HomeMy WebLinkAbout0040 MUSKEGET LANE - Health 40 Muskeget Lane
Centerville P
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UPC 12543
No. 3_LOR 4i;
MOs71NGS aN
9 TOWN OF BARNSTABLE
LOCATION .f '° ? SEWAGE # °
VILLAGE ASSESSOR'S MAP & LOT
INSTALLER'S NAME&PHONE N0: O', A
,,,rTIC TANK CAPACITY
LEACHING FACILITY: (type) 1 C size)
> v
No.OF BEDROOMS
BUILDER OR OWNER °
PERMTTDATE: —' .� '„1 A"—/`
COMPLIANCE DATE:'�'` �'• c�`d ��'
Separation Distance Between the:
Maximum Adjusted Groundwater Table and 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
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COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS .
DEPARTMENT OF ENVIRONMENTAL POTECTI.ON
DOrAA� � -� L' R
2004PARCEL 0 3��� RiJS7ABLEa DEPPT:
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 40 Muskeget Lane
Centerville
Owner's Name: Nancy Hatton
Owner's Address:
Date of Inspection: -- -®
Name of inspector:(please print) Wi 1 l-i am E_" Robinson Sr.
Company Name: William E. Robinson Septic Service
Mailing Address: P 0 Box 1089
Centerville, MA
Telephone Number:_f 5081 775-8776
CERTIFICATION STATEMENT
1 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 apd maintenance of on site sewage disposal systems.I am a DEP
approved system inspector pursuant to Se ton 15340 of'Title 5(310 CMR 15.000). The system:
Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: Date:
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of HeaKhm
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 appro.ving
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 I I '
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued).
Property Address: 40 Muskeget Lane
Centerviiie
Owner. Nancy Hatton
Date or inspection: — v
Inspection S mmary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. Sys Passes:
1 have not found any information which indicates that any of the failure criteria described in 310 CM,
15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated arc indicated below.
Comments:
�. 4
B. System Conditi ally Passes:
One or more syst m components as described in the"Conditional Pass"section need to be replaced or
repaired.The system,upo completion of the replacement or repair,as approved by the Board of Health,will pass.
Answer yes,no or not determ ed(Y,N,ND)in the for the following statements.if"not determined"please
explain.
The septic tank is metal d over 20 years old*or the septic tank(whether metal or not)is.structurally
unsound,exhibits substantial inri lion or exfiltration or tank failure is imminent_System will pass inspection if the
existing tank is replaced with a co plying septic tank as approved by the Board of Health.
•A metal septic tank will pass insp ction if it is structurally sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 0 years old is available.
ND explain:
Observation of sewage backup r break out or high static water level in the distribution box due to-broken or
obstructed pipes)or due to a broken, ttled or uneven distribution box.System will pass inspection if(with
approval of Board of Health):
b en pipe(s)are replaced
ob ction is removed
dis 'button box is leveled or replaced
ND explain:
The system required pumping mo than 4 times a year due.to broken or obsWultud pipe(s).The system will
PASS inspection if(with approval of the B ard of Health):
broke pipe(s)are replaced
obstru lim is removed
ND explain:
Page 3 of 11
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OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 40 Muskeget Lane
Centerville
Owner: Nancy Hatton
Date of inspection:./A —G
C. urther Evaluation is Required by the Board of Health:
Conditions exist which require further evaluation by the Board of Health in order to determine if the system
is fail' to protect public health,safety or the environment.
1. S stem will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the
sy (cm 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. Syste will fail unless the Board of Health(and Public Water Supplier,if any)determines that the
system_ is nctioning in a manner that protects the public health,safety and environment'.
_ e system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a
surfac water supply or tributary to a surface water supply.
e system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply.
— T e system has a septic tank and SAS and the SAS is within 50 feet of a private water supply,well.
e system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more front a
privat water supply well•• Method used to determine distance
'•T s system passes if the well water analysis,performed at a DEP certified laboratory, for coliform
-bact ria and volatile organic compounds indicates that the well is free from pollution from that facility and
the resence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
fai a criteria are triggered.A copy of the analysis must be attached to this form.
