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HomeMy WebLinkAbout0020 MAIN STREET (CENT.) - Health (2) 20 Main Street (Cent.) Centerville P A = 228 013 I No. 4210 1/3 ORA 10% a o o II TOWN OF BARNSTABLE LOCATION I� (��^ ) ��.� SEWAGE # VILLAG ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO.SEPTIC.TANK CAPACITY L CM acutw LEACHING FACEL=: Cr1��l'� ( ' )(type) sue NO. OF BEDROOMS 1A � BUILDER OR OWNER I v'/ � PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by Ac3 M 3° �c bc Ll6, 1 r LOT NO. : ADDRESS:. ac)mri►n F, - ,Oemo u OWNERS NAME: Q�2� _ SEWAGE PERMIT NO. : RE-£tR: DATE ISSUED: DATE INSTALLED: INSTALLERS NAME: INSTALLATION OF: „ (Sp6 G',aj 4ccr, 9 WATER TABLE: FINAL INSPECTION BY: DRAWING OF INSTALLATION ON REVERSE SIDE : Y J ` © � �AA C74 L" 99Trc, IB SOJLIP .." ,, ;' :, i�'Tyca^G�P• srz�r= �a�I+aews Ica o�-t:.lc zP „pfm: � �.�r :�4-r;^i�a.=w�ra°� eavt� . x:tivs�Y'aB �'vA�3' ,s+s.■rzmc�yd�7zra.gr,��@??�'?1�,'-"R3.'TJ",�'�. - f p� •2 •w•..t.. "�.. t.. l.. . ::- .xti,:'. ..".i C� '..�:: �..•i: ,:,:. 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Ala o� � � _ _ SKy4a MT, I - 1, �. • Hove Jvl,.* •��ggg♦yyy!•••1 . 19 _.$_ 1'•3 -��. --__ .-4+C3aGr _ _ _ it ' )'2M wmM.•K .QI.N I.GI_4_Q.2e.l1N i 1't t�J.laLL�'_G_1 G J A Y.e•1 � Is S 3_M-a.w.- �Ilro•+ G 1M Ir1{'M 3�se f L9' Ift=o o " OFFI Le Ji `� °�• °fc — ° 7I l.a a _rz.y... N �y CT ,a C . T FjPTiG GLIDE. O A1ASTEtt DEPfa OOM P w � J 3V. iL � w id 'f'.E�I. 1. I4V j /3 o almo ae , II I xa3f. r � Ra-s ief rxa�x © e'-°•�'N �� Ms�.a-s�SJI ;.� • 77 z... O� �1 �Q Q r �' ?��k.�' S; `a� r_ I n.IlyeY4 ,q7. --- '�' z' I,d�.:� y�• r;. v Yro v 0 3 ,6o I.n GUEST BEDROOM IVA ! WORKSPACE l t`s h 1 dining room 14 ®r co eAsting kitchen i d �tT v C CURRENT LIVING ROOM OoO O v CURRENTBATH CURRENT BEDROOM O Tro.r ca'edr COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION n � , � C A if C O� '�M SJe v TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE:SEWAGE DISPOSAL SYSTEM FORM PART A RECEIVED t., CERTIFICATION Property Address: 20 MAIN STREET CENTERVILLE,MA 02632 2 V C 13 JUL 2 5 2002 Owner's Name: JIM DONNELLAN, TOWN OF BARNSTABLE Owner's Address: 20 MAIN STREET CENTERVILLE, MA 02632 HEALTH DEPT. Date of Inspection: 7/10/02 L ¢ Name of Inspector: (please prin't.). .. .,t JOHN GRACI Company Name: SEPTIC INSPECTIONS I Mailing Address: R O.BOX 1119 TEATICKET,MA.02536 r . Telephone Number: 508-564-6813 FAX 508'564-7270 . 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 the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: X Passes _ Conditionall sses _ Needs FurtI valuation by the Local Approving Authority Fails ; Inspector's Signature: Date: 7/10/02 The system inspector shall submit 1copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspecti n. 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 cop.ies;sent to.the;buyer, if applicable,and the approving authority. Notes and Comments SYSTEM PASSED TITLE V INSPECTION. RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE. s a,0 • ****'Phis report only describes coyrlitiOns at the time of inspection and uuder the conditions ol•use'it Iltnl Iime.This inspection does not address how the`system will perform in the future under the same or different conditions of use. Title 5 ImnP('tlnn Fnrm A/1 VW1M I Page 2 of l I OFFICIAL INSPECTION FORM--NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 20 MAIN;STREET CENTERVILLE, MA 02632 Owner: JIM DONNELLAN '! Date of Inspection: 7/10/02 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: X I have not found any informaticfn'Uich 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: SYSTEM PASSED TITLE V INSPECTION. RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE. 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 oiyrepair,,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. n/a The septic tank is metal ariNV&20,ye4s 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 oTdiis%VaiIable. ND explain: n/a n/a Observation of sewage back:60!grbreak out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled'6i Dui 2'ven 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: n/a n/a The system required pumping more fhan`4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the hoard of-Health): _broken pipe(s)are replaced obstruction is.removed ND explain: n/a r 7 Page 3 of I I OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE'SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) E Property Address: 20 MAIN STREET CENTERVILLE,MA 02632 Owner: 31M DONNELLAN Date of Inspection: 7/10/02 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: ti _ 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 un less,theBoard 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 an'd SAS and the SAS is within a Zone 1 of a public water supply. _ The system has a septic tank+and