Loading...
HomeMy WebLinkAbout0041 MAPLE AVENUE - Health 41 MAPLE AVENUE;CENTERVILLE A= 207`033 UPC 12534 ' No.2_ `�sr HASTINGS,MN zo , Commonwealth of Mas a setttts Title 5 Official Inspection Form 3 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wN 41 Maple Ave Property Address John Cox Owner Owner's Name information is required for Centerville MA 02632 October 20, 2011 every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Important:When filling out A. General Information forms on the computer,use 1. Inspector: only the tab key to move your Patrick M. O'Connell cursor-do not Inspector Name of Ins use the return p key. Septic Inspection Services Co. Company Name 189 Cammett Road Company Address Marstons Mills MA City/rown State 02648 Zip Code 508-428-1779 SI 12855 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site LU sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of `_"Title 5(,,l0 CMR 15.000). The system: CCI — t�1 ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority ILL- U.- } October 20, 2011 Job# 11-186 C1114In e'ctors Signatur Date 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 to the buyer, if applicable, and the approving authority. 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. 11-186 Cox 41 Maple.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 15 I � � c V � V TOWN OF BARNSTABLE LOCATION §Lt'°E# r. VILLAGE i II AS SOR'S MAP&PARCEL //// ME&PHONE JNO. =1 d M O 4,,,e,/1 -'y'Zf.177 g SEPTIC TANK CAPACITY / B 0® LEACHING FACILITY:(type) �i�T (size) ` NO.OF BEDROOMS J OWNER D Arl Q i PERMIT DATE: DATE: /020 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 4 \ \ \ \ \ \ 4 • 4 1 \ 4 \ 4 \ 4 f f f 1 f f f f f f ! 1 f f f f f J ♦ \ 4 4 \ 4 ♦ 4 \ \ 4 4 4 \ k \ � f f f f f f r r r 1 f+f r f r r J - 4 ♦ 4 t k t ♦ 4 4 t 4 \ ♦ ♦ 4 ♦ t ! f ! f f ! 1 l f ! f f f f ! 1 J f f f ! / f\f4f♦!♦J\f•f\?4f♦f\1\f♦f\I•J4i♦!♦f t 4 \ 4 t 4 4 4 ♦ 4 \ 4 4 4 ♦ 4 \"\ 4 ♦ k 4 t t \ t • 4 t 4 \ t • ♦ • 4 \ • 4 4 \' t ♦ t 4 ♦ k 4 4 ♦ 4 t ♦ ♦ 4 ♦ 4. ♦ 4 ♦ t J f ! f ! f f f r J f ! f f r f 4 4 ♦ 4 4 t k ♦ k 4 4 4 4 4 ♦ \ f ! r ! r ! f { ! f 1 f ! f ! f t t 4 k t t ♦ t 4 • t \ t t t t tf♦f♦f4f♦f4fkJ♦ ♦f4{4 {♦ f♦Jtr♦f4!•f4f•J f ! f ! r f J l ! I J r { f { f f f ! ! f J 4 4 t 4 k \ 4 t 4 ♦ 4 t k ♦ 4 t \ 4 ♦ ♦ t 4 38 26 24 30 �,r:�i u�wm�g ,� ' J }��� 4 J••.rtr4f4`t f•v J+,r4r4{t!t i F4 \ 4 •v 4 v.�4 4 v. t t 4 t v ffiY•4J♦?Vi+a r^ff M.�?4{4J4 Y YYF f f { ! !/+ { { y f !+1 +J 1 v v f+J 4 fv. 1v/ f fv. . Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 41 Maple Ave Property Address John Cox Owner Owner's Name information is required for Centerville MA 02632 every page. City/Town October 20, 2011 State Zip Code Date of Inspection B. Certification (Cont.) 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: Tank is not in need of pumping at this time, Leaching pit had 30" of standingwater and has never been more than half full. 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 11-186 Cox 41 Maple.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15 . Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments w y 41 Maple Ave Property Address John Cox Owner Owner's Name information is required for Centerville MA 02632 October 20, 2011 every page. Citylrown State Zip Code Date of Inspection B. Certification (Cont.) B) System Conditionally Passes (cont.): ❑ 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: 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. I. 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. 11-186 Cox 41 Maple.cloc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments r 41 Maple Ave Property Address John Cox Owner Owner's Name information is required for Centerville MA 02632 October 20, 2011 every page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ 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 indicates absent 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: D) System Failure Criteria Applicable to All Systems: 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 cesspool is less than 6" below invert or available volume is less than_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. 11-186 Cox 41 Maple.doc•08l06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15 . Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments w 41 Maple Ave Property Address John Cox Owner Owner's Name information is required for Centerville MA 02632 October 20, 2011 every page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No ❑ ® 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 fecal coliform bacteria indicates absent 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 and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® 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 Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. 