3 Other:
3
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Page 4 of I l
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS 6
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 40 Muskeget Lane
Centerville
Owner: Nancy Hatt n
Dale of Inspection B
D. S stem Failure Criteria applicable to all systems:
You m st indicate"yes"or"no"to each of the following for all inspections:
Yes o
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.
_ 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 f et from a private Kater
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(hat the Hell 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.)
(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 Systems:
To a considered a large system the system must serve a facility with a design now of 10,000 gpd to 15,000
gpd
You ust indicate either"yes"or"no"to each of the following:
(Tlte llowing criteria apply to large systems in addition to the criteria above)
yes n
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
e system is located in a nitrogen sensitive area(Interim We Protection Area—IWPA)or a mapped
one 11 of a public water supply well
If you havc answered"yes"to any question in Section E the system is considered a significant threat,or answered
"yes"in S ction D above the large system has failed.The(Miner or operator of wry 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.Ic system owner should contact the appropriate regional office of the Department.
4
Page S of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 40 Muskeget Lane
Centerville
Owner: Nancy Hatton
Date of Inspection: —6
Check if the following have been done.You must indicate"yes"or"no"as to each of the following:
Yes No
, �
_ AZ-1 Pumping information was provided by the owner,occupant,or Board of Health
v 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?
_ 4 Have large volumes of water been introduced to the system recently or as part of this inspection 7.
_ 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?
signs of break out?
Was the site inspected for si
_. g
_ 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?
— ,4) 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 1 l '
b
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 40 Muskeget Lane
Centerville
Owner: Nancy Hatton
Date of Inspection: —6- — 6'-
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design):. Number of bedrooms(actual):Z
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): ca-y
Number of current residents:
Does residence have a garbag grinder(yes or no):kcj
Is laundry on a separate sewage system(yes or no):&o [if yes separate inspection required)
Laundry system inspected(yes or no):Z.,e)
Seasonal use:(yes or no):
Water meter readings,if a ilable(last 2 years usage(gpd)): 2 0.0 3 57 , 000
Sump pump(yes or no):O U 2002 - 70, 0010
Last date of occupancy:
COMMERCIAL/INDUS- RIAL
Type of establishment:
Design flow(baryes
R 15.203): gpd
Basis of design rsons/sgft,etc.):
Grease trap pre ):Industrial wasteresent(yes or no):Non-sanitary w to the Title 5 system(yes or no):_
Water meter r dings,if available:
Last date/(de
ccupancy/use:
OTHE scribe):
GENERAL INFORMATION
Pumping Records
Source of information:
Was system pumped as part of the inspection(yes or no):—
If yes,volume pumped:_gallons-=How was quantity pumped determined?
Reason for pumping:
TYPEA SYSTEM
_Ieeptic 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 co of the current operation and maintenance contract to be
gY PY P (
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 informa�ign:
Were sewage odors detected when arriving at the site(yes or no): 0
6
Page 7 of
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 40 Muskeget Lane
Centerville
Owner: Nancy Hatton
Date of Inspection:
BUILDING SEWER, locate on site plan)
Depth below grade:
Materials of cons coon:—cast iron —40 PVC—other(explain):
Distance from p vate water supply well or suction line:
Comments(on ondition ofjoints,venting,evidence of leakage,etc.):
SEPTIC TANK: ocate on site plan)
Depth below grade:
Material of construction: concrete ass—metal fiber l
_other(explain) — g ---Polyethylene
if tank is metal list age:_ Is age confirmed—by a Certificate of Compliance(yes or no):—(attach a copy of
certificate) o
Dimensions: (i c1� (� q- L
Sludge depth: if4-/
Distance from top of sludge to bottom of outlet ice or baffler
Scum thickness: _
Distance from top of scum to top of outlet tee or baffle:.,
Distance from bottom of scum to bottgai of outlet tee or baffle:
How were dimensions detcrmined6 i:�" Co U 6,2
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of Ieaka�ete.):
S®� d r►. de.L
GREASE TRAP: /tionw:/c�'
tc on site plan)
Depth below grade
Material of cons _concrete._metal fiberglass_polyethylene—other
(explain): —
Dimensions:
Scum thicknes
Distance fro top of scum to top of outlet tee or baffle:
Distance fr bottom of scum to bottom of outlet tee or baffle:
Dale of las pumping:
Commen (on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as relate to outlet invert,evidence of leakage,etc.):
7
Page 8 of 11. '
a
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:40 Muskeget Lane
Centerville
Owner:_ Nancy Hatton
Date of lnpe sctioa: e2 Z-/
TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:
Material of construction: oncrete metal fiberglass_polyethylene other(explain):
Dimensions:
Capacity. allons
Design Flow: gallons/day
Alarm present(yes or ):
Alarm level: Alarm in working order(yes or no):
Date of last pumpin .
