge depth: 2" Distance from top of sludge to the bottom of outlet tee or baffle: 28" Scum thickness: 0" Distance from top of scum to top of outlet tee or baffle: 12" Distance from bottom of scum to bottom of outlet tee or baffle: 18" How were dimensions determined: ASBUILT AND TAPE Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): MAIN TANK AT WORKING LEVEL. INLET TEE,OUTLET BAFFLE.TANK AND COVERS r BELOW GRADE.NO SIGN OF OVERLOADING IN TANK. GREASE TRAP(located on site plan) N/A Depth below grade: Material of construction: concrete metal fiberglass polyethylene other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): Title 5 Inspection Form 6/15/2000 7 Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 76 LONG BEACH ROAD CENTERVILLE,MA 02632 Owner: MINCHELLO,LINDA Date of Inspection: DECEMBER 16,2002 TIGHT or HOLDING TANK: N/A (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass polyethylene other(explain) Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no) Alarm level: Alarm in working order(yes or no): Date of last pumping Comments(condition of alann and float switches,etc.): DISTRIBUTION BOX: N/A (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.,): PUMP CHAMBER: ✓ (locate on site plan) Pumps in working order(yes or no): ✓ Alanns in working order(yes or no): ✓ Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): PUMP CHAMBER STEEL COVER.NEW PUMP AND FLOATS NOVEMBER 2002 BY A&B CANCO. Title 5 Inspection Form 6/15/2000 8 Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 76 LONG BEACH ROAD CENTERVILLE,MA 02632 Owner: MINCHELLO,LINDA Date of Inspection: DECEMBER 16,2002 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number: ✓ leaching chambers,number: 3 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.) LEACHING IS THREE INFILTRATORS.LEACHING IS 8"BELOW GRADE. DID TEST HOLE BESIDE LEACHING,DRY.NO SIGN OF OVERLOADING. CESSPOOLS: N/A (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth—top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation etc.): PRIVY: N/A (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.) Title 5 Inspection Form 6/15/2000 9 Page 9 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 76 LONG BEACH ROAD CENTERVILLE,MA 02632 Owner: MINCHELLO,LINDA Date of Inspection: DECEMBER 16,2002 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two pennanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. [AI 22 1.7 [ • 5d J ` Title 5 Inspection Form 6/15/2000 10 i Page 1 1 of 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 76 LONG BEACH ROAD CENTERVILLE,MA 02632 Owner: MINCHELLO,LINDA Date of Inspection: DECEMBER 16,2002 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to no groundwater 6 feet Please indicate(check)all methods used to detennine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: ./ Observation site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with local excavators,installers-(attach documentation Accessed USGS database-explain: You must describe how you established the high ground water elevation: HAND DUG TEST HOLE 6',NO WATER. TEST HOLE 4' BELOW BOTTOM OF LEACHING. 7��/ �v Title 5 Inspection Form 6/15/2000 11 V COMMONWEALTH OF MASSACHUSETTS I EXECUTIVE OFFICE OF ENVIRONMENT AFAIRS �c�f loxDEPARTMENT OF ENVIRONMENTAL�PR EC, ONE WIN-TER STREET, BOSTON, MA 02108 617-2.92-5500 !T"99 9g WILLIAM F.WELDa tioFlsrq�4r TRUDY CORE Governor •�.� �? Secretan ARGEO PAUL CELLUCCI DAVID B.STRUHS Lt.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM" -Z - Commissioner h �P�ApRT A tP � CER M1� CATION no Property Address: rv &aaIL t Address of Owner: � Date of Inspection. ag'� l (If different) to /) _/S� / Pep Name of Inspector: WA��_M " lT G/1 ' , ) ���lll I am a D P approved system inspector pursuant to Section 15.340 ,of'T,itle 5 (310 CMR 15.000) /,}//nd�pl "' Company Name: U'1C V� `7V(t Mailing Address: Telephone Number: - Q ' d-703 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: Passes Conditionally Passes Needs Further Evaluation B the Local Approving Authority _ F JI �( Inspector's Signature: _ Date: v 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: I 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. COMMENTS: B] SYSTEM CONDITIONALLY PASSES: One or more system components as descri the "Conditional Pas " ion need to be replaced or repaired. The system, upon completion of the replacement or repair,_as approve the B of Health, will pass. Indicate yes, no, or not determined (Y, N, or ND). Descri asis of determl on in all instances. If"not determined", explain why not. The septic tank is metal, unless t wrier or operator has provi he system inspector with a copy of