HomeMy WebLinkAbout0049 POWDERHORN WAY - Health 49-Powderhorn Way
Centerville P
A 190 004
No. 4210 1/3 ORA
Pendaf lexo
10%
`IX
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
• DEPARTMENT OF ENVIRONMENTAL PROTECTION
MAP
PARCEL,
L07
OFFICIAL INSPECTION FORM TITLE S
OT
SUBSURFACE SEWAGE DSPO VOLUNTARYL SYSTEM FOMENTS
PART A
CERTIFICATION
Property Address:
H w t 7�� I
Owner's Name: G �
Owner's Address• N 0 V 2 6 20 03
Date of Inspection: /p o O TOWN Or i ABLE
HEALTH DEPT.
Name of Inspector:(please prilpt)
Company Name:
Mailing Address: o p d
Telephone Numbe
CERTIFICATION STATEMENT T
I certify that I have personally inspected the sewage disposal system at this address below is true,accurate and complete as of the time of the" that the information reported
training and experience in the inspection.The inspection was performed based on my
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
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature:*6z�-
`O
Date: p
The system inspector shad submit a copy of this
DEP)within 30 inspection report to the Approving Authority(Board of Health or
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
DEP.The original should be sent to the system owner and copies sent to the buyer, regional
e�° office of the
authority. and the approving
Notes and Comments rap, i7$6 Ns �y�in'4
****This report only describes conditions at the time of ins
pection time.This inspection does not address how the system will perform in
conditions futur under e u undercond thesame or differetions of use at nt
i� conditions of use. rent
Page 2of11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 9 /�o 1VCtV&,/)4 ,h �q
Owner. ,L..Gi�,se
Date of Inspection: /o ,jo .0 j
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
��I
Passes:have not found any information which indicates that any of the failure criteria described in 310 CNM
15.303 or in 310 CMR 15.304 exist Any failure criteria not evaluated are indicated below.
Comments:
B. System Conditionally Passes:
One or more system components as described in the"Conditional Pass"section repaired.The system, upon completion of the replacement or need to be replaced or
repair,as approved by the Board of Health,will pass.
Answer yes,no or not determined(Y,N,ND)in the for the following statements.If"not determined"please
explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally
unsound,exhibits substantial infiltration or exfltration or tank failure is imminent.System will pass inspection if the
existing tank is replaced with a complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
Observation of sewage backup or break out or high static water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will approval of Board of Health): pass inspection if(with
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will
pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain:
Page 3 of 11
OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: /'oWd,2r &- ".,
eW7 ✓V1 e-
Ow
ner.
r to '?
Date of Inspection: O ,70
YC- FerEvaluation is Required by the Board of Health:
nditions existwhichrequire further evaluation by the Board of Health in order to determine if the system
o protect public health, +ue environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR I 303(1)(b)that the
system is not functioning in a manner which will protect public health,safety and the environment:
_, Cesspool or privy is within 50 feet of a surface water
_ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the
system is functioning in a manner that protects the public health,safety and environment:
The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a
surface water supply or tributary to a surface water supply.
___. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply.
— The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
_ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a
private water supply well**.Method used to determine distance
**This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform
bacteria 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.provided that no other
failure criteria are triggered. A copy of the analysis must be attached to this form -
3. Other:
Page 4 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 4t/
Owner:
Date of inspection:
D. System Failure Criteria applicable to all systems:
You must indicate`yes"or"no"to each of the following for all inspections;
Yes No
ackup of sewage into fa&fity or component due to overloaded or clogged_. ace
Discharge or ponding of effI to them rf SAS or cesspool
/clogged SAS or cesspool of the ground or surface waters due to an over, or
C/ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
�Sspool
�iq� in cesspool is less than 6"below invert or available volume is less than%:day flow
_ Required pumping more than 4 times in the last year NOT due to clogged or obstructed ay flow
Number
_ _��es pumped
Any portion of the SAS,cesspool or privy is below high ground water elevation Any portion of cesspool or privy is within 100 feet of a
- Zwater supply. surface water supply or tributary to a surface
AnY portion of a cesspool or privy is within a Zone 1 of a public well.
nY Portion of a cesspool or privy is within 50 feet of a private water supply
Any portion of a cesspool or privy is less than 100 feet but greater than fe well.
supply well with no acceptable water 50 feet from a private water
quality analysis. [Thls system passes if the well water analysis,
Performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than S ppm,provided that no other failure criteria
are triggered.A copy of the analysis must be attached to this form.]
,&X(Yes/No)The system faill.I have determined that one or move of the above failure cri
described in CMR 15.303,therefore the stem syste tens exist e
Health to determine what will be necessary to correct the f m owner should contact the Board of
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-
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)
ye no
Athe system is within 400 feet of a surface ddnldng water sum,
youthc
the system is within 200 feet of a tributary to a surface drinking water supply
system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped
Zone Il of a public water supply wella answered"yes"to any question in Section E the system is considered a Significant
"Yes" in Section D above the large system has failed The owner or operator ofcant threat,or answered
significant threat under Section E or failed under Section D shall u any larg �m considered a
15.304.The system owner should contact the a lade the system in accordance with 310 CMR
appropriate regional office of the Department.