SASrlhnd the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and.S`AS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used tosdetermine distance n/a "This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates t6t 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. ` ii i 3. Other: n/a k :8 "sa ' I t Page 4 of I I . OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE'SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 20 MAIN STREET CENTERVILLE, MA 02632 Owner: JIM DONNELLAN Date of Inspection: 7/10/02 D. System Failure Criteria''applicable fo'all systems: You niusi indicate"yes"or"no",fo each of the following for alLinspections: Yes No X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool _ X Static liquid level in the—distribution box above outlet invert due to an overloaded or clogged SAS or cesspool _ X Liquid depth in cesspool is less than 6"below invert or available volume is less than ''/z day flow X Required pumping more';than A times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped nLa. , X Any portion of the SAS,cesspool or privy is below high ground water elevation. _ X Any portion of cesspool,or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone 1 of a public well. _ X Any portion of a cesspool or privy is within 50 feet of a private water supply well. X Any portion of a cesspool or privy,is;less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. (This system passes if the well water analysis, performed 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 titancopy 5 ppm,provided that no other failure criteria are triggered. A of the analysis must be attached to this form.) (Yes/No)The systemi fails. 1,have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the sysfdin fails:'Th' system owner should contact the Board of Health to determine what will be necessary to correct the failure. ` ,5 s E. Large Systems: To be considered a large system the system must serve a facility with a design now 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) 4 yes no X the system is within 400 feet of a surface drinking water supply X the system is within 200-feet as tributary to a surface drinking water supply X the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone 11 of a public water supply well If you have answered"y,es"yto'any question in Section E the system is considered a significant threat,or answered "ye;" in Seclitin n ahwe IIic IarE�e 9)slcni'h' 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 CM 15.304. The system Owner should contact the appropriate regional office of the Department. '.r d i Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE.SEWAGE DISPOSAL SYSTEM INSPECTION FOR M PART B CHECKLIST Property Address: 20 MAIN STREET CENTERVILLE,MA 02632 Owner: 31M DONNELLAN Date of Inspection: 7/10/02 Check if the following have been don�i:•'-1'ou must indicate"yes"or"no"as to each of the following: Yes No X _ Pumping information was provided by the owner,occupant,or Board of Health X Were any of the system eomponents pumped out in the previous two weeks X _ Has the system received normal flows in the previous two week period`? X Have large volumes'of water been introduced to the system recently or as part of this inspection ? X _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) X _ Was the facility or dwelling inspected for signs of sewage back up? X _ Was the site inspected for signs of break out'? X _ Were all system components,excluding the SAS, located on site'? 2C _ Were the septic tank maUles,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? X _ 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 X _ Existing information. For example,'a plan at the Board of Health. X _ Determined in the field('if any oftF.e failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)].' s , 'tail . F ' i• 4 t Page 6 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE'SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 20 MAIN STREET CENTERVILLE,MA 02632 Owner: JIM DONNELLAN Date of Inspection: 7/10/02 'PLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):Sj, ,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: 2 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):;NO Seasonal use: (yes or no): NO Water meter readings, if available(last 2 yearslusage(gpd)):At4a_C> Sump pump(yes or no): NO ;:,; CA /bL)D Last date of occupancy: n/a COMMERCIAL/INDUSTRIAL Type of establishment: n/a Design flow(based on 310 CMR 15'293):.n/agpd Basis of design flow(seats/persons/sgft,etc.): n/a Grease trap present(yes or no): NO x Industrial waste holding tank present(yes or no): NO Non-sanitary waste discharged to the fitle 5 system(yes or no): NO Water meter readings, if available: n/a Last date of occupancy/use: n/a OTHER(describe): n/a ;4 GENERAL INFORMATION Pumping Records V Source of