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. 11-186 Cox 41 Maple.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 41 Maple Ave Property Address John Cox Owner Owner's Name information is required for Centerville MA 02632 011 every page. CitylTown October 2 State Zip Code Date of Inspection tionn C. Checklist 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: ® ❑ 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(5)] 11-186 Cox 41 Maple.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 41 Maple Ave Property Address John Cox Owner Owner's Name information is required for Centerville MA 02632 every page. Citylfown October 20, 2011 State Zip Code Date of Inspection D. System Information Residential Flow Conditions: 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 ® No Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): 44,000 gal. _ 60 gpd. Sump pump? ❑ Yes ® No Last date of occupancy: Unknown Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe): 11-186 Cox 41 Maple.doc-08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 15 . Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M .•'• 41 Maple Ave Property Address John Cox Owner Owner's Name information is required for Centerville MA 02632 October 20, 2011 every page. 61 own State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: Tank pumped in 2008 Was system pumped as part of the inspection? ❑ Yes ® 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: Compliance date: 8/7/92 Were sewage odors detected when arriving at the site? ❑ Yes ® No 11-186 Cox 41 Maple.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15 . Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 41 Maple Ave Property Address John Cox Owner Owner's Name information is required for Centerville MA 02632 October 20, 2011 every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): Depth below grade: 1 feet Material of construction: ®cast iron ❑ 40 PVC ❑ other(explain): -- Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): Septic Tank (locate on site plan): Depth below grade: 1 _ feet Material of construction: ® concrete ❑ metal ❑ fiberglass (] polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ 'No --------------------------------------------------------------------------------------------------- Dimensions: 8.5' long x 5.2'wide- 1000 gai:__ Sludge depth: 3" Distance from top of sludge to bottom of outlet tee or baffle 7--- --— Scum thickness 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 13" How were dimensions determined? Measured ---i 11-186 Cox 41 Maple.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 or 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System sal S 9 p y Form Not for Voluntary Ass essments 41 Maple Ave Property Address John Cox Owner Owner's Name information is required for Centerville MA 02632 October 20, 2011 every page. Clty/rown State Zip Code Date of Inspection D. System Information (cont.) 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 intact and clear, liquid level at bottom of outlet invert. Grease Trap(locate on site plan): Depth below grade: feet 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: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): 11-186 Cox 41 Maple.doc-08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 41 Maple Ave Property Address John Cox Owner Owner's Name information is Centerville required for MA 02632 October 20, 2011 every page. Cltyrrown State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank(cont.) Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): "Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No Distribution Box (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 ❑ No Alarms in working order: ❑ Yes ❑ No 11-186 Cox 41 Maple.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15 Commonwealth of Massachusetts y Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 41 Maple Ave Property Address John Cox Owner Owner's Name information is required for Centerville MA 02632 October 20, 2011 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ® leaching pits number: One 6x6 pit. ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leaching pit was found with 30"of standing water at time of inspection. Hlgh stain lines indicate pit has never been more than half full. 11.186 Cox 41 Maple.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 41 Maple Ave Property Address John Cox Owner Owner's Name information is required for Centerville MA 02632 October 20, 2011 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Cesspools (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 ❑ No 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.): 11.186 Cox 41 Maple.