Page 5ofII
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
// CHECIfLIST
Property Address: t✓�2/J�r�r (,✓Gi
Owner. a h
Date of Inspection• O ,o
Check if the followinghave been done.You most indicate es"or"no"as to each of the following:
Y �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
-- the system received normal flows in the previous two week period
Have large volumes of water been introduced to the system recently or as part of this inspection
— Were as built plans of the system obtained and examined?(If they were not available note as N/A)
Was the facility or dwelling un.Vected for signs of sewage bads
nP
Was the site inspected for signs of break out
Were all system components,excluding the SAS,located on site
the
of
of the baffles o Were
tees,
septic,material attank manholes uncovered,opened,and the interior of the tank inspected for the condition
construction,dimensions,depth of ligm4 depth of sludge and depth of scum
Was the facility owner(and occupants if di$'er,ent from owner)provided with information on the proper
maintenance of subsurface sewage disposal systems
The size and location of the Soil Absorptioa System(SAS)on the site has been determined based on:
Yes no
x st mg wformatioa 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)P 10 CMR 15.302(3)(b)]
i
• Page 6 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
A04wz,�=
SYS
TEM INFORMATION
Property Address: (V cr
/Owner: L—R-
Date of InspectioQ............ Q p
RESIDENTIAL FLOW CONDITIONS
Number of bedrooms(design): Number of bedrooms
DESIGN flow based on 310 (for for ( be
Number of current residents: example: 110 gpd x#of bedrooms):
Does residence have a garbage mi (yes or no):L(/p
is laundry on a separate sewage system,(yes or mm): Q [i f yes
system inspected(yes or no):Lv ' separate inspection
Seasonal use:(yes or no): &V
Water meter readmM if available(mac 2 years usage(gpd)):
sump Pump(Ynes or mm): �
Last elate of occupancy:— .— �a--, J-1-
COM[ERCIALANDUSTRIAL
Type of establishment:
Design flow(based on 316 CI4tR 15.203): and
Basis of design flow(seats/persons/sgft,etc.):
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/use-
OTHER(describe):
GENERAL INFORMATION
Pumping Records /
Source of information: ItIzo ��v� J ��j ��t c'i•,
Was system pumped as part of the inspection(yes or no
b
If yes,volume pumped _____90ons—How was quantity pumped mined?Reason for
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)
_Innovati%WAlternative technology.Attach a copy of the current operation and maintenance contract(to be
obtained from system owner)
—Tight tank _Attach a copy of the DEP approval
—Other(describe):
Approximate age of all components. installed(' O/ )and source of information:
qq
Were sewage odors detected when arriving at the site(yes or no):All-p
i
y
r
Page 7 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: % 7 40 wcler d oeh (✓Gf
Owner: f•�
Date of Inspection• po o p
BUILDING SEWER(locate qq site plan)
Depth below grade:
Materials of construction ✓cast iron —40 pVC
other in private water —
CommentDistanm s(on rivat is to �Ty well or suction line: ( �)
joints,venting evidence of leakage,etc.):
SEPTIC TANK;
_(loc
6 on site plan)
Depth below grade:
Material of construction-_concrete—metal
—other(explain)
—PolyYle�
If tank is metal list age:_ Is age confirmed by a Certificate of Com certificate) �/ Phones(yes or no):—(attach a copy of
Dimensions: /� M
Sludge depth. 4
/
Distance from top of sl�udge to bottom of outlet tee or bale:
Scum thidmess:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet teeg `!
How were dimensions determined boo 7C K baffle: L .
Comments(on pumping recommendatio ev i c e_
as ry�ated to outlet. evidence of g�e,e�ttcand outl tee or baffle condition,sttvc�i
a "' hC ��01 0"4 c'�er . •) H sty,liquid levels
o e
GREASE TRA.p/�oc ate on site Plan)
Depth below grade:_
Material of construction:— tal concrete_me
(explain): —�_PolyethYlene_other
Dimensions:
Scum thickness:
Distance from top o�oscum top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or ba$la$
Date of last pumping:
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,
as related to outlet invert,evidence of leakage,etc.): moral irctegritY,liquid levels
Page 8 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:C. r w�8r
Owner. L•a,, o vi
Date of hwpectkm, —'
TIGHT or HOLDING TANK; must be pumped at time of mspection)(locate on site
Depth below grade: PL an)
.
Maternal of construction concrete metal
Dimensions; fiberglass--.polyethYleae other(eacp]ain).
� traLons
Desig1n Fkw. PflozWday
Alarm Present(yes or no):
Alarm level: Alarm in working order(yes or no):
Date of last ping
Comments(condition of alarm and float switches,etc.):
DISTRIBUTION BOX: t�(ifent must be
opened)(locate on site plan)
Depth of liquid level above outlet invert:l/10/4�'Ip /
Comments(note if box is level and distribution to outlets
leaks into or out of box,etc.) �' any evidence pf solids carryover,any evidence of
/ V49 -G/Ivf
------------
PUMP CHAMBER. (locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no):
Comments(note condition of pump chamber,condition of
Pumps and apQurtenances,etc.):
ii
I t
Page 9 of l I
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
Q SYSTEM FORMATION(continued)
Property Address:
Owner•. r-
Date of Inspection: o O
SOIL ABSORPTION SYSTEM(SAS): pocate on site plan,excavation not required)
If SAS not located explain why.
Type
leaching ma
leaching c .number. !/�7 /f l �i/� 7�O✓f (�
leaching galleries,number. f7