information: n/a Was system pumped as part of the inspection(yes or no): NO If yes,volume pumped: n/agallons,--'How was quantity pumped determined? n/a Reason for pumping: n/a t' TYPE OF SYSTEM X Septic tank,distribution box,soil"absorption`system _Single cesspool _Overflow cesspool _Privy _Shared system(yes or no)(if yes,attach previous inspection records, if any) _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 6EP approval Other(describe): n/a '4 l � 5 ; Approximate age of all components,date installed(if known)and source of information: 1860,SYSTEM 20-25 YEARS OLD BY OWNER Were sewage odors detectedwhen arrivingmt the site(yes or no): NO y i Page 7 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 20 MAIN STREET CENTERVILLE, MA 02632 Owner: JIM DONNELLAN Date of Inspection: 7/10/02 BUILDING SEWER(locate on site plan) Depth below grade: 12" Materials of construction:_cast iron 940'PVC; other(explain): n/a Distance from private water supply well or suction line: n/a Comments(on condition of joints„venting,evidence of leakage,etc.): TOWN WATER SEPTIC TANK: X(locate on site plan) Depth below grade: 6" Material of construction: Xconcrete_metal_fiberglass_polyethylene other(explain)n/a If tank is metal list age: n/a Is ag'e confirmed by a Certificate of Compliance(yes or no): NO(attach a copy of certificate) Dimensions: 1000G L 8' 6" H 5' 7" W. 4' 10"" Sludge depth: 1" Distance from top of sludge to bottom of,outlet.tee or baffle: 33" Scum thickness: 0" Distance from top of scum to top of outlet tee or baffle: 6" Distance from bottom of scum t6;80 om of outlet tee or baffle: 18" How were dimensions determined: MEASURED Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY. RECOMMEND PUMPING EVEItY'TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE. GREASE TRAP: _(locate on site plan) pt u 1 Depth below grade: n/a Material of construction:_concrete_metal fiberglass_polyethylene_other(explain): n/a Dimensions: n/a Scum thickness: n/a Distance from top of scum to top of outlet tee or baffle: n/a Distance from bottom of scum to bottom of outlet tee or baffle: n/a Date of last pumping: n/a Comments(on pumping reconmi6ndations, inlet and outlet tee or baffle condition,struchiral integrity, liquid levels as related to outlet invert,evidence of leakage,etc;): n/a „a;,. ; Page 8 of I I <I i, OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 20 MAIN STREET CENTERVILLE,MA 02632 Owner: JIM DONNELLAN Date of Inspection: 7/10/02 -r TIGHT or HOLDING TANK,::, (tank'must be�pumped at time of inspection)(locate on site plan) i Depth below grade: n/a Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a Dimensions: n/a ' Capacity: n/a gallons ;F Design Flow: n/a gallons/day Alarm present(yes or no): Alarm level: N/A Alarm in working,order(yes or no): NO Date of last pumping: n/a '.,i. , Comments(condition of alarm and float switches,etc.): n/a . DISTRIBUTION BOX:X(if present;lnust be opened)(locate on site plan) Depth of liquid level above outlet invert: n/a 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.): is NO D-BOX. PUMP CHAMBER:_(locate on site plan) 4 Pumps in working order(yes or no): NO Alanns in working order(yes or no):NO Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): n/a `€t t 1t'q fll 3 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: 20 MAIN STREET CENTERVILLE,MA 02632 Owner: JIM DONNELLAN Date of Inspection: 7/10/02 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required) t. If SAS not located explain why: ' n/a Type 1000 GAL 6' X 6' leaching pits, number: 1 n/a 1, leaching chambers, number: n/a n/a leaching galleries, number: n/a n/a leaching trenches, number, length: n/a n/a leaching fields, number: n/a n/a overflow cesspool, number: n/a n/a 4 S innovative/alternative system f s Type/name of technology: n/a Comments(note condition of soil,signs'of hydraulic failure, level of ponding,damp soil,condition of vegetation,etc.): LEACH PIT IS STRUCTURALLY SOUND AND FUNCTIONING PROPERLY.SYTSEM SHOWS NO SIGNS OF FAILURE. PIT WAS HALF FULL AT TIME OF INSPECTION.STAIN LINES INDICATE PIT HAS NEVER BEEN MORE THAN 3/4 FULL.THERE IS 3' OF STONE AROUND PIT. CESSPOOLS: (cesspool must be phmped=as-part of inspection)(locate on site plan) Number and configuration: n/a P Depth—top of liquid to inlet invert: n/a Depth of solids layer: n/a Depth of scum layer: n/a Dimensions of Asspool: n/a Materials of construction: n/a Indication of groundwater inflow(yes or no): NO Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): n/a PRIVY: (locate on site plan)' Materials of construction: n/a Dimensions: n/a . . 'g Depth of solids: n/a Comments(note condition of soil,signs;of hydraulic failure, level of ponding,condition of vegetation,etc.): n/a At:l..1 , ;) . 