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 41 Maple Ave _ Property Address John Cox Owner Owner's Name information is required for Centerville MA 02632 October 20, 2011 _ _ every page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) 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. Maple A ve Water Service \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ 77, , 38 i 26 24 30 / / / J / • r / / J J Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 41 Maple Ave Property Address John Cox Owner Owner's Name information is required for Centerville MA 02632 October 20, 2011 every page. Cltyrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to ground water: 20 feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ 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: USGS topo map and town GIS. You must describe how you established the high ground water elevation: Town groundwater contour map shows water at el. 10 and topo map shows property above el 40 11.186 Cox 41 Maple.doc 0a/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15 CERTIFIED SEPTIC SYSTEM REPORT LOCATION 41 MAPLE AVE CENTERVILLE, MA MAP 207 PARCEL 033 PREPARED FOR SELLER MR. & MRS . H . HILLER 41 MAPLE AVE CENTERVILLE, MA 02632 BUYERr f MR. & MRS . JOHN F. COX 792 MAIN STREET APR 1 WALPOLE, MA 02081 1995 1 OF Wkiffgg LE SUBSURFACE SEWAGE DISPOSAL SYSTE'. ,',-;:_�`NSPECTION FORM Address of property 4(/ owner's name /7/4 c./fi.lo 41-a L✓��f/ h�/GG/_=/! Date of Inspection L11,27,1 S� PART A CHECKLIST Check if the following have been done: i/ Pumping information was requested of the owner, occupant, and Board of Health. ' None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. As built plans have been obtained and examined. Note if they are not available with N/A. W4rc/1EQ 7_11G 5VSTI',o1 6Z-e G /,v5riivLG/40 The facility or dwelling was inspected for signs of sewage back-up. The site was inspected for signs of breakout. V All system components, excluding the SAS, have been located on the site. The septic tank -manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. _ 1 The size and location of the SAS on the site has been determined based on existing information or approximated by non-intrusive methods. V The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of SSDS. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION ...: FLOW CONDITIONS If residential 3 number of bedrooms -!� number of current residents X. garbage grinder, yes or no _X laundry connected to system, yes or no seasonal use, yes or no If nonresidential, calculated flow: Water meter readings, if available: o� a S)� , G� L /°RF6 Last date of occupancy gy 7/4/ 000 GENERAL INFORMATION Pumping records and source of information: T /�!/ P.�p 6/GAG �7/ � 5 YSTiL.�r /•�''j�9GG�� �,C� /� � System pumped as part of inspection, yes or no if yes, volume pumped Reason for pumping: Type of system _L,,*' Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system (yes or no) (if yes, attach previous inspection records, if any) Other (explain) Approximate age of all components. Date installed, if known. Source of information: 3 Yr rs fie! Sewage odors detected when arriving at the site, yes or no SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM _ PART B :.� SYSTEM INFORMATIC+ i "continued SEPTIC TANK: (locate on site plan) depth below grade: /,;? // material of construction: // concrete metal FRP other(explain) dimensions: yi��� A Y� X y� DEEP /o� Cs/G sludge depth 9)" distance from top of sludge to bottom of outlet tee or baffle O scum .thickness — distance from top of scum to top of outlet tee or baffle — distance from bottom of scum to bottom of outlet tee or baffle Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, recommendations for repairs, etc. ) 7LL6 /,!/ lip 611--.a Ors 13,p,r ' rse o (/c DISTRIBUTION BOX: (locate on site plan) O 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 SYSTEM INSPECTION FORM PART SYSTEM INFORMATION continued SOIL ABSORPTION SYSTEM (SAS) : c/ (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 leaching chambers and number leaching galleries and number leaching trenches, number, length leaching fields, number, dimensions overflow cesspool , number Comments: (note condition of soil , signs of hydraulic failure, level of ponding, condition of vegetation, recommendations for maintenance or repairs,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, 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. ) s = SUBSt':a,'ACE SEWAGE DISPO ry;j SYSTEM INSPECTION zi-" RM 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 ' n ,Q i Gd H� DEPTH TO GROUNDWATER 1� /7� depth to groundwater method of determination or approximation: G-/S 6- 3 3 AviPR!