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HomeMy WebLinkAbout0223 PINE STREET (HY - Health (2) ..r L.3 PINE STREET, CENTERVILLE A= 248 003 1�1� CYCfE�� /�GLKG p 2 �m UPC 12543 HAS11NG8.wri a ti i Christopher P. Ohon Real Estate Brober • 15 Bird Street Foxboro,Massachusetts 02035 office: 774.215.1000 facsimile: 774.215.1001 colson@christopherolsonre.com mobile: 617.834.2975 www.christopherolsonre.com toll free: 800.256.3539 / ) / C y I • � 1 1 Commonwealth of Massachusetts _ Title- 5 Official Inspection Form Subsurface Sewage Disposai,System Form - Not for Voluntary Assessments Property Address C1,�/Z/S O/��SD� ?S-/�/y6�.a/LG�/� � �.��o•�,1y/�S�r'a�?Gc i Owner Owner's Name information is C"�,y?f2///LL f �i�-ss. DZCv Z17-71,1 3' required for 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. Please see completeness checklist at the end of the form. Important: A. General Information When filling out forms on the computer, use 1. Inspector: only the tab key to move your .414—PAN//VD cursor-do not Name of Inspector use the return !� 10VXW4fA-"*, !<f key. T Ny Company Name Company Address /y1�ySFiE�v� ,�l.�Ss O?oy r Cityrrown State Zip Code 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, accura+.? and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: '\ Passes ❑ Conditionally Passes ❑► Fails ❑ Needs Further Evaluation by the Local Approving Authority a�27// R Inspector's Signature 101, .00' Date -The system inspector sha!I.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 t- e 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 tii.R onditiorls of u at that time.This inspection does not address how the system will perform in the futurd and the same or different conditions of use. � t t5ins•1 V10 Title 5 Official Inspection Form:Subsurface Sewage_Disposal System- ge 1 of 17 /2 . vv� ' 1 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voiuntary Assessments Property Address Owner Owner's Name /� information is required for L fiWT�/l�//GGf /7ij$• 4,Z(to l 3 2 271� every page. City/Town 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 .10 CMR. 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ,V oV' ❑ 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. Check the box for"yes", "no" or"not determined" (Y, N, ND) 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. ❑ Y ❑ N ❑ ND (Explain below): ;Sins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official, Inspection Form Subsurface Sewage Disposal System.Form - Not.for.Voluntary Assessments Property Address Owner Owner's Name information is �F f/l!l/LL� /J4!'5- 0�631/ 21Z7//3 required for every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ 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 ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ 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 ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b) that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address n Owner Owner's Name information is �� T7��Ul�f 7�/ required for Z1z every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 111 2. System will fai unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ . The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply, ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for 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 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 1/day flow t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 2�3 �i•�F Ste' Property Address Owner Owner's Name information is required for ��/7�Tf/Z! Lf /�i�fs� 424R _ �lZ7/./,3 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® 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. ❑ ❑ 84 Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ❑ 14A Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ❑ /IA Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ❑ /11A 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- 10,000g pd. ❑ The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CM 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. t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M Property Address Owner Owner's Name information is ��/�� /L/J�LG Iys• �.2 L? required for f � every page. City/Town State Zip Code Date of Inspection 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? �f/1rttl�' /V;OlaSf R� OS,y,H 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) <y ❑ Was the facility or dwelling inspected for signs of sewage back up? F;X ❑ 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: Q ❑ 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)] D. System Information Residential Flow Conditions: r�vusf s Number of bedrooms (design): Number of bedrooms (actual): SSa DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Pace 6 of 17 i Commonwealth of Massachusetts r Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ?'Zz 4:z�-A/e' 5: Property Address G'�izis, ��so,v Owner Owner's Name information is sell required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: 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) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts `title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments '57 Property Address Owner Owner's Name information is ��f -21Z7/E,l required for every page. City[Town State Zip Code Date of Inspection D. System Information Description: A1.4 Number of current residents: 6-1 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 A?W Seasonal use? ❑ Yes [&- No Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes [F No Last date of occupancy: �l�6✓S E/�O� O c G y 1pfv 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 [3 No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: zip ;Sins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Pace 7 of 17 _ I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address Owner Owner's Name information is ���✓Tf�LU/LLf /Y4�fs- !