4 i Page 10 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 20 MAIN STREET CENTERVILLE,MA 02632 Owner: JIM DONNELLAN Date of Inspection: 7/10/02 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. .l RR A L j A AS n P L r in r � Page 1 I of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 20 MAIN STREET CENTERVILLE,MA 02632 Owner: JIM DONNELLAN Date of Inspection: 7/10/02 SITE EXAM _Slope _Surface water _Check cellar Shallow wells Estimated depth to ground water 10+feet Please indicate(check)all methods used to determine the high ground water elevation: NO Obtained from system design plans on record- If checked,date of design plan reviewed: n/a YES Observed site(abutting property/observation hole within 150 feet of SAS) NO Checked with local Board of Health-explain: n/a NO Checked with local excavators, ►nstallers-(attach documentation) NO Accessed USGS database-explain: n/a You must describe how you established the high ground water elevation: HAND AUGER- 10+FT. John Grad D.E.P. Titie V Septic Inspector 564-68i3 -- _ - SUBSURFACE SEWAGE DI8P08AL BYSTEH INSPECTION FORK Address -of property ao 111VA l owner's name _ C�►�� - __ 4b r Date of- Inspection q;ZL rEW a-9 PART A - � S EP 2 7 -1W �N CHECICLIBT sazie, c check if the following have been done: cc - Pumping information was requested. of the owner, occupant, an 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. VJA As built plans have been obtained and examined. Note if they are not available with N/A. , _Z The facility or dwelling was inspected for signs of sewage back-up. The site was inspected for signs of breakout. __Z All system components, excluding the SAS, have been located on the site. The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. The size and location of the SAS on the site has been determined based on exist: ng information or approximated by non-intrusive methods. _l The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of SSDS. e SUBSIIRFACE SEWAGE DISP09AL`SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION - FLOW CONDITIONS ..If- residential -- number -of bedrooms - number of current residents garbage grinder - - - Yes or no laundry connected to system, yes or no - - AO_ seasonal use, yes or- no - - If nonresidential-, calculated flow: Water-meter readings, if available: 19ti3 ll4,coo GNP -J—tkc `0u Last date of occupancy GENERAL INFORMATION Pumping records and source of information: -b System pumped as part of inspection if yes, volume pumped Yes or no Reason for pumping: Ty of system Septic tank/distribution box/soil absorption sorption system Single cesspool Overflow cesspool Privy Shared system (yes or no) (if yes, attach previous ins records, if any) inspect ion Other (explain) Approximate age of all components. Date installed, if known. Source of information: f Sewage odors detected when arriving at the site, yes or no 9 SUBSURFACE SEWAGE- DISPOSAL SYSTEM INSPECTION FORM PART 8 - - SYSTEM INFORMATION continued SEPTIC TANK: _ . (locate .on site plan-) - _ depth below grade: / _ material of construction: i� concrete metal -FRP other(r(explain) , dimensions:_ �� 7 w y to sludge depth _ _ distance from top of sludge to bottom of outlet tee or baffle V1 scum thickness - V distance from top of scum to top of outlet tee or baffle I'' distance from bottom of scum to bottom of outlet tee or- baffle - Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in:-relation to outlet invert, structural integrity, evidence of leakage, recommendations for repairs, etc. ) S4�4m be DISTRIBUTION BOX: (locate on site plan) depth of liquid level above outlet invert Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, recommendation for repairs, etc. ) PUMP CHAMBER (locate on site plan) pumps in working order, yes or no Comments: (note condition of pump chamber, condition of pumps and appurtenances, recommendations for maintenance or repairs,etc. ) I SUBSURFACE SEWAGE DISPOSAL SYSTEX INSPECTION PORK PART B BYSTEX IN70RKATION continued. SOIL ABSORPTION SYSTEM. .(SAS) : (locate on site plan,-_if .possible; excavation not required, but may be-- approximated by non-intrusive methods) - If not determined to -be present, explain: Type - - - leaching-pits and ,number _ H►o ir�,oc•c,4 c�+, leaching chambers and number J leaching galleries a-nd number leaching trenches, number, length - leaching fields, number, dimensions overflow cesspool , number ` Comments: (note condition of soil , signs of hydraulic failure, level of ponding, condition of vegetation, recommendations f r aintenance or repairs, etc. ) S\14eM ke,5 -ben YL C,,J) A+ ore 1^e SUM SAv��� e /1a,n every /car CESSPOOLS (locate on site plan) : number and configuration depth-top of liquid to inlet invert depth of solids layer depth of scum layer dimensions of cesspool materials of construction indication of groundwater inflow (cesspool must be pumped as part of inspection) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, recommendations