/Si9lJG/s' v 6 G5 GO���GiiGif� �i'7/Gd a q Z'►N� QJ � % ,S • 12 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C FAILURE CRITERIA Indicate yes, no, or not determined (Y, N, or ND) . Describe basis of determination in all instances. If "not determined" , explain why not) Backup of sewage into facility? Discharge or ponding of effluent to the surface of the ground or surface waters? 1 Static liquid level in the distribution box above outlet invert? Liquid depth in cesspool <6" below invert or available volume< 1/2 day flow? Required pumping 4 times or more in the last year? number of times pumped � .i 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? EV within 50 feet of a surface water? Nwithin. 100 feet of a surface water supply tributary pp y or to a surface water supply? E " within a Zone I of a public well? Nwithin 50 feet of a bordering vegetated wetland or salt marsh (cesspools and privies only, not the SAS) ? N1 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 analysi for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. 13 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART D CERTIFICATION Name of Inspector Company Name Company Address < ; -�- S Certification Statement 41 i fy\c:ce `4_) 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 manitenance of on-site sewage disposal systems. Che 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. n Inspector' s SignatureCf Date Original to system owner Copies to: Buyer (if applicable) Approving authority r :a,EY NUMBER <159 > NAME <DAVIS, PHILLIS, L > B-C 1 B-C 2 C/O HILLEARD HILLER B-C 3 B-C 4 STREET 41 MAPLE AVENUE CITY CENTERVILLE ST MA ZIP 02632-3420 REF 1 REF 2 PHONE ( ) - REF 3 REF 4 METER NO. < 71> DATE READING CONS STREET <MAPLE AVE NO. 41> 1$2 31 94,- 248 5y 36 7yi CITY CEN P ST LOC 0 0 F94 212 38 PHONE ( ) - 12%31/93Y 174 13 43 8y 0,6' 3; 131 46 ROUTE NUMBER 22 --2 85 �51s7 SERVICE DATE 03/23/39 06� 3iv�92- 34 9a 6 METER DATE 03/15/91 12 31urA. 28 r20` CAPACITY 7 8 16 STYLE T10 TT SIZE 1 RATE SCHEDULE KEY PIT PLASTIC NOTE RR RIGHT SIDE ADDITIONAL CONS 0 ALTERNATE MIN 0 r TOWN OF BARNSTABLE YVl SEWAGE # /to p I,� LOCATION � d.- BSI VILLAGE ASSESSOR'S�1r M , ASSESSOR'S MAP & LOT INSTALLER'S NAME PHONE NO.�r� ,� � tadriclZs, ���"ag3� SEPTIC TANK CAPACITY I F3 d-b LEACHING FACILITYAtype) L Pd (size) [ 0ab C11 NO. OF BEDROOMS-PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER ► �\ kl y-ac, \—\� \ Y,�z . DATE PERMIT ISSUED: (o DATE COMPLIANCE ISSUED: T} -7 '' • VARIANCE GRANTED: Yes No MAP (, �je-, ' :" 3� Q� zak.®r p r 3 U Fx$ ©.:.�..... THE COMMONWEALTH OF MASSACHUSETTS l BOAR® OF HEALTH WN OF BARNSTABLE Appliratioo for Uiipoiial Warkii Tvtutru ion Permit Application is hereby made for a Permit to Construct ( ) or Repair ) an Individual Sewage Disposal System at .•----Loc do -Add s or Lot \ Ow er l 4d ress (ft,, ' a �— J.. !• ...... ..... _`�6 C.,�G..�.. I ---------------•�---- ........ �_.i�+3 �-`----`.......r `.`, .> . ------------- Installer Address d Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms................................ .Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building ............................ No. of ersons......................_.__.. Showers — a Other—Type g p ( ) Cafeteria ( ) A4Other fixtures ---------------------------------•--------------------•••---------......••----•-••----- ------ ...................................................... Design Flow............................................gallons per person per day. Total daily flow.........---................................gallons. WSeptic Tank—Liquid capacity............gallons Length...::........... Width................ Diameter-_--___---__-- Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground-water-.--_-_-_____-__---_._-. 44 Test Pit No. 2................minutes per inch Depth of.Test Pit...:................ Depth to ground water........................ a -•-•••-•-•••------------•-••-------....-•--•-------••...............•-••.....---•---••---•---•--•---......................................................... 0 Description of Soil._.____._.. U --••-•••-•-•-•-----------•------••-•-••---- v�...0~•--•..............•---------•-•-•--•-•••-•--------•-•----••---• •-- ----------------------------------------------------------------------------------------••---•••......--•--------- ------------------------------------_--�t _ --.----I V Natur of Repairs or Alterations Answer when a licabl ..--- �'S _ ��-s T_h�,,....... 