HomeMy WebLinkAbout0007 PHEASANT WAY - Health 7 PHEASANT WAY, CENTERVILLE
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COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS John Grad
DEPARTMENT OF ENVIRONMENTAL PROTECTION DEP Title V Septic Inspector
ONE WINTER STREET BOSTON MA 02108(617)292-3500 P.O.Box 2119
TeaTicket,Ma.
(508)564-6813
TRUDY COXE
Secretary
ARGEO PAUL CELLUCCI DAVID B.STRUHS
Governor Commissioner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
Property Address: 7 PHEASANT WAY CENTERVILLE MAP 208 PAR 147 LOT 1 'I'A!.9
Name of Owner ANDY KASICA
Address of Owner: SAME
Date of Inspection: 10/18/99
Name of Inspector:(Please Print)JOHN GRACI Q
1 am a DEP approved system inspector pursuant to Secfion 15.340 of Tide 5(310 CMR 15.000) ,. C T 2 2 1999 A
Company Name: n/a _1\ H�i�►NSTgg�
Mailing Address: n/a
Telephone Number: n/a
r o
CERTIFICATION STATEMENT
'I certify that I have personally inspected the sewage disposal system at this address and that the Information reported below is true,accurate
and complete as of the time of inspection.The inspection was performed based on my training and experience In the proper function and
maintenance of on-site sewage disposal systems.The system:
X Passes The inpection is based on criteria defined in Title V
Conditionally Passes code 310 CMR 15.303.My findings are of how the system is
Needs Further Evalua on By the Local Approving Authority performing at the time of the Inspection.My inspection does
_ Fails not Imply any warranty or guarantee of the longgevity of the
septic system and any of Its components useful life.
Inspector's Signature: Date:10/20/99
The System Inspector shal ubmit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within thirty(30)days of
completing this inspection. f the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner
shall submit the report to the appropriate regional office of the Department of Environmental Protection.The original should be sent to the
system owner and copies sent to the buyer,if applicable,and the approving authority.
NOTES AND COMMENTS
THE SYSTEM PASSES TITLE V INSPECTION.RECOMMEND PUMPING THE SYSTEM EVEY TWO YEARS TO PROLONG THE SYSTEM'S USEFULL
LIFE.
revised 9/2/98 Page 1 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 7 PHEASANT WAY CENTERVILLE MAP 208 PAR 147 LOT 1
Owner: ANDY KASICA
Date of Inspection:10/18/99
INSPECTION SUMMARY: Check A, B, C, or D:
A. SYSTEM PASSES:
I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist.Any failure criteria not evaluated
are indicated below.
COMMENTS:
System passes Title V inspection
B. SYSTEM CONDITIONALLY PASSES:
Wa One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system,upon completion of the
replacement or repair,as approved by the Board of Health,will pass.
Indicate yes,no,or not determined(Y,N,or ND).Describe basis of determination in all instances.If"not determined",explain why not.
nla The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate of
Compliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection;or
the septic tank,whether or not metal,Is cracked,structurally unsound,shows substantial infiltration or exfiltration,or tank
failure is imminent.The system will pass inspection if the existing septic tank is replaced with a complying septic tank as
approved by the Board of Health.
Wa Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s)
or due to a broken,settled or uneven distribution box.The system will pass inspection if(with approval of the Board of Health).
broken pipe(s)are replaced
obstruction is removed
distribution box is levelled or replaced
Wa The system required pumping more than four times a year due to broken or obstructed pipe(s).The system will pass
inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
revised 9/2/98 Page 2 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 7 PHEASANT WAY CENTERVILLE MAP 208 PAR 147 LOT 1
Owner: ANDY KASICA
Date of Inspection:10/18/99
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 the public health,safety
and 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 ThE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
Cesspool or privy is within 50 feet of surface water
_ Cesspool or privy is within 50 feet of a bordering vegetated wetland or 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 AND SAFETY AND THE 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 soil absorption system and the SAS is within a Zone I of a public water supply well.
The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well,
_ The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a
private water supply well,unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the
well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less
than 5 ppm,Method used to determine distance nta-(approximation not valid).