a Certificate of Compliance (attached) indi ng that the tank was installed within twen 20) years prior to the date of the inspection; or the septic tank, w r or not metal, is cracked, structurally unsound, shows s tantial infiltration or exfiltration, or tank failure is im " ent. The system will pass inspection if the existing septic tank is rep a with a conforming septic tank as ap ed by the Board of Health. (revised 04/25/97) Page 1 of 10 DEP on the World Wide Web: http:1twww.magnet.state.ma.us/dep ZJ Printed on Recycled Paper ,i SUBSURFACE SEWAGE DISPOSAL SYSTEM 11-41WECTION FORM PAR7 A CERTIFICATION (continued It ) Property Address: o Lan RYo�& ) We VA Owner: Date of.Inspection: Bj SYSTEM CONDITIONALLY PASSES (continued) 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). Describe observations: broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced _ The syste required pumping more than four times a year due to br en or obstructed pipe(s). The system will pass inspection i ith approval of the Board of Health): broken pipe(s) are replaced truction is removed CJ FURTHER EVALUATION IS REQUIRED BY TH BOARD OF ALTH: Conditions exist which require further evaluatio 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 EALTH D MINES THAT THE SYSTEM-IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC LTH AND SA F AND THE ENVIRONMENT: Cesspool or privy is withi 50 feet of a surface water Cesspool or privy is wi in 50 feet of a bordering vegetate wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLE THE BOARD OF HEALTH (AND PUBLIC TER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCT NING IN A MANNER THAT PROTECTS THE P LIC HEALTH AND SAFETY AND THE ENVIRONMENT: The sys m has a septic tank and soil absorption system (SAS) and the SAS within 100 feet to a surface water supply or tribu ry to a surface water supply. _ T system has a septic tank and soil absorption system and the SAS is within a ne I of a public water supply well. _ e system has a septic tank and soil absorption system and the SAS is within 50 fe of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less than 100 t but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile anic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and itrate nitrogen is equal to or less than 5 ppm. Method used to determine distance (approximation not valid). 3) OTHER (revised 04/25/97) Page 2 of 10 u�. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: L05 Owner: -! Date of Inspection: Ct ul_0)to D) SYSTEM FAILS: You must indicate ewer "Yes" or "No" as to each of the following: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No -• _ Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or / cesspool. _ tatic liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspo _ Liqui depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow. _ Required p ping more than 4 times in the last year NOT due to clogged or obstructed pip Number of ti s pumped _. _ Any portion of the it Absorption System, cesspool or privy is below the high undwater elevation. _ Any portion of a cesspoo or privy is within 100 feet of a surface waters ply or tributary to a surface water supply.. �g[ _ Any portion of a cesspool or -ivy is within a Zone I of a public ell. _ Any portion of a cesspool or privy within 50 feet.of a pr' ate water supply well. _ Any portion of a cesspool or privy is les than 100 f t but greater than 50 feet from a private water supply.wefl with no acceptable water quality analysis. If the II has een analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compoun ammonia nitrogen and nitrate nitrogen. E] LARGE SYSTEM FAILS: You must indicate either "Yes" or "No" as to each of a following: The following criteria apply to large syste s in addition to the cri ria above: The system serves a facility with a d ign flow of 10,000 gpd or great (Large System) and the system is a significant threat to public health and safety and the a ironment because one or more of th following conditions exist: Yes No _ the system is w' in 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the sys m is located in a nitroger, sensitive area (Interim Wellhead Protection Ar a- IWPA) or a mapped Zone 11 of a publi water supply well) The owner or operat r of any such system shall bring the system and facility into full compliance with th groundwater treatment program requirements of 31 CMR 5.00 and 6.00. Please consult the local regional office of the Department for fu her information. (revised 04/25/97) Page 3 of 10 t° SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: u Lon *,CIA V d , ((V i4 Owner: Date of Inspection. ' Gccol b q-aq-q.1 Check if the following have been done: You must indicate.either "Yes" or "No" as to each of the following: Yes No -!""NI _ 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. As built plans have been obtained and examined. Note i1 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. V _ 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: The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of Sub-Surface Disposal System. _ Existing information. Ex. 