Comments(condit' n of alarm and float switches,etc.):
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.):
- L
PUAIP CHAMBER: (locat n site plan)
Pumps in working order(yes r no):
Alarms in working order(y s or no):
Comments(note conditio of pump chamber,condition of pumps and appurtenances,etc.):
8
Page 9 of 11
1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 40 Muskeget Lane
Centerville
Owner: Nancy Hatton
Date of Inspection:
SOIL ABSORPTION SYSTEM(SAS):_,,.,((o cate on site plan,excavation not required)
If SAS not located explain why:
Type ,
eaching pits,number:_
leaching chambers,number:
leaching galleries,number:
leaching trenches,number,length:
- leaching fields,number,dimensions:
overflow cesspool,number:
innovative/altemative system Type/name of technology:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,
etc.): ( _ y� J , Z�I
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 in ow.(yes or no):
Comments(note condition f soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
PRIM': (local on site plan)
Materials of cons ction:
Dimensions:
Depth of solids:
Comments(no 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: 40 Muskeget Lane
Centerville
Owner: Nancy Hatton
Date of Inspection: —6
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.
o C)
6?
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3
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Page 11 of 11
`t OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 40 Muskeget Lane
Centerville
Owner. Nancy Hatton
Date.of Inspection: —
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:
C d"cked with local excavators,installers-(attach documentation)
ccessed USGS database-explain:
You must describe how you established the high ground water elevation:
S
11
N.. Fee
THE COMMONWEALTH OF MASSACHUSETTS
Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
ZippYication for Miopo.5al *potem Congtruction Permit
Application for a Permit to Construct( )Repair( x)upgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. Owner's Name,Address and Tel.No.
40 Muskegat Lane , Centerville Dan Hatton
Assessor's Map/Parcel
Installer's Name Ad re§s,and Tel.No. Designer's Name,Address and Tel.No.
.Wm. E . Rotinson Septic ervice
P 0 Box 1089, Centerville
Type of Building:
Dwelling No.of Bedrooms 4 Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil Sand.
Nature of Repairs or Alterations(Answer when applicable) N e w s e pt i s s y s t e m, c o n s i s t ing o f
a 'Tank, D-box anA13 leach chambers .
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued by this Board of Health.
Signed ��� �. Date
Application Approved by - Date
Application Disapproved for He fo wing reasons
Permit No. Date Issued
`7G
No. Ft?- Fee
f THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
Zipprication for -Mi9;p1ogal *p!9tem Construction Permit
Application for a Permit to Construct( )Repair( )o Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. Owner's Name,Address and Tel.No.
40 Muskegat Lane , Centerville . Dan Hatton
Assessor's Map/Parcel
taper's ame Ad ress,and Tel.No. F Designer's Name,Address and Tel.No.
'gym. . $o`�inson Septic ervice
P 0 Box 1089, Centerville
_.. f
Type of Building:
Dwelling No.of Bedrooms 4 Lot Size sq. ft. Garbage Grinder( )
Other Type of Building No.o�Persons Showers( ) Cafeteria( )
1 Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type'of S.A.S.
Description of*Soil Sand.
Nature of Repairs or Alterations(Answer when applicable) N e w s e Pt i c system, consisting of
a Tank, D-box an# 3 leach chambers .
y Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with"the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued by this Board of Health.