3) OTHER
nta
revised 9/2/98 Page 3 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 7 PHEASANT WAY CENTERVILLE MAP 208 PAR 147 LOT 1
Owner: ANDY KASICA
Date of Inspection:10/18/99
D. SYSTEM FAILS:
You must indicate either"Yes"or"No"to each of the following:
identified below.The Board of Health should be contacted to determine what will be necessary to correct the failure.I have determined that one or more of the following failure conditions exist as described In 310 CMR 15.303.The basis for this determination is
Yes No
X Backup of sewage into facility or system component due to an 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 1/2 day flow,
X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped nLa.
X Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation.9 9 anon.
X Any portion of'a 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 I 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.If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic ompounds,
ammonia nitrogen and nitrate nitrogen.
X The liquid level in the SAS is over the invert pipe,is in Hydraulic Failure.
E. LARGE SYSTEM FAILS:
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:
The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and
safety and the environment because one or more of the following conditions exist:
Yes No
X the system is within 400 feet of a surface drinking water supply
X the system is within 200 feet of a 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 II of a public
water supply well)
The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.30412).Please consult the local regional office of the
Department for further information.
revised 9/2/98 Page 4 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 7 PHEASANT WAY CENTERVILLE MAP 208 PAR 147 LOT 1
Owner: ANDY KASICA
Date of Inspection:10/18/99
Check if the following have been done:You must indicate either"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 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.
X As built plans have been obtained and examined.Note if they are not available with N/A,
X The facility or dwelling was inspected for signs of sewage back-up.
X The system does not receive non-sanitary or industrial waste flow.
X The site was inspected for signs of breakout,
X All system components,excluding the Soil Absorption System,have been located on the site.
X The septic tank manhole
s were uncovered,opened,and
d 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 cum.The size and location of the Soil Absorption
System on the site has been determined based on:
X Existing information,For example,Plan at BAH,
X Determined in the field(if any of the failure criteria related to Part C Is at issue,approximation of distance is unacceptable)
[1 5.302(3)(b)]
X The facility owner(and occupants,if different from owner)were provided with Information on the proper maintenance of
SubSurface Disposal Systems.
revised 9/2/98
Page 5 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 7 PHEASANT WAY CENTERVILLE MAP 208 PAR 147 LOT 1
Owner: ANDY KASICA
Date of Inspection:10/18/99
FLOW CONDITIONS
RESIDENTIAL:
Design flow:—UQ g.p.d./bedroom
Number of bedrooms(design): 3 Number of bedrooms(actual):3,
Total DESIGN flow: IV
Number of current residents:)
Garbage grinder(yes or no):NQ
Laundry(separate system)(yes or no): NQ If yes,separate inspection required
Laundry system inspected(yes or no):M
Seasonal use(yes or no):.MQ
Water meter readings,if available(last two year's usage(gpd): n&
Sump Pump(yes or no): NQ
Last date of occupancy: Wa
COMMERCIALIINnUSTRIA
Type of establishment: n&
Design flow: Wa gpd(Based on 15.203)
Basis of design flow: Wit
Grease trap present:(yes or no):_M
Industrial Waste Holding Tank present:(yes or no): NQ
Non-sanitary waste discharged to the Title 5 system:(yes or no):NO
Water meter readings.if available:n&
Last date of occupancy: n&
OTHER: (Describe)
Wa
Last date of occupancy: Wa
GENERAL INFORMATION
PUMPING RECORDS and source of information:
n[a
System pumped as part of inspection:(yes or no):MO
If yes,volume pumped n/a gallons
Reason for pumping: Wit
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)
I/A Technology etc.Attach copy of up to date operation and maintenance contract
Tight Tank Copy of DEP Approval
Other: Wa
APPROXIMATE AGE of all components,date installed(if known)and source of information:
1993 THE SYSTEM WAS INSTAI I Fn
Sewage odors detected when arriving at the site:(yes or no) NO
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 7 PHEASANT WAY CENTERVILLE MAP 208 PAR 147 LOT 1
Owner: ANDY KASICA
Date of Inspection:10/18/99
BUILDING SEWER:
(Locate on site plan)
Depth below grade: 22"
Material of construction:_ cast iron X 40 PVC _ other(explain)
Distance from private water supply well or suction line: TOWN
Diameter: Wa
Comments: (condition of joints,venting,evidence of leakage,etc.)