>263 e/ -Z/Z-r1oV required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: a yhs a�• 5 ys>"��J.� f 2 �i�s�•vs>.�-lGtA 8's' Were sewage odors detected when arriving at the site? ❑ Yes No Building Sewer(locate on site plan): �JpySf js/O io Depth below grade: 3'�" ��''�l�✓ '�>bG "' 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.): ii I• ►� ►� L000 �' .� ' ' Septic Tank(locate on site plan): yvNSf Syo�' Depth below grade: feet Material of construction: [l concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other (explain) If tank is metal, list age: years //OJ far Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: SX s'g/o Sludge depth: t5ins-1 ill 0 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 . Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments. b cwM e�.�3 �✓�f S1 Property Address Owner Owner's Name information is rFyTr-ed1L1f �'Y�SS G16 3 required for every page. City/Town . State Zip Code Date of Inspection D. System'! Information (cont.) Septic Tank (cont.) �,/pt/v`f S..Pa'° Distance from top of sludge to bottom of outlet tee or baffle "��� Scum thickness D Distance from top of scum to top of outlet tee or baffle 7 -7 Distance from bottom of scum to bottom of outlet tee or baffle �1�'.d5�//Z��✓� sr1 cis How were dimensions determined? Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): fcc0Aifa/0 7;�N& AeAl AA:piD AV 7yl!' S7A' 4yere111,*,e- ,o 0 0, AlD yf 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. t5ins•11l10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of i7 Commonwealth of.Massachusetts Title 5 official Inspection Fora Subsurface Sewage Disposal System Form - Not for Voluntary Assessments *7� P y E Property Address Owner Owner's Name information isjyZ.7�/� required for C� every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 1#0 Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Hbl�F 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): 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 t5ins-11/10 Title 5 Official inspection Form:Subsurface Sewage Disposal System•Pace 11 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address Owner Owner's Name information is �fyr���jLL� AWW, a2,9 3y required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert , D��s ; c�V�y�h�iia ofTL�Tr,vv fc7 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.): e x /S 4 fPf.4 0,15 r ?-W Dui eo £ /d $ p. =�30�t 2/.�✓�0�2 17/Z>�g !,!�>sy 94.t.��,��d�✓� C,�.1fC6�fo 4-n>T�2/p �yas9l A/d Wf Pump Chamber (locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No 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: t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 \ Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address 6111916 Owner Owner's Name information is ��•�?����L� Iyif • 026 3Y required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: 2 leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: F-1 innovative/alternative system Type/name of technology: — Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): �� I • So AL 1-5 S&,,/0 3 ''Or' /V,o 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 15ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth cif Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address Owner Owner's Name information is C;r /Tf/L l/1LGf' *Mo- required for every page. City/Town .State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 4 p, Privy(locate on site plan): Materials of construction: Dimensions t Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): ,5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments w„ ��3_ �i•yf Property Address Owner Owner's Name information is 4���/TfjLl,/LL F �_�•fS 0.2 L 7/;c 3 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view 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. Check one of the boxes below: - ❑ hand-sketch in the area below ❑ drawing attached separately 1 �rv . T" t5ins•11/10 Ttle 5 Official Inspection Form:Subsurface Sewage Disoosal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address Owner Owner's Name information is �L d�63 -0/Z7/If required for C— • every page. City/Town State Zip Code Date of inspection D. System Information (cont.) Site Exam: © Check Slope XL,0T m Surface water Check cellar s/IopNDNf ® Shallow wells 440-4/r Estimated depth to high ground water: 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: You must describe how you established the high ground water elevation: 0,4 13r ,1ZeC-Al- Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection F®rn Subsurface Sewage Disposal System Form - Not for Voluntary Assessments.. k -17 F1,V f ST Property Address Owner Owner's Name information is required for C— every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist 2 Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information — Estimated depth to high groundwater. Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System—Page 17 of 17 Your Sep Sepfic Sy9tem and It is important to understand how your system works and how this treatment affects it in order to protect your investment. The typical system consists of three (3) main components. S . The Septic Tank The Distribution Box The Drainfield The Septic Tank Waste exits the house and enters the septic tank where solids settle to the bottom, grease and scum from the household detergents float to the top, and liquids stay in between. The solids that settle create their own bacte- ria which decompose the solids naturally. There is no need to add additional enzymes and bacteria to the tank. The tank eventually fills with solids and scum requiring it to be pumped. A septic should be pumped every two (2) years. The Dt ainf eld The liquid (gray water) flows to the distribution box where it is evenly dispersed into the drainfield. Finally, the drainfield begins treating the gray water. Microorganisms in the soil consume organic pollutants in the gray water and the pure water is absorbed by the ground below. How Problems Start From the first day of use, the drainfield of your septic system begins to deteriorate. Some solids, grease, and scum always pass through the septic tank into the laterals. This is because of natural solu- bility or the lack of setting time in the septic tank during periods of heavy use. Problems especially arise when the septic system is not maintained and the septic tank fills with solids and scum that ov ow into the drainfield. As the drainfield becomes cloQaed. the water flow becomes restricted. Since the ,a��. cannot drain into the soil, it filters upward causing ponding, foul odors, wet spots in the yard, and an unhealthy envi- What Causes Problems What you don't read about is that bacteria has a waste called biomat, and they also create a gas, bacteria eats human waste. It does not eat, hair,wool, polyester and other particles. The biomat is like grease. The gas cre- ates bubbles and this causes particles to float up the T and into the distribution box and into the leeching fa- cility, plugging up the stone. Septic tanks should be pumped every two (2) years. Cesspool Cesspools were made by digging a hole in the ground and walls were made of stone then later on they were built with concrete blocks. The waste entered the cesspool, and solids settled to the bottom, the liquids seeped out the sides into the soil. Cesspools should be pumped every year. State Environmental Code Title V Chap. 5 Inspection Procedures Guidance on Completing Inspection Form Part A Certification. The Certification Section has two principal functions. First it provides identification information on the property being inspected and the inspector. Second, it presents the results of the inspection relative to the failure criteria outlined in 310 E'1VIER 15:303. in the certification statement, the inspector is certifying that the conditions existing at the time of inspection are accurately presented in the inspection report. The inspector is not certifying that the system is adequate for the current use of the system nor for the future use of the system. TONY CAPONIGRO 215 North Main Street Mansfield, MA 02048 Title Z% Insioections JAN-16-96 TUE 14 :53 DOWN CAPE ENGINEERING 508 362 98.80 P. 02 '7 AssescoTs Map # Parcel Lot I SUBSURFACE SEWAGE DISPOSAL SYSTEM. INSPZCTION FORM Address of property OR 3 c9zsct Owner's name C4A,404 W4 INN Date of Inspect 'on PART A CHECKLIST Wdyl, 6,4r#/ .0" Check if the following have been done: VPumping 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. --ZAs built plans have been obtained and examined. Note if they are not available with N/A. , '_''he facility or dwelli..g was inspected for signs of sewage bbt�k--up. ' ` The' site was inspected for signs of breakout. system components, excluding the SAS, have been located on the The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, naterial of construction, dimensions, depth of liquid, depth of 1 (sludge , depth of scum. �he E i Ze FnH 1 nrpt 9 nn n.f the SAI nn the site hat been determined baced }�On existing information cr approximated by non-intrusive methods. The facility owner (and occupants, if' different from owner) were prov_ ­ed with information on the proper maintenance of SSDS . JAN-16-96 TUE 14 :54 DOWN CAPE ENGINEERING 508 362 9880 P. 03 S SUBSURFACE BSxAGF DISTOBAL SYSTEM INSPECTION FORS'. p}►.xcT D • BY6TSH INTOMWON FLOW GONDI'TIONS If residential number of bedrooms „ number of current residents No-- garbage grinder, yes or no Laundry connected: to system, yes or no ND_ seasonal use, yes or no If nonresidential, calculated flow: ,gam ppjelag his 9)4 T na cxuau �vc� � water meter reading$, if available: /9M �9�3 o� 70/006 5y,coo d�cv€.11l�v j v6 ��� , Last, date of occupan y/",�oa l9q,Aan �daa GENERAL INFORMATION Pumping records and source of information: Syste.. pumped as part of inspection, yes or no if yes , volume pumped Reason for pumping: Type of system j/ Septic tank/distribution box/soil absorption system(No v'AoX Single cesspool Overflow cesspool Privy Shared system (yes or no) (if yes, attach previous inspection records, if any) Other (explain) -- — Approximate age of all components. bate installed, if known. Source of information: w b$fict eG 4 S . _ Sewage odors detected when arriving at the site, yes or no J MI`i-10-70 1 VG iT • .JT LV WII lr rlrG GIlV 11lGGR 11lV VVO I:OG JOOV r • GyT SUBSURFACE DEW-AGE DISPOSAL SYSTEM INSPECTION PORM PART B SYSTEX xNrORUTIOH eantinued SEPTIC TANK$ (locate on ante gla,n) �� '+�- -2- de t below fl Q q & dE �' .• /cS�G PL_ ,�dVMS Cs. p h b grae:.1�C5G t material of construction: concrete metal FRP other(explain) dimensions : 11500 rlGGd dN a4W . �" sludge depth to bottom of outlet tee orbaffle _ distance from top of .sludge 3 ' 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 L 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. ) DISTRIBUTIO'� BOX: (locate on site plan) uN acrrac�.