Signed �„�� ,:�. Date
Application Approved by, Date
Application Disapproved for a fo wing reasons
(
Permit No. Date Issued
----------------------------------------
THE COMMONWEALTH OF MASSACHUSETTS i
Vktton BARNSTABLE, MASSACHUSETTS
Certificate of Compliance � k
THIS IS TO CERTIFY,-that the On-site Sewage Disposal System Constructed( )Repaired(X )Upgraded( )
Abandoned( )by Wm Robinson Septic Service
at 40 Muskegat Lane; Centerville . has been constructed in accordance
with the provisions of Title 5 qnd the for Disposal System Construction Permit No. �/l 9®7
Installer dated. `
Wm. F. Robinson Sr . _
Designer
The issuance of this pe �'t s all not be construed as a guarantee that the sys e i 1 func, on as desig4ed, 1
Date Inspector � Ayu G1
---------------------------------------- 9 .
No. / d n�_ Fee $5 0
THE COMMONWEALTH OF MASSACHUSETTS
Hatton PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
lnigpozar bpgtem Construction Vermit
Permission is hereby anted to Construct( )Repair Upgrade(( )Abandon( )
System located at 40 Muskegat Lane , Centerville
and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to
comply with Title 5 and the following local provisions or special conditions.
Provided:Construction must be completed within three years of the date of this permit.
Date: - _ ,2 9' - `� Approved by
r
1/6/99
NOTICE: This Form Is To Be Used For the Repair Of Failed
Septic Systems.Only.
CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL
WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANS)
William E . Robinson,SAereby certify that the application for disposal works
construction pemait signed by me dated S— Qi , concerning the
property located at 40 Muskegat Lane , Centerville meets all of the
following criteria:
t
• The failed system is connected to a residential dwelling only. There are no commercial or business
uses associated with the dwelling.
• The soil is classified as CLASS i aYof
percolation rate is less than or equal to 3 minutes per inch.
00 f the ro sedse tic systemThere are no wetlands wttlun 1P Po P
There are no private wells within 50 feet of the proposed septic system
• There is no increase in flow or change in use proposed
• There are no variances req ested or needed.
• The bottom of the propo d leaching facility will not be located less than five feet above the
ma imtrn adjusted groundwater table elevation. (Adjust the groundwater table using the Frimptor
method when appli lel
• If the S.A.S. will located with 250 feet of any vegetated wetlands, the bottom of the proposed
leaching facility "If not be located less than fourteen(14) feet above the maximum adjusted
groundwater le elevation,
Please co fete the following:
A) Top of Ground Surface Elevation(using GIS information)
B) G.W. Elevation +the MAX High G.W. Adjustment ._--__
DIFFERENCE BETWEEN A and B _
SIGNED DATE:
[Sketch proposed plan of system on back].
q:health folder:cen
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V✓
�C o
TOWN OF BARNSTABLE
LOCATION
SEWAGE #
VILLAGEc.1t 1
r ASSESSOR'S MAP & LOT �—�2
INSTALLER'S NAME&PHONE NO. 4, 0 J)
SEPTIC TANK CAPACITY
LEACHING FACILITY: (hype) -J � —.-2 L- L -�
(size) d.? "-7 �1
NO.OF BEDROOMS
BUILDER OR OWNER
PERMITDATE: -'- ��" A `f" COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and 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) r Feet
Furnished by
1"
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03 (0
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...... SUBSURFACE SEWAGE DISPOSAL SYSTEM INBPE NORI B
Address of property qo rnus<eQ�- ,Nb,
r �
Owner' s.•name r\
Date of Inspection
VV ,.-
PART A
CHECKLIST
Check if the following have been done:
V Pumping information was requested of the owner, occupant, and Board of
Health.
None of the system components have been pumped for at least two weeks
and the system has been receiving normal flow .rates during that
period. Large volumes of water have not been introduced into the
system recently or as .-part of this inspection.
As built plans have been obtained and examined. Note if they are not
available with N/A.
The facility or dwelling was inspected for, signs of sewage back-up.
The site was inspected for signs of breakout.
JAll system components, excluding the SAS, have been located on the
site.
The septic tank manholes were uncovered, opened, and the interior of
the septic tank was inspected for condition of baffles or tees,
material of construction, dimensions, depth of liquid, depth of
sludge, depth of scum.
✓ The size and location of the SAS on the site has been determined based
on existing information or approximated by non-intrusive methods.
.�- The facility owner (and occupants, if different from owner) were
provided with information on the proper maintenance of SSDS.'