nLa
SEPTIC TANK: X
(locate on site plan)
Depth below grade: ].6"
Material of construction:X concrete_ metal_ Fiberglass _ Polyethylene _ other(explain)
n/a
If tank is metal,list age Is age confirmed by Certificate of Compliance(Yes/No): NQ
D&
Dimensions: L8'6"H6'7"W 4'10"
Sludge depth: 2"
Distance from top of sludge to bottom of outlet tee or baffle: 3
Scum thickness:-Q
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle: A
How dimensions were determined: MEASURED
Comments:
(recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage,
etc.)
SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND RECOMMEND PUMPING EVERY TWO YEARS,
GREASE TRAP:
(locate on site plan)
Depth below grade:
Material of construction:_concrete_ metal_ Fiberglass _ Polyethylene_other(explain)
n&
Dimensions: Wa
Scum thickness: nLa
Distance from top of scum to top of outlet tee or baffle:-n&
Distance from bottom of scum to bottom of outlet tee or baffle Wa
Date of last pumping: n&
Comments:
(recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage,
etc.)
Wa
revised 9/2/98 Page 7 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 7 PHEASANT WAY CENTERVILLE MAP 208 PAR 147 LOT 1
Owner: ANDY KASICA
Date of Inspection:10/18/99
a
TIGHT OR HOLDING TANK: NO (Tank must be pumped prior to,or at time of,inspection)
(locate on site plan)
Depth below grade: nla
Material of construction:_ concrete_ metal_ Fiberglass _Polyethylene_ other(explain)
n(a
Dimensions: nLa
Capacity: nla gallons
Design flow: n& gallons/day
Alarm present: NO
Alarm level:jIL& Alarm in working order:Yes—No—: NO
Date of previous pumping: n&
Comments:
(condition of inlet tee,condition of alarm and float switches,etc.)
nta
DISTRIBUTION BOX: X
(locate on site plan)
Depth of liquid level above outlet invert:LIQUID LEVEL WITH BOTTOM OF PIPE
Comments:
(note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.)
DISTRIBUTION BOX IS STRUCTURALLY SOUND
PUMP CHAMBER: NO
(locate on site plan)
Pumps in working order:(Yes or No): NO
Alarms in working order(Yes or No): NO
Comments:
(note condition of pump chamber,condition of pumps and appurtenances.etc.)
n&
revised 9/2/98 Page 8 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 7 PHEASANT WAY CENTERVILLE MAP 208 PAR 147 LOT 1
Owner: ANDY KASICA
Date of Inspection:10/18/99
SOIL ABSORPTION SYSTEM(SAS): X
(locate on site plan,if possible;excavation not required,location may be approximated by non-intrusive methods)
If not located,explain:
nta
Type:
leaching pits,number: 1000 GALLON LEACH PIT
leaching chambers,number: -n&
leaching galleries,number: .n(a
leaching trenches,number,length: nLa
leaching fields,number,dimensions: nZa
overflow cesspool,number: nLa
Alternative system: Wa
Name of Technology: JILa
Comments:
(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.)
THE LEACH PIT IS STRLICTURALL SOUND AND FUNTIONING PROPERLY THE PIT HAS NOT HAD MORE THAN 1-OF WATER IN IT
CESSPOOLS: _
(locate on site plan)
Number and configuration: nta
Depth-top of liquid to inlet invert: nLA
Depth of solids layer: iVA
Depth of scum layer. n&
Dimensions of cesspool: nta
Materials of construction: Wa
Indication of groundwater: Wa inflow(cesspool must be pumped as part of inspection)Wa
Comments:
(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.)
nLa
PRIVY: _
(locate on site plan)
Materials of construction:Wa Dimensions:nLa
Depth of solids: nLa
Comments:
(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.)