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) 115.302(3)(b)J (revised 04/25/97) Page 4 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: Lon VOIA Owner: Date of Inspection: Ss cco� �— �q FLOW CONDITIONS RESIDENTIAL: Design flow:. d./bedroom for S.A.S. Number of bedrooms: Number of current residents: b Garbage grinder (yes or no): N Laundry connected to sys a (yes or no)A Seasonal use (yes or no T Water meter readings, if a ailable (last two (2) year usage (gpd): Sump Pump (yes or no):R 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 systenii: (ye r n Water meter readings, if available: Last date of occupancy: OTHER: (Describe) Last date of occupanZaVsorce GENERAL INFORMATION PUMPING RECORormation: r System pumped as part of specti n: (yes or no) If yes, volume pumped: gallons Reason for pumping: TYPE OF SYSTEM pU�nti Septic tank/di�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. Copy of up to date contract? 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 04/25/97) Page 5 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 4� w� �L �� ����'✓ C Owner: ---- /� Date of Inspection: 1 , Cccck BUILDING SEWER: Ll— a(..�.- cta (Locate on site plan) l Depth belo Material of�co�nstrwio�n- t 40 PVC _other (explain) • Distance from private water supply well or ion line Diameter Comments: (condition of joints, venting, evidence of lea etc.) SEPTIC TANK: (locate on site JDpan) Depth below grade: Material of construction: Xoncrete _metal _Fiberglass _Polyethylene _other(explain) If tank is metal, list age _ Is age confirmed by Certificate of Compliance _(Yes/No) Dimensions: 1,600 (� Sludge depth:_ �1 Distance from top of sludge to bottom of outlet-tee or baffle: I`t 0 S�U� Scum thickness:_ \ e 9 Distance from top of scum to top of outlet tee or baffle: 'y W Distance from bottom of scum to bottom o utlet tee or baffle: How dimensions were determined: Comments: (recommendation for pumping, condi ' n tan outlet tees. r baffles, ept of liq id level in rel 'on to outlet ' vert, tructural integrity, evid ce of leakage, etc.) "t _ on GREASE TRAP:- (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 Distance from bottom of scum to bottom of outlet or le: Date of last pumping: Comments: (recommendation for pumping, c dition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage tc.) (revised 04/25/97) Page 6 of 10 LV_ n SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Wl, r2R(1A ` Owner: S. C('�oto j Date of Inspection: LFD - Q j TIGHT OR HOLDING TANK: (Tank must be pumped prior to, or at time, of inspection) (locate on site plan) i i Depth below grade: Material of construction: _concrete metal —Fiberglass _Polyethylene —other(explain) I i Dimensions: Capacity: gallons I. Design flow: gallons/day jAlarm level: Alarm in working order_Yes; _ No Date of previous pumping: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) I DISTRIBUTION BOX:_ (locate on site plan) Depth of liquid level above outlet invert: _ i Comments: (note if level and distribution is equal, evidence of solids carryover, evi a of leakage into or out of box, etc.) PUMP CHAMBER•_ (locate on site plan) Pumps in working order: (Yes or No) Alarms in working order (Yes or No)� Comments: (note condi ion of pump chamber, condition of pumps and appurtenances, etc.) Alcompriparlts I (revived 04/IS/97) Page 7 of 10 r• SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION ontinued) Property �o P Y Address: K/n �Q el", L•f'i P t b Owner: �, Cl c 10 J Date of Inspection: I _I 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, number:_ leaching chambers, number:3 leaching galleries, number: leaching trenches, number,length: leaching fields, number, dimensions: overflow cesspool, number. Alternative system: q Name of Technology: Comments: (rjpte condition of soil sign of hyd aulic failure, level of o i g, condi ion of vegetation, etc.) 