-� depth of liquid level above outlet invert Comments: (note if level and distribution is equal, evidence of solids carryover, evidence cf leakage into or out of box, recommendation for repairs, etc. ) f x 01MA 7MIS 6r 41 u r 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. ) 1 - 4 MfM-lb-7b I VG 1'f :L7.7 1JUWn I.MrC Mr4U lNM=M 4NU YL 100 10 SUBSURFACE SEWAGE DIBPOS)►L SYSTEM INSPECTION FORK PART B 8Y6TE,X ZKYO ATION continued 1^ SOIL ABSORPTION SYSTEM SAS 1 Q�•� iUYCIL "°� "���' ���� (locate on site plan, if possible; excavation ZIA required, . but may be approximated by non-intrusive methods) •. If not determined to be Arosent, expla : t t Type leaching pits and number r er 0 n5 Comments: (note condition of soil, signs of hydraulic failure, level of ponding, c0XI9i i n f vegetation, ,ream dati ns for mainten nce or re airs etc. ) CESSPOOLS (locate on site plan) : Nam '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-, cignc of hydraulic failyr�, level 'of p riding, condition of vegetation., recommendations for maintenance or repairs,ete. ) PRIVY: NQA.IL (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. ) JAN-16-96 TUE 14 :56 DOWN CAPE ENGINEERING 508 362 9880 P. 06 21 SUBSURFACE $SWAGE DISPOSAL SYSTEM INSPECTION FORM PART 8 SYSTEM XNFORMATIOK COUtinued SKETCH OF SEWAGE DISPOSAL SYSTEM: Include ties to at least two permanent references landmarks or benOhmarks locate all wells within 100 ' I � env p p p -' u4eriw, 1�3 2j1 - 51R C1'rr+tQs � g1Utc� DEPTH To GROUNDWATER - - -� --- — depth to' groundwatei method of determination or approx'mation: $ - JAN-16-96 TUE 14 :56 DOWN I:HYt 1--NL.iNtt-k1,Nt. ow 9 6bae 7t5R5F0 Y. U f $u$SURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C FNI LURE CRITERIA Indicate yes, no, or not determined (Y, N, or ND) . Describe basis of determination in all instances. If "not determined", explain why not) . N1 Backup of sewage into facility? Discharge or ponding of effluent to the surface of the ground or surface waters? �w���� �� �1�s 10DVS PLL ` O� C-CD U^cl x -- Sm C� �S Cb`e v'G %0Qtz �.. -�.►� v �'� t h1\2N�YL ' '�C11�,� }��'t. cx„l�o ,�rac�.�u..c ow ��o w►. 1 cwC�� 1,�k voorvt , static liquid level in the distribution box above outlet invert? �• Liquid depth in cesspool <b" below invert or available volume< 1/2 day flow? Required pumping 4 times or more in the last year? number of times pumped Septic tank is metal? cracked? structurally unsound? substantial infiltration? substantial exfil,tration? tank failure imminent? Is any portion of the SAS, cesspool or privy: below the high groundwater elevation? within 50 feet of a Surface water? `� within . 100 feet of a surface water supply or tributary to a surface water supply? within a Zone I of a public well? within 50 feet of a bordering vegetated wetland or salt marsh (cesspools and privies only, not the SAS) ? within 5o. 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 analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. r + JAN-16-96 TUE 14 :57 DOWN. .CAPE ENGINEERING 508 362 9880 P. 08 !3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM FART D r CERTIFICATION Name of Inspector R,alpb Ojaia Company Name Down Cape Consulting Company Address 939 Route 6A, Yarmouthport, MA 02675 Certif cation Statement I certify that r 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: 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 dofinod in 310 CM 15. 303 . The basis for this determination is provided in the FAILURE CRITERIA section of this form. Inspector ' s sig ature pate y Original to system owner 4rAt�JE11..� Copies to: AbFU , t�U�s� ssL ,7�bfas1L"�1.�� Euyer (i f applicable) 16.C�� YL 4*_,yM*A-Z ' Ap oving authori,t I i L- 0CAT40N SEWAGE PERMIT NO. V'lLLAGE C' T"!-lZ y,e,Z 45 INSTA LLER'S NAME i ADDRESS IVA re OR OLWKER OA: TE PERMIT IS-SUED- DATE COMPL-I- ANCE ISSUED Z- i I/P 2d"IAL: THE COMMONWEALTH OF MASSACHUSETTS BOAR® F HE,A1,Tfi ..........,- ",Ojv_1.2.---:..'..OF...:r . - --... ......................•-----•-•- Appliration for Ditfillaaal.Workii Tvmtrnrtinn Famit Application is hereby made for a Permit to Construct ( ) or Repair C� an Individual Sewage Disposal Sys em at .. : .. ..... l ...........a • �.1 LoconA dres �N1- ..... ........ ..---- . . ... .... a2 : ... ................... Address --------------- - ......................... .................................._................._................ Installer Address Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) '4 Other—T e of Building ............................ No. of persons____________________________ Showers — Cafeteria Aa 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 ( ) Percolation,Test Results Performed by.......................................................................... Date........................................ aTest Pit No. 1________________minutes per inch Depth of Test Pit.................... Depth to ground water..........._............ f� Test Pit No. 2................minutes per inch Depth of Test Pit..................._ Depth to ground water........................ ----------------------------------------- / ODescription of Soil................................... (............................................................................ U ------------ -------------•--------------•------._....-•-•-----•----------......_....----._...------.....---------------------------•---•------....----------....._..----.......----._....-•------------ x --••--------•- ----------------------------------------------------------------------------•••--•-------••------•-•-•-----•••--••-- U Nature of Repairs or Alterations—Answer when applicable-------------------- _�� __._ _ :_. =._.