nla
E
revised 9/2/98 Page 9 of t 1
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
Property Address: 7 PHEASANT WA SYSTEM INFORMATION(continued)
Y CENTERVILLE MAP 208 PAR 147 LOT 1
Owner: ANDY KASICA
Date of Inspection:10/18/99
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent reference landmarks or benchmarks
locate all wells within 100'(Locate where public water supply comes Into house)
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 7 PHEASANT WAY CENTERVILLE MAP 208 PAR 147 LOT 1
Owner: ANDY KASICA
Date of Inspection:10/18/99
NRCS Report name: n&
Soil Type: n/a
Typical depth to groundwater: n&
USGS Date website visited: n&
Observation Wells checked: �Q
Groundwater depth:Shallow _ Moderate _ Deep _
SITE EXAM _ Slope
_ Surface water
_ Check Cellar
_ Shallow wells
Estimated Depth to Groundwater 12 Feet
Please indicate all the methods used to determine High Groundwater Elevation:
_ Obtained-from Design Plans on record
Observed Site(Abutting property,observation hole,basement sump etc.)
_ Determined from local conditions
Checked with local Board of health
_ Checked FEMA Maps
_ Checked pumping records
_ Checked local excavators,installers
X Used USGS Data
Describe how you established the High Groundwater Elevation.(Must be completed)
USGSMAPS AND CHARTS.12+FEET
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y
Commonwealth of Massachusetts
Executive Office of Environmental Affairs
De artrt ant of R
ECEIVED
Environmental Protection 997
William F.weldT.Govemor rn rMF
Trudy Coxe
Secretary,EOI_A .
David B. Struhs
Commissioner _
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION `
Property Address: 7��e'`�S�t�.��'(v s17 �r wT r�-..��\� Address of Owner: L co i (AP A Vl�k-)ry U
Dale of Inspection: `I—D,:-? _ci 7 . (If different)
Name of Inspector: 1� cQ�av k. <✓"�_S
Company Name, Address and Telephone Number:
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate
and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems. The system:
asses
Conditionally Passes
_ Needs Further Evaluation By the Local Approving Authority
_ Fails
---- —
Inspector's Signature: Dale: 7
The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (30) days of completing this
inspection. If the system is a shared system or has a design flow of i0,000 gpd or greater, the inspector and the system owner shall submit
the repot, to the appropria!e regional office of the Department of Environmental Protection.
The original should be sent iU ^e s�sterii ov�ner and copies sent to the buyer, if applicable and the approving aL:hcri;').
INSPECTION SUMMARY:
Check A, B, C, or D:
A] SYSTEM PASSES:
I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303.
Any failure criteria not evaluated are indicated below.
B] SYSTEM CONDITIONALLY PASSES:
One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair,
passes inspection.
Indicate yes, nu, or nol delemiined (Y, N, of ND), pescriln, basis of delmininalion in all instances. If"not determined", explain why not)
_ The septic tank is metal, cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is
imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as
approved by the Board of Health.
(revised 8/15/95)
One Winter Street • Boston,Massachusetts 02108 • FAX(617) 556-1049 • Telephone (617)292-5500
`a Printed on Recycled Paper
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Properly Address;
Owner: ;E'ws0'Ir-ko
Dale of Inspection:
Lt
B] SYSTEM CONDITIONALLY PASSES (continued)
Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed
pipe(s) or due to a broken, settled or-uneven distribution box. The system will pass inspection if(with approval of the
Board of Health):
broken pipe(s) are replaced
obstruction is removed
distribution box is levelled or replaced
_ The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass
inspection if(with approval-of the Board of Health):
broken pipe(s) are replaced
obstruction is removed
C] FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
/ 4 Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the
public health, safety and the environment.
1) SYSTEM WILL. PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER
WHICH WILL PRO'IE0 THE PUBLIC HEALTH AND SAFETY AND 11-IL 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.
1) SYSTEM WILL FAIL UNLESS 1HL BOARD Of- IILALThI (AND PUBLIC WATER SUPPLIER, 11- APPROPRIATL) DETERMINES THAT
THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
_ the ,\-Sion) hay it Septic tanK anu Soil ausurpoull system anu is withill iou icci io a 'Yule'- 3upp!) or tribata.)- t0 a
surface water supply. ' :
_ The system ha! a septic tank and soil absorption system and is within a Zone I of a public water supply well.