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 04/25/97) Pare 8 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C 7 /� SYSTEM INFORMATION ( ontinued) �^ Property Address: l 6 O Owner: C`CCU Q Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) �u U M P 1o©� (revised 04/25/97) Page 9 of 10 I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION ( ontinued Zc� Lon &aclr, ?d Property Address. � Owner: Date of Inspection: \ r Depth to Groundwater Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observation of Site (Abutting property, observation hole, basement sump etc.) Determine it from local conditions Check with local Board of health Check FEMA Maps Check pumping records Check local excavators, installers Use USGS Data Describe in your own words how you established the High Groundwater Elevation. (Must be completed) —TesC 1-, Ode C I 4D uorTpm S Tp�N K 1 y a irs w� Tide",) (revised 04/25/97) Page 10 of 10 TOWN OF BARNSTABLE LOCATION SEWAGE # VILLAGE 0Q,1JRfl)J I ASSESSOR'S MAP &LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY o0 0 0 LEACHING FACII.TTY: (type) (size) Zink x2 NO.OF BEDROOMS 0z BUILDER OR OWNER C.% -PE DATE: j w 6 f, COMPLIANCE DATE: i Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet j Private Water Supply Well and Leaching Facility (If any wells exist tt on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist y within 300 feet of leaching facility) 5 3 Feet 1 Furnished by ___ w w D ' 6 o i L►► P�2— �4�o► �l2— o� o `►� � 7 T 4 r.y 00 No*............... Fps. ..................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH APPWM TOWN OF BARNSTABLE ApplirFation for Ui"og al Works Cann Application is hereby made for a Permit to Construct ( ) or Repair ( an Individual Sewage Disposal System d°�- .! �1......... ... Ed,------ --•- --------- L ............................. ®. anon-Address or Lot No. =�-----•---.5:.1. L...���................................. .............................................. ...Y..................!-�•n �t-- ............................... ...........On..��Y:.�L��r`SS........................................... Installer Address d Type of Building Size Lot............................Sq. feet aDwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) P4Other fixtures -----------••---•----------------------------•--------••••-------•-•------•--•--•---••---------------•---•....--•-..........•---...........-••-...... W 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 ( ) Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1................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........................ 1:4 •---•---•---------------------•••-••-•-•--••---•-•---------•--••-••-----•---••-•••-------•----.....•......................................................... 0 Description of Soil........................................................................................................................................................................ W --- ----- --- U Nature of Repairs meter bons—Answer when applicable� C�l� ._____: `_ ---- �Z L.__ _/.s -� �-----------T----- •------ -�t��:l?�f�p�� A eement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance h bee by t oard of alth. f gned -- - . - ....- --- -- .. ... . ... ...................' ......C.�l 1�.. '...�'. Application AppoB .Doim4si -0 --- . ....... -)-- : q{- cam' - t Application Disapproved for the following rear f: .. .......................................................... ................................................................... ........................................... -------------------- ----------------------------------------- --- --- --------------------------------------------------------------------------------- .................................... Dace Permit No.w. ....�,5 ........................ Issued --------------- Date t No: - - F$a__3, 0 O ' THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Appl ration for flispnsttl Works Tons "_ 7 ,O ruat l z --2 Application is hereby made for a Permit to Construct ( ) or Repair ( an Individual Sewage Disposal System at: 2— - vocation-Address - or Lot No. 4W , ------------------------------ ---------�»�-�- L C2C2L, s— ----.. _�»»..»._._ Installer Address UType of Building Size Lot----------------------------Sq. feet Dwelling—No. of Bedrooms--------------------------------------------Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building a —Type g ____________________________ No. of persons---------------------------- Showers ( ) — Cafeteria ( ) Other fixtures ------------------------------------------------------- -----------------•-------------------- W Design Flow--------------------------------------------gallons per person per day. Total daily flow--------------------------------------------gallons. W Septic Tank—Liquid-ca acit ------------gallons Length--------------- Width---------------- Diameter_____ ----------- Depth---------------- x Disposal Trench—No--------------------- Width-------------------- Total Length_------------------ Total leaching area-------------------- ft. Seepage Pit No--------------------- Diameter.................... Depth below inlet-------------------- Total leaching area------------f---sq. ft. Z Other Distribution box ( ) Dosing tank ( ) •-' Percolation Test Results Performed by = ----------------- Date - Test Pit No. I................minutes per inch Depth of Test Pit-------------------- Depth to ground water-•--__-______-_•-_---__. (_, Test Pit No. 2----------------minutes per inch Depth of.Test Pit-------------------- Depth to ground water..