for maintenance or repairs,etc. ) PRIVY: (locate on site plan) materials of construction dimensions depth of solids Comments: (note condition of soil , signs of hydraulic failure, level of ponding, condition of vegetation, recommendations for maintenance or repairs,etc. ) -SUBSURFACE. SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM- INFORMATION continued SKETCH OF SEWAGE DISPOSAL SYSTEM: - include ties to at least two permanent references landmarks or benchmarks locate all wells within 100 ' - r� 6 6 AA /Ay 1� o"I' AC a6i 1 C DEPTH TO GROUNDWATER f depth to groundwater method of determination or approximation: SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C - FAILURE CRITERIA - Indicate yes-, no, or not determined (Y, N, or ND) . Describe basis of determinet-on in-all -instances. If "not determined", e-plain why not) Backup of sewage into facility? - Discharge or ponding of- effluent to- the surface of the ground or surface waters? Static liquid level in the distribution box above outlet invert? Liquid depth in cesspool <611 - below invert or available volume< 1/2 day flow? - /V Required pumping 4 times or more in the last ear? number of times pumped y Al Septic tank is metal? cracked? structurally unsound? substantial infiltration? substantial exfiltration? tank failure imminent? Is any portion of the SAS, cesspool or privy: below the high groundwater elevation? _AL within 50 feet of a surface water? , N within 100 feet of a surface water supply or tributary to a surface water supply? _QL within a Zone I of a public well? Al within 50 feet of a bordering vegetated wetland or salt marsh (cesspools and privies only, not the SAS) ? within 50 feet of a private water supply well? less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis? If the 'well has been analyzed to be acceptable, attach copy of well water analy! for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. itA = 13 SUBISUBFACE:SZWAQE DISPOSAL SYSTEM .INSPECTION FORK PART D y CERTIFICATION Name of Inspector - company -Name . JOHN GRAC!_ _ - TdIe Y Inspector. Company. Address P.O. Box 2119 Teaticket, MA 02536 - Certif-ication. Statement I cent-ify-that I have personally inspected the sewage disposal system at _ this address and that the information reported is true, accurate and complete as- of the time of inspection. The inspection was . performed and any recommendations regarding upgrade, maintenance and repair are consistent with my training and experience in the proper function and manitenance of on-site sewage disposal systems. Check one: I have not found any information which indicates .that the system fails to adequately protect public health or the environment as defined in 310 CMR ,15. 303 . Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form. I have determined that the system fails to protect public health and the environment as defined in 310 CMR 15. 303 . The basis for this determination is provided in the FAILURE CRITERIA section of this form. Inspector' s Signature / • Date Original to system owner Copies to: Buyer (if applicable) Approving authority . h _ � _ --�--.---------- .:- TOWN OF L_�., _ N(U�� BOARD OF HEALTH SUBSURFACE SEWAGE DISPOSAL SYSTEM: I`NSI'F.CTION FORM - PART D - CERTIFICATION --- -- - .� -TYPE OR PRINT DEARLY- _ . - . PROPERTY INSPECTED STREET ADDRESS �C) ASSESSORS MAP , BLOGK AND PARCEL # OWNER' s NAME Q PART- D - CERTIFICATION _ NAME OF INSPECTOR JOHN GRACI COMPANY NAME - P.O. Box 2119 COMPANY ADDRESS Teatick t A 02536 Town or city State LIP Street COMPANY TELEPHONE (LTC_\a) ' FAX CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported is true , accurate , and complete as of the time of inspection . The inspection was performed and any recommendations regarding upgrade , maintenance , and repair are consistent with my training and experience in the proper function and maintenance of on- site sewage disposal systems . Che one : System PASSED The inspection which I have conducted has not found any information which indicates that the system fails to adequately protect public health or the environment as defined in 310 CMR 15 . 303 : Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form . System FAILED* The inspection which I have conducted has found that the system fails to protect the public health and the environment in accordance with Title ,5 , 3tO CMR 15 . 303 , and as specifically noted on PART C - FAILURE CRITERIA of this inspecti form . Inspector Signature Date One copy of this certification must be provided to the OWNER, the BUYER ( where applicable ) and the BOARD OF HEALTH. * If the inspection FAILED, th*e owner or."operator shall upgrade the system within one ,year of the date of the inspection, unless allowed or required otherwise as provided in 310 CMR 15 . 305 . partd.doc y