_ T.he.system_has�,a septic.tank and soil absorption system and is within 50 feet of a private water supply well.
_ The sysien-i has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water
supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is
free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5
ppm.
D) SYSTEM FAILS:
I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis
for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct
the failure.
Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool.
Discharge or ponding of effluent to the surface of the ground or surface waters due to an uverloaded or clogged SAS or
cesspool.
(revised 6/15/95)
I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
-` PART A
CERTIFICATION (continued)
Property Address:1 r��>Sr�•Y- (,.s�/, eeliN`t
Owner: .Z•`+/� 1 NO
Date of Inspection:
D] SYSTEM FAILS (continued):
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 1/2 day flow.
I 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 Soil Absorption System, cesspool or privy is below the high groundwater elevation.
Any portion of a 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 I of a public well. -
l` Any portion of a cesspool or privy is within 50 feet of a private water supply well.
L�1 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`'anal`ysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for
coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
FJ LARGL SYSIEA1 FAILS;
_ The following criteria apply to large systems in addition to the criteria above:
The design flov., of system is 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety
and the environment because one or more of the following conditions exist:
the system is within 400 feet of a surface drinking water supply
the system is %%ithin 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'
The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program
requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.
(revised 6/15/95) 3
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
- Property Address:
Owner: Zctivvv��ti.p
Date of Inspection:
LA' lOX7-7
Check if the following have been done:
-L-/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 pan 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 system does not receive non-sanitary or industrial waste flow
f,/The site was inspected for signs.of breakout.
!'All system components, excluding the Soil Absorption System, have been located on the site.
2The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or
tees, material of construct ion;°dimensions, depth of liquid, depth of sludge, depth of scum.
The size and location of the Soil Absorption System on the site has been determined based on existing information or
approximated by non-intrusive methods.
y TIe facia;;, o•,. , ;: • ' occ ,,a:;:, if di'!er to-r ov,'ner; were provided with information on the proper maintenance of Sub-
Surface Disposal System.
(revised 8/15/95; 4
I �
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: -7 j�Y�e- mac•,o,-r L,. (•
Owner: Z,,%s v\.0'i -v
Date of Inspection:
FLOW CONDITIONS
RESIDENTIAL:
Design flow: gallons
Number of bedrooms:
Number of current residents.
Garbage grinder (yes or no):
Laundry connected to system (yes or no):7
Seasonal use (yes or no):_N
Water meter readings, if available: N (X
Last date of occupancy: ('e'C'6L
COMMERCIAUINDUSTRIAL:
Type of establishment:
Design flow:_rgallons/day
Grease trap present: (yes or no)_
Industrial Waste Holding Tank present: (yes or no)_
Non-sanitary waste discharged to the Title 5 system: (yes or. no)_
Water meter readings, if available:
Last date of occupancy:
OTHER: (Describe)
Last date of occupancy.
GENERAL INFORMATION
PUMPING RECORDS and source of information:
System pumped as part of inspection: (yes or no)_ 1'
If yes, volume pompc'd gallons
Reason for pumping.
TYPE OF YSTEM
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 AGL of all components, date installed if known) and source of information:
Sewage odors detected when arriving at the site: (yes or no)/-/
(revised 8/15/95) 5
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: ? r�i�c 5;� t,A.y
Owner:
Date of Inspection:
LA-a-7 7
SEPTIC TANK: L l
(locate on site plan)
Depth below grade: �(
Material of construction: concrete _metal _FRP —other(explain)
Dimensions: �r�T
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(t es or baffles, depth of liquid level in relation to outlet invert, structural .
integrity, evidence of leakage, etc.) c_' ���= c+� �' «lt - ""yv✓) CC)�ti c0�T►n u
GREASE TRAP:-Ll
(locate on site plan)
Depth below grade:
Material of construction: _concrete _metal _FRP —other(explain)
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Dicta^ce from bottom M crlim 1ri ho!Inm OttowipI tee or bdllie-
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
integrity, evidence of leakage, etc.)