•---__________---__--_ a ----------------------------------------••---------------------------------------------------------------------------------------------------------- 0 Description of Soil------------------------------------------------------------------------------- c --------------------------------------------------------------------------------------------•------------------------ - - x ---------------------------------------------------------------------------------------------------------------------------- - U Nature of Repairs q�.terations—Answer when applicable,,W_W_Q _..__..5y:s _'f vl -'_l__---_/ <?-___ �- /pOCJ ------,�JrJ1yl7 ......... �?l • l--' --- ----- Agfeement: l/ " J ' The undersigned agrees to Finstall the aforedescribed.Individual Sewage Disposal System in accordance with theprovisiots'of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance hps bee gue. by t oard of'h- lth. � Signed d%-CJ-��------------- A,( Application Approved BY : ! = /12, -- AI. 1.� 1.IY,f ------------- i� / -'' - Application Disapproved for the following reasons: ---_-------- ~--------------------------------------------------------------------------------------------------------- -------------------------------- ------------------------------------------------------------ ----------------------------------------------- ---------------------------------------- Dare Issued Permit No. _--__--_- Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE C�P�t�tC�t�E of �IIrit�J.�t�IttCE l/ THISNQ TIFY, That the Individual Sewage Disposal System constructed b � g p y ( ) or Repaired ( ) --------------- -- ------ ------------ Y - at _. I��au -- -------------------- - ,.� -- -- // - has been installed in accordace with the provisions of TITLE 5 of The State Environmental Code as described in the application for Disposal Works Construction Permit No_ ________________________________________________ dated _.____________-__-..--.-_-----.----_-.---------- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE.---------f Inspector --------- - 11 - _ L --- /!_. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE F>� 5 ��Permission is hereby granted.-______________�,�`' /11 e Z: - _ l-------- = - - ---- to Construct ( ).or Repair an Individual Sewage DispoVit �&i t /� ' ! �- as shown on the applicati n for DispoUWorks Construction Permi o.. 7�WDatird, +;l —_� �a a�_g --------- t= : �� DATE= %/y1 ------ �` -------------------------------------- Board of Health FORM 36508 HOBBS R WARREN,INC_.PUBLISHERS TOWN OF BARNSTA LE � LOCATION SEW AGE # ,P.? VILLAGE ���7ASSESSOR'S MAP & LOIJ- l INSTALLER'S NAME 6t PHONE NO. SEPTIC,TANK CAPACITY d�7 Cif LEACHING FACILITY:(type) �(size) NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER`>:` BUILDER OR OWNER � �...� DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: / �Z VARIANCE GRANTED: Yes �— No k4f' 7�oCr—<41 hL:. TOWN OF BARNSTABLE � r ISZyCATIi�N� �XO�� SEWAGE # s� VILLAGE ASSESSOR'S MAP & LO'�QZQk; LS INSTALLER'S NAME & PHONE NO. SEPTIC TANK CAPACITY ho O LEACHING FACILITY:(type) 9 / A (size) NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER � l '`""Gf t e—, DATE PERMIT ISSUED- DATE COMPLIANCE ISSUED: ly �� VARIANCE GRANTED: Yes No a " t S link o �- � y : TOWN OF BARNSTABLE NOCATION / � ��'�� 6 f W e11 'Off-) SEWAGE # VILLA E- e £'�'� ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. 446 SEPTIC TANK CAPACITY £���c- LEACHING FACILITY: (type) (size) NO.OF BEDROOMS BUILDER OR OWNER PERMIT DATE: COMPttk1qtE 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 h \r-N rROAl a �� �O e e TOWN OF BARNSTABLE LOCATION 'I (f (Ong [S24C� Ke, SEWAGE# VILLAGE ASSESSOR'S MAP&PARCEL Q0G-S�I INSTALLERS NAME&PHONE NO. SEPTIC TANK CAPACITY UW LEACHING FACILITY.(type) 3 !A}�� f/J ors (size) NO.OF BEDROOMS 3 OWNER ,'fZ('erAl� PERMIT DATE: 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 Q 1 ►3 30 ado ty 3 3 3v mac. w . ..a Ul �s l I I 1 I i S . } 1 nn , �C-7� IF a fR a 3 F , IF f , f p, - _ I c Los F-r fIrlAhl vN ",tv. i L