__, � -----------------------------------------------------------•------------------------._....__............................................................................................................. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with 1 the provisions of LITL L 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. �7 :/ / Application Approved BY; ----- -- ...-•--•--••-•-•--•---•-----...--•............................... zZ{�/_l` r' Date Application Disapprove or t e following reasons---- -----------•----------------------------------------------•--------------------------•-•-----•--------_.._.. ....................._................................................................................................................................................................................... Date PermitNo.................-............-.......................... Issued-....................................._................. Date V No.R-L--3-2.L.. 12... THE COMMONWEALTH OF MASSACHUSETTS _.R�.. BOARD—OF HEALTH .........OF.....».t '�" F' > � t`................................. Appliration for Diillosaal Workii Tontrurtion ami# Application is hereby made for a Permit to Construct ( ) or Repair (` ,) an Individual Sewage Disposal System at a Location A�dress { r a or Lot No `w.�.,.. 1-•'1 Jw`� Ownerf rry 1 I j y-_ Address W i... 0 A fl. ... Installer Address Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms................................ .Expansion Attic ( ) Garbage Grinder ( ) F � p, Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) a' Other fixtures ---------------------------------- W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. 9 Septic Tank—Liquid'capacity............gallons Length................ Width................ Diameter................ Depth................ 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. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Test Pit No. 2................minutes per inch Depth of Test Pit...................... Depth to ground water........................ --------------------- . . ................. ..-- ....-•--- ... -----­---------------------- ---------------- 0 ...!to 4 .. ,� ...... .. f Description of Soil................................... = ._:...:...:.....:...:=- ..:.:. W •---•------------------•-----------------------...--•--•------------•--------•-•....----•---..__...------•--••--•----------. UNature of Repairs or Alterations—Answer when applicable..............:_._.._.i- ___> /'.. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TiTI:,. 5 of the State Sanitary Code—The undersigned fuitl:er agree not to place the system in operation until a Certificate of Compliance has been issued by the board..of health. dffs�i a -. ^• i... ' j.'r Signe �cr� ✓ f .... f .sip � Date Application Approved By -• --f E ......4 ............................................................. k` f Date Application Disapproved f'or the following reasons------------------------------------•--------------------------•-------------------- --------------------------- Date PermitNo......................................................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARDS OF HEALTH , -,.- 1 t j s$ `... ....OF....... .. A� l � . .. .............. ...w+...... �f..... .. 1..�.«....1 ............................. (Intif iratr of TompliFanrr THIS-IS TO CERTIFY That the,,-Ind viyGdual-Sew e Disposal System constructed ( ) or Repaired b --_...._ .� ............................................................. f^ /&, r +Installer/ s } 1 y �s`1�.....r� l S.�'i. .?"f i ,A'.1�-P.- s� eS�•1,. ... ... ...�� -' . at.__... --------------•-----•--•-•-•- .....__ . has been installed in accordance with the provisions of TITLE j of The State Sanitary Cod, described in the • Ile �,f application for Disposal Works Construction Permit No.. ��.. . ....:............. dated__-r ._. .4...._................. THE ISSUANCE OF THIS CERTIFICATE SMALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE.-----••------•.........................•---..........-.. 00`.'--- Inspector------------------[�-� ' THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH d n t .., �.,, l i l may• ` ,,E a' ,.j:.:. . ...f. ....OF......../ P._.:� ....a., ..._ ✓ � .................... FEE ' `1) io�roo�ar aa #rion ernti# Permission is hereby granted--- ------- fly . % ,� 1 to ConstrtV or e�air Individual Fexnge Dxsp�osal Syst ............ ''�...... .. . #�.,. ..... . St t / as show/the cat' n for Disposal Works Construction ,)----. Dated..: ,.r .. i fir............... •----.. ...... -----•-•-•-----------•------------------------•-•-----•----........_...._--------� •---• Board of Health DATE-- •---- ------••-•-----------•--------------FORM 12WARREN, INC., PUBLISHERS 03 The Town of Barnstable Health Department 367 Main Street, Hyannis, MA 02601 rua �OIUY r' Office 508-790-6265 Thomas A. McKean FAX 508-775-3344 Director of Public Health July 10, 1995 Chuck Carey Carey Commercial Business& Investment Property 1441 Rt. 132 Hyannis, MA 02601 Dear Mr. Carey: I am in receipt your letter dated July 6, 1995 requesting the Board of Health to void a septic system inspection conducted by Ralph Ojala at 223 Pine Street, Centerville. Please be advised that the Health Division Office will continue to maintain all the septic inspection records received. If an additional inspection report is received regarding this property, we will maintain a copy of that additional inspection report also. Sincerely yours, Thomas McKean Director of Public Health CAREY COMMERCIAL BUSINESS & INVESTMENT PROPERTY I r 10 4 dd� July 6, 1995 .ez r Board of Health Town of Barnstable South Street, Hyannis, MA 02601 Re: 223 Pine Street, Centerville Septic Inspection Dear Board of Health: A septic,inspection for the above property owned by Calaska Partners was recently submitted to you by Ralph Ojala, Down Cape Consulting. We are requesting that you void that inspection based on a possible conflict of interest in that Calaska Partners recently foreclosed, and took back, Mr. Ojalas property. This letter is not an accusation. We simply request the opportunity to submit a second inspection which is being performed now. Thank you, Chuck Carey Representing Calaska Partners CC:rd 1441 Rt. 132 • H annis MA 02601 • Fax 08 5 7 0-8 8 Voice 08- 0- 0 3 y 9 99 5 79 89 0 O Cx.