(revised e/15/95) 6
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: �Y�t•�6c.�Z- ctij, LP.�F
Owner: Z�e:,v--,(Y%r-O
Date of Inspection:
-j>-7--i-7
TIGHT OR HOLDING TANK:r
(locate on site plan)
Depth below grade:
Material of construction: _concrete _metal _FRP—other(explain)
...-Dimensions:
Capacity: gallons
Design flow: gallons/day
Alarm level:
Comments:
(condition of inlet tee, condition of alarm and float switches, etc.)
DISTRIBUTION BOX:
(locate un site Ilan)
Depth of liquid level above outlet.invert: / J0VV�
Comments:
(note tf ievei and distribut-w: i> ryua', e1-Vence of.ul:J: co; )u,,er, evidence of leakage into or out of box, 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, etc.)
(revised 8/15/95) 7
I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
Owner:
Date of Inspection:
SOIL ABSORPTION'SYSTEM
(locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods)
If not determined to be present, explain:
Type: (
leaching pits, number:_
leaching chambers, number:!
leaching galleries, 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,etc.)
T lJ6b �y`/ ��awi�r i lac S
.CESSPOOLS: LEI w,....4,...... .
(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 groundv ate:.
inflow (cesspool must be pumped as part•of inspection)
Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
PRIVY:41
(locate on site plan)
Materials of construction: Dimensions:
Depth of solids:
Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
(revised 8/15/95) 8
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: '7
Owner:
Date of Inspection:
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100'
G �
N
O 0
s ►l�r
DEPTH TO GROUNDWATER
Depth to groundwater: �� feet
method of determination or approximation: -- `�'����^ _ l' ._ �,� �` ✓t 6), [
(revised 8/15/95) 9
TOWN OF BARNSTABLE
Ph
LOCATION L0+ VVeS+SEWAGE # ' Y43
VILLAGE 6N �(,jj� ASSESSOR'S MAP & LOT L
INSTALLER'S NAME & PHONE NO.
SEPTIC TANK CAPACITY ��000 k S
LEACHING FACILITY:(type) LeA (size) L,DOD �i11.6�,s
NO. OF BEDROOMS PRIVATE WELL O PUBLIC WATER
BUILDER OR OWNER �'� 51 V/1��6�ii (01 QL/
DATE PERMIT ISSUED: l `�
DATE COMPLIANCE ISSUED: � Cj -- �
VARIANCE GRANTED: Yes No �/
L o4 V j
1
ae
46
,
a� /ao..
THE COMMONWEALTH OF MASSACHUSETTS
/ BOAR® OF HEALTH
TOWN OF BARNSTABLE
Appliration for 11i iposal Workii &nstrnrtion thrutit
Application is hereby made for a Permit to Construct (X) or Repair ( ) an Individual Sewage Disposal
K ----- --
•--
oc o -Addre, y j
t or Lot No.
,el...... ._.. ................
W Address
. nh
a ------------ ---- -- .. .1'--- .
Installer Address
UType of Building Size Lot._gz.A .......Sq. feet
0-4 Dwelling—No. of Bedrooms........._.. ____________.........Expansion Attic ( ) Garbage Grinder ( )
'� Other—T e of Buildin >._._ —
a Other—Type g!� _ __�_.._ No. of persons____________________________ Showers ( ) — Cafeteria ( )
dOther fixtures .................................... ----------------•---------------
W Design Flow___________________jl>t ................gallons per per day. Total daily flow..____._____._.� _v_.___________.gallons.
WSeptic Tank—Liquid capacity W.gallons Length................ Width................ Diameter................ Depth................
x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area......4............sq. ft.
Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosingank ( )
Percolation Test Results Performed by.-.K.... .............................. Date•-
Test Pit No. 1.....<. ._minutes per inch Depth of Test Pit.................... Depth to ground water.._._......o........'-
44 Test Pit No. 2................minutes per inch Depth of Test Pit...:................ Depth to ground water........................
W /�� ------- ..... ---------------------------------
••-........
----------•---.....-------
--•-----------•._......._-----_- ----•---••--•-----
O Description of Soil------.Z ----------------------------•---•----'-----------•------•-----•----------•------•-•--------•---------•-•••-•••-------......__.
W
UNature of Repairs or Alterations—Answer when applicable-----------------------------------------------------•_•-.......................................
---------------------------------------------------------------------------------------------------------------
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Compliant as been issued by the board of health.
Signed -'----------- ------- -------------- -- - 911
-------.-- --------------
Dare
Application Approved BY ---
.......................----.... Dace
Application Disapproved for the following reasons- ------------------------ - -- - -- - --------------------------------------------------------------- ---------------
--. -- --------- -- ------------------------------------------------------------------------------- .-------.................................................. ........................................
Dare
Permit No. ---------- -....L1 ��------------------ Issued ...................9..--f'.1.-...9 3----------------
Dace
/S/"7
No................_.....-• Fims.... ......
d3 THE COMMONWEALTH OF MASSACHUSETTS
9a- - BOARD OF HEALTH
TOWN OF BARNSTABLE
Appliration for Uhiposal Works Tons rnrtiun 1hrutit
Application is hereby made for a Permit to Construct (x) or Repair ( ) an Individual Sewage Disposal
System at i, 1,'�
/ Locallion�Addres 1 J I or Lot No
............
............................................
✓1� Orier �� Address
Installer Address
UType of Building Size Lot... ......Sq. feet
Dwelling—No. of Bedrooms`...............----------------
.----__......Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Buildingf/�C -No. of persons............................ Showers ( ) — Cafeteria ( )
dOther fixtures ------------------5--- --------------------------------------------------------
W Design Flow....................Ile) per pel'son-per day. Total daily flow_.__..........._ .........................gallons.
WSeptic Tank—Liquid capacity.!"_gallons Length.............•.. Width................ Diameter................ Depth................
x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by......................... ........ ......................... Date----
Test Pit No. 1.....<.!;�_minutes per inch Depth of Test Pit-------------------- Depth to ground water......yQ f`.
fq Test Pit No. 2................minutes per inch Depth of Test Pit..................... Depth to ground water........................
Descriptionof Soil - P' ! ^----------------•-----------•--••------------------------------------------•--------.
c.� ----------------------------------
---------•-•-•------•---•-•--------------------------------------
••----------------------------------------------•------------------------------•••-------------
W
UNature of Repairs or Alterations—Answer when applicable................................................................................................
. ---•-----------------------------------•--------..................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Compliance-,as been issued by the board of health.
Signed 1.1141, ...................
Dare
Application Approved By ............... ... ------
_ f _
Application Disapproved for the following reasons: ................. .. ....'-''-"- ........---'-'--"--'---'----------... -- -- ----'------..._................... ---
-' .........-'--"..............." ---------------------------------------......------_-----------------------.......................... ' . --- ---"--'--'........................-'---'---.. '-'---.................................
Dare
Permit No. ........... Issued 9...: f ................
llare
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Terttftcate of Compliance
VMS QLS- TO CERTIIF/'Y, That the Individual Sewage Disposal System constructed ( X ) or Repaired
V ( )
at --'...... . . .........''..........,---. -- ' " - -
has been installed in accordance with the provisions of TITLE 5 o jjThe Sta e Environmental Code as described in
the application for Disposal Works Construction Permit No. .........f....c .-.. .. dated -----------------------------------------------
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE..... .. d_-- ...........................................---- Inspector ................... r-
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE 1�G
No. ... ..'...... � FEE..... ....
Bispopa1 arks Tono#r ion antic
Permission is hereby granted... _ ------------------------------------........----------------------------
to Constrruc�t/(X or Repair ( ),-an Individual Sewage Disposal Sy§t
at No. ;; ........
��� 1 t------------•--
el
t /11^ 03
as shown on the applica7-1
nfor Di posal Works Construction No..../----------------- D�� 2 ------._c'---------•._-__ e
Board of Health
DATE -. -•-------
r
FORM 36508 HOBBS 6 WARREN.INC.,PUBLISHERS
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