5 uta 5 Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Envir mental Code—The undersigned further agrees not to place the system in operation until a Certificate of Co pli nc4e has been issued by the board of health. q Signed .-.. )- 3C—�l"l l .............. ...................................... Date ApplicationApproved By ............. -------- .,...,------------------------------------------------------------------------------ . ... T�- Date Application Disapproved for the following reasonr- ---------------------------------------------------------------------------- .............-------------------------- ----------------------------------- --- ----------------- - ------------------------------------------- ---- -------------------------------------------------------............................. ..............----------- ---------- Permit No. .............. Issued ........... --......`6_-. -- -77 Date - ----- --- --- ---- --- .. Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Certificate of Grayliance THIS IS TO.0 RTIFY, That t Individual Sewage Disposal System constructed ( ) or Repaired ��.. .... .. ...------ ----------.. �___ stalle ............. 1at ........ .... -----1------ ----------. ----'-----..-...-----------------------...------------------------------.......................... has been installed in accordance with t4 provisions of TITLE 5 of The State Environmental Code as described in the application for Disposal Works Construction Permit No. .--.......9, .......-. -1... dated :-...I-� "_a-..7 - — THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE................ . �-------�-�------ -- ---------------- --- -- Inspector .... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH v 38 TOWN OF BARNSTABLE 3 No...._/. ..........L. FEE........................ Disp asat,10 rkii Tumit ion\ rrmit Permission is hereby granted------ - __��v'::..._--���Q\V- ��1�S^ --------•-••........................................................ ................ to Construct ( ) or Re a'r ( n Indiv'du 1 Sew ge Disposal System t .� at No............................ .. .................................... ...........---- `I� ` i- �... .----"Street _�.._._._..--•---------=---••-----•------•• ' as shown on the application for Disposal Works Construction Permit No..................... Dated----R............�_..c; ........ r �y ---------- ...................................... ................................ / iBoard of Health DATE__......----�----•--------•----•--- tJ' � FORM 36508 HOBBS&WARREN.INC..PUBLISHERS THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH mot. 69 TOWN OF BARNSTABLE Appliration for Dispniittl Works Tnnitrnrtion Permit Application is hereby made for a Permit to Construct ( ) or Repair el) an Individual Sewage Disposal System at: !� �-� ..... ............................. ....................f/Loc do -Add s or Lot ( 4 ......... _ *a-� ` ........ :I I I YI (� I-t N� "- \ �. A,d ress - ....h!._... -1 �................ ,.J. � ...`.::J............. Installer Address Type of Building Size Lot............................Sq. feet U DwellingNo. of Bedrooms. Expansion Attic— p ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) � Other 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 ( ) aPercolation 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........................ 9 •-----------------------------------------------'-------------.....--------..............----'.............------•'-...'•••'•----......-'••--................ ODescription of Soil----- ='� -- -------------------•------•----...-----------•---•------------------------------------------...--------------------.......-•----•-•---'---._.. x ------------ --- v ---------------- ---------------------- U Nature of Repairs or Alterations Answer when applicabl � s r�... .______ 1`�}._s_ _S_ _ ...._c�a 1?w S Agreement: 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 t system in operation until a Certificate of Co plince has been issued by the board of health. Signed W4n.. - ---------------------- A ^�. - Dace pplicationApproved By .. ...---- I------------------------------------------------------------------------------ ------------ �.te --.�-------- Date Application Disapproved for the following reasons- ---------- ----------------------------------------------------------- --------------------------------------------------------- - - - ----------------------- -- -- -- ----------------------------------- --------------- ------------------ -- -------- -------------------------- ---------- ........................................ Permit No- .......................................................... ----- Issued w (,A ..� � a Date ............................................. Date