---,, COMMERCIAL I ,G pP,q --------------------- 66 BUSINESS & INVESTMENT PROPERTY k 1441 Route 132, Hyannis, MA 02601 J 4 JUL � FotUSa�dresses only .. - P Board of Health Town of Barnstable South Street, Hyannis,MA 02601 I .. \ F-PFl!:l l-l-!III I I fill it 1.t l ll.:11 1:11 i a I i } 1 E l i �, .� I ` � C � i f i � i r;._._ '� {c I F F i f � i \ � \\1 +, r _ - -� Ou DOUSFIELD SANITARY SERVICE x� ( \ 451 ROUTE 6A I'.U. [1OX 438 EAST SANUWICI-I, MASSACIIl1SETTS 02537 Cb r 6.0 8 888-2010 n a "L{/ 00 JUL 2 l 1995 7 'ba SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION Fo 0 Address of property Q23 Owner' s name 7-6kN Tit G2 NeX Date of Inspection PART A CHECKLIST Check if the following have been done: Pumping information was requested of the owner, occupant, i+nd Beard oL ' Health.' > None of the system components have been pumped for at least two veeka ' and the system has been receiving normal flow rates ,during 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 nat. available with N/A. X The facility or dwelling was inspected for signs of sewage back-ittp: X The site was inspected for signs of breakout. ,, X All system components, excluding the SAS, have beenlJlocated 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 .ofthe 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 SSDSt . s= 440 U144 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION .l FLOW CONDITIONS If residential number of bedrooms number of current residents iV o /VD garbage grinder, yes or no yeS �/ laundry connected to system, yes or no NDN� seasonal use', yes or no It nonresidential , calculated flow: Wat-r meter readings, if available: Last date of occupancy GENERAL INFORMATION Pumping records and souce: of information: Ad System pumped as part of inspection, yes or no if yes, volume pumped Reason for pumping: `1lyp 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) Other (explain)_ Approximate age of all components. Date installed, if known. Source of information: NO Sewage odors detected when arriving at the site, yes or no i 9 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION continued SEPTIC TANK: (locate on site plan) depth below grade: eOret5 OA/ SUeeF.AC.d�- A f 13 material of construction: t-,' concrete metal FRP other(explain) dimensions: A + -B #qrr� L-� �� �� � 4�✓ �d -� 0 sludge depth a9ti 6304' distance from top of sludge to bottom of outlet tee or baffle O scum thickness 7% T� distance from top of scum to top of outlet tee or baffle a-v 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. ) DISTRIBUTION BOX: O O (locate on site plan) depth of liquid level above outlet invert Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, recommendation for repairs, etc.) PUMP CHAMBER:_ (locate on .site plan) pumps in working order, yes or no Comments: (note condition of pump chamber, condition of pumps and appurtenances, recommendations for maintenance or repairs,etc. ) r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION continued SOIL ABSORPTION SYSTEM (SAS) :_ V (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 A 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 pondirig, 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 art of ins ection P P ) 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. ! iz fry SUBSURFACE SEWAGE;DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION continued SKETCH OF SEWAGE 'DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells withinr310011, ' �7` �fi ' � • . -� tit. a. ..s y� � � , , Y �7 DEPTH TO GROUNDWATER ., / depth to -groundwater method of determination or approximation: SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C " FAILURE CRITERIA I x Indicate yes, no, or not determined (Y, N, or ND) . Describe basis of determination in all instances. If "not determined" , explain why not) &f _ Backup of sewage into facility? N N 70 Discharg e or ponding of effluent to the surface of the ground or surface waters? Static liquid level in the distribution box above outlet invert? Liquid depth in cesspool . <6" below invert or available volume< 1/2 c flow? Required pumping 4 times or more in the last year? number of times pumped /V A/ Septic tank is metal? cracked? structurally unsound? substantial infiltration? substantial exfiltration? tank failure imminent? N Is any portion of the SAS, cesspool or privy: 5 below the high groundwater elevation? V within 50 feet of a surface water? Al within . 100 feet of a surface water supply or tributary to a surface water supply? Al N within a Zone I of a public well? /V within 50 feet of a bordering vegetated wetland or salt marsh (cesspools and privies only, not the SAS) ? within 50 feet of a . private water. supply well? N 'less than 100 feet but greater than 50 feet from a private water er 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 r• �, SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART D CERTIFICATION Y. Name of Inspector EDW190C..6ouSFIELD Company Name Company Address - 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 manitena a of on-site sewage disposal systems. Chec one: I have not found any information which indicates that the system fails to adequately protect public health or the environment as defined in 310 CMR 15. 