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SUBSURFACE SEWAGE DISPOSAL 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
ar0 _ seasonal use, yes or no
If nonresidential, calculated flow.:
Water meter readings, if available:
53e poo ►993
Last date of occupancy
GENERAL INFORMATION
Pumping records and source of information: -
4c5-_ System pumped as part of inspection, yes or no
if yes, volume pumped
Reason for pumping:
MA:n f1Ac� fltQcaC� ;1 tit ICt flea, dsaf��iACd,t�itn
Type of system _
Septic tank/distribution box/soil absorption system
Single cesspool '
—6� 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:
_�!0 SewagF odors detected when arriving at the site, ves_or no
5
9
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION continued
SEPTIC TANK:
(locate--on site plan)
depth below grade•
material of construction: concrete metal FRP _other(explain)
dimensions•
sludge depth
distance from top of sludge to bottom of outlet tee or baffle
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. )
f
DISTRIBUTION BOX: ✓A
(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. )
1
PUMP CHAMBER: �R .
(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. ) '.
1
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION continued
SOIL•ABSORPTION SYSTEM (SAS) :
(locate on site plan, . if possible; excavation not required, but may be
approximated by non-intrusive methods)
If not determined to be present, explain:
�r
{
Type.
leaching pits and number Ac
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. )
l- (nh 6 ugh 2"1 to i-(OX h o;' LFP of Rc SAS 41e, in Sncc) .,�®��'ns to�Yllhan a� llme
ac tnsa< <on Ala 0c1.
CESSPOOLS (locate on site plan) :
number. and configuration �Sf,pca� Gx8 Leif.
depth-top of liquid to inlet invert /L41
depth of solids layer
depth of scum layer 31,
dimensions of cesspool �Kg
materials of construction
indication of groundwater
inflow (cesspool must be pumped as
part of inspection) r/D
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding,
condition of .vegetation, recommendations for maintenance or repairs,etc. )
77
PRIVY:
(locate on site plan)
materials of construction
s 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 NS I PECTIAN 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 '
40 we5e�
• r ,, r
`et
/0.(of 96 ffo�►"g �A�
So, .S�est pAck[�•
r
U '
• rt
DEPTH TO GROUNDWATER
e�®•� depth to groundwater
method of determination or approximation: b , 'Y
�� hales Fro knpH 9.0B w
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?
ND Static liquid level in the distribution box above outlet invert?
@s Liquid depth in cesspool <6" below invert or available volume< 1/2 day
flow?
o Required pumping 4 times or more in the last year?
number of times pumped
<esip"l
:. --V_ Septic tank is metal? cracked? structurally unsound? substantial
infiltration? substantial exfiltration? tank failure imminent?
Is any portion of the SAS, cesspool or No privy:the high groundwater elevation?
No within 50 feet of a surface water?
a
ko within 100 feet of a surface water supply or tributary to a surface
water supply?
y0 within a Zone I of a public well?
tiPO J .•
within 50 feet of a bordering vegetated wetland or salt marsh
(cesspools and privies only, D—ot the SAS) ?
4
40 within 50 feet of a private water supply well?
0 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 analys.,-
for coliform bacteria, volatile organic compounds, ammonia nitrogen
and nitrate nitrogen.
TOWN OF bwnsWht, BOARD OF HEALTH
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART D - CERTIFICATION
-TYPE OR PRINT CT,EARLY-
PROPERTY INSPECTED L! n
STREET ADDRESS I o mUSKe�e.� rc�• C�n�
ASSESSORS MAP , BLOCK AND PARCEL #
OWNER' s NAME
PART D - CERTIFICATION
NAME OF INSPECTOR WM"'Iry\ IWolanson
COMPANY NAME 1061n50,1 Seeks'
COMPANY ADDRESS qI c4p+ 6,11is L►1v, {�ysr �� mq
Street Town or City State LIP
COMPANY TELEPHONE (30� 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 .
Check one:
V 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 , 310 CMR 15 . 303 , and as specifically noted on PART C - FAILURE
CRITERIA of this inspection form .
Inspector Signature but& JI Jyn __ Date -•It-9S
One copy of this certification must be provided to the OWNER, the BUYER
( where applicable ) and the BOARD OF HEALTH.
* If the inspection FAILED, the 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.doe