303 . Any failure criteria not evaluated are as . stated in the FAILURE CRITERIA section of this form. I have determined that the system fails to protect public health and the environment as defined in 310 CMR 15. 303 . The basis for this determination is provided in the FAILURE CRITERIA section of this form. Inspector 's Signature Date Original to system owner Copies to: Buyer (if applicable) Approving authority JAN-16-96 TUE 14 :53 DOWN CAPE ENGINEERING 508 362 9880 P. 01 � t lei.(WS)362•454.1 839►r►a sheet rt 60 tax I5�$136?988D y8rm06jth port Ma5902b75 down cape egineerkt Civil 4,noineers S.land surveyors =trueturAt desipn ca FACSIMILE,TRANSMITTAL FORM M+eH.opeep�•Pls Tana court 5083629880 R� 1996 �;te ptann�np o., DATE : — sewage system OIL TO: inspection: FROM: permits MESSAGE: CLIENT NAME: J O g lk NUMBER OF PACES ( INCL. COVER) : IF YOU DO NOT RECEIVE ALL PAGES OF THIS TRANSMISSIOR, PLEASE CALL 508-362-4542 . TOXIC AND HAZARDOUS MATERIALS REGISTRATION FORM NAME OF BUSINESS: �t1 t 113L 4-cc- Mail To: BUSINESS LOCATION: a 3 P/o e S-7- �dt 'DUI/le : UI/� Board of Health MAILING ADDRESS: tl Town of Barnstable P.O. Box 534 TELEPHONE NUMBER: 22 Hyannis, MA 02601 CONTACT PERSON: G l4c'-- DARSC-# EMERGENCY CONTACT TELEPHONE NUMBER: Does your firm store any of the toxic or hazardous materials listed below, either for sale or for your own use, in quantities totallin , at any time, more than 50 gallons liquid volume or 25 pounds dry weight? YES NO This form must be returned to the Board of Health regardless of a yes or no answer. Use the enclosed envelope for your convenience. If you answered YES above, please indicate if the materials are stored at a site other than your mailing address: ADDRESS: TELEPHONE: LIST OF TOXIC AND HAZARDOUS MATERIALS The Board of Health has determined that the following products exhibit toxic or hazardous character- istics and must be registered regardless of volume. Please estimate the quantity beside the product that you store: Quantity/Case Quantity/Case Antifreeze (for gasoline or coolant systems) Drain cleaners Automatic transmission fluid Toilet cleaners Engine and radiator flushes Cesspool cleaners Hydraulic fluid (including brake fluid) Disinfectants Motor oils/waste oils Road Salt (Halite) Gasoline, Jet fuel Refrigerants Diesel fuel, kerosene, #2 heating oil Pesticides (insecticides, herbicides, Other petroleum products: grease, lubricants rodenticides) Degreasers for engines and metal Photochemicals (fixers and developers) Degreasers for driveways & garages Printing ink Battery acid (electrolyte) Wood preservatives (creosote) 1 Rustproofers Swimming pool chlorine Car wash detergents Lye or caustic soda Car waxes and polishes Jewelry cleaners Asphalt & roofing tar Leather dyes Paints, varnishes, stains, dyes Fertilizers (if stored outdoors) Paint & lacquer thinners PCB's Paint & varnish removers, deglossers Other chlorinated hydrocarbons, Paint brush cleaners (inc. carbon tetrachloride) Floor & furniture strippers Any other products with "Poison" labels Metal polishes (including chloroform, formaldehyde, Laundry soil & stain removers hydrochloric acid, other acids) (including bleach) Other products not listed which you feel may Spot removers & cleaning fluids be toxic or hazardous (please list): (dry cleaners) Other cleaning solvents Bug and tar removers Household cleansers, oven cleaners White Copy-Health Department/ Canary Copy-Business I-LOCAT- 110KA SEW QC,E-P_E.RMIT_IJ O. N/_L1_1_ R F-SS D P E_R_IsAIT l-55U -�'�/f'� -t. , � , ,+ C ,� � ; � -,; J 610 No.--- .5.: ....... FEE..�...-/..... THE COMMONWEALTH OF MASSACHUSETTS BOARD H H 11'- ---OF. . .....................................0 Appliration for 01spaoul Works Tonsin rrutit Application is hereby made for a Permit to Construct ( or RepairT�)"anoIndividual Sewage Disposal System at: / ......... .__ .. ::------- ------ � ►• --- -- -- --------- ------------------------- --------------------------------------------------- n sr or Lot No. -----------------------------•- --•------- - ........................... -----------•--••••----•- ---.................................................... W Owr ddress a ..........� ................................................ ................... Installer Address Type of Building Size Lot............................Sq. feet aDwelling—No. of Bedrooms.__..I............... ..._______Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............ No. of persons------/___________________ Showers ( / ) — Cafeteria ( ) Otherfixtures --------------------•----------------------------------------••-•-------------------•------•-----._....•••-•----••-•----------...----•••---•--••---- W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No_ ____________________ Width-------------------- Total Length.................... Total leaching area....................sq. ft. Seepage Pit No..................... Diameter-------------------- Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ aTest Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water..........._............ a' ----•---•-•-----------------••------•-•---•---•---------....._......---•-•------..._...---•--------•......................................................... 0 Description of Soil........................................................................................................................................................................ w ------------- -----: ------- '---- ------------ -. ---- ::: i -- , ---=-:.:--- ---... ------ UNature of R airs or Alte tf� ion—Answer whe applicable................................................................................................. ------------------------•-------•---------------------•------------•••-••-•--•-------------_....._..--•---•--•••-------------------•••-----••---•---------------•--------••----•--------•--...........-- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary lode— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has n issued by the board of health. Siged .".—I .......... ...l..... .................................... ate Application Approved BY -.__... ,� /ate ..... Date Application Disapproved for the following reasons:................................................................................................................ •---•.............•--....-•--------............-•--•---------------....--•--------._...---------------------------------•--•-----..-------•-----•• --- / / Date Permit No....__ Issued._-•{1 ----{--z /e •= --------•---- 1 A No..I.Y s:........ YmE.. ...................... THE COMMONWEALTH OF MASSACHUSETTS BOAR® F- H�XH ------- -------------OF...... .................................... Apphrativn for DifiVoti l Works Tonstrudion 1hrutit Application is hereby made for a Permit to Construct ( ) or Repair an Individual Sewage Disposal System at 1 yr' ��L9ion•A dress ! or Lot No. ....:...L:..�'t L1.•S�!�1 ::....:............................ '' .............. t...�'?!._..................._.__...-'---........_.............................. s Owner Address . ....--••--•---•---•----•..................... ...•--• Installer Address U Type of Building n Size Lot___________________________Sq. feet F-I Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building !A!f No. of persons......Z.................... Showers f — Cafeteria Otherfixtures ------•---•-•-------•-•------•------•--------•------------------------•------------•--------•'----------'-•-•-----.._............-•---.........•-•--- 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........................ M ----•--••--------------•--------•---•--•........._..---•-----------._..--------.......-----..........-'-......-'•--------..._........--••------'•--.......... 0A� Description of Soil........................................................................................................................................................................ W ...............................................'..__._._..._____....__.........._._..__.__ f d /, ------------------- .......... ................G----- c. dt/,f�ZQ�t.'4 � ' !?....� r_t +LG ,..:r:�..y..`: x , ..----------•• - 7- , U Nature of R airs or Alte ations—Answer when applicable.............................................................................. .............. --------------------•----------------------•----.....-••------•---•------------------------.._......--------------•---------------•-----•'-•----•----•---•-•-------------•--------------------......---- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary ode— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has en issued by the board of health. rSig -d fi` ''1 ..... . .4:ln--_-4?.....•............................... ................................ �V20 ate Application Approved By... � e' � L�* -ty =- Date-------------••---••----• 7�/-------- / �� f/ Application Disapproved for the following reasons---------------------------------•----------•--•----•--•---•-----------••--••----------•--...---•---•----....... .................•-•---------------------------------------•-------------•-•-•-•-----.........------------•---•--•--•-------•---------'--•---------------••-------------....._..---•----•--•--------•--- Date PermitNo......................................................... Issued........................................................ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALT ...........OF.......... ... .Ci,I. .................... (9rdifiratr of Tom liana THIS I CE IF ha Jt Individual Sewage Disposal System constructed ( ) or Repaired �� k.. - er ....... -------------------------------------------------- - - . at. . ............................................................... has been installed in accordance with the provisions of Article XI of The State Sanitary C94e s des ribed in the application for Disposal Works Construction Permit No.__"'_.._ _. '_5.�............. dated.____ ? . _ _ ._......... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CON ® AS A NTEE THAT THE SYSTEM IL FUN TION ATISFACTORY. -..D ... Inspector ..... .... ./THE COMMONWEALTH OF MASSACHUSETTS BOARD O, HEALT -- o-� OF.......... .. .�J'�'�e_ ��� ........_.._......... NO.....� ........_ FEE." .............. � �� ion rrntit Permission is hereby granted Me.. +? :...................................................... to Construct ( ) or pair ( a� Ind" i ual S wage' al Systems - at Street as shown on the application for Disposal Works Construction r it N .___ ..._..,. Dated....(.../7.....,/....... .L Boa of Healt DATE--.�r..-�-f`-��•/............................................ h FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS BOUSFIELD.SANITARY SERVICE 17 Burbank Street Sandwich,?Massachusetts 02563 Name �Z9,-,- .ja r g e A/ Sevier Permit No.'? _ Locations- /1�107 e- B4ilderl s-Kame and Address Date'Permit Isffuedi � /"7,Sr' Date Compliance Issued: t 0 0 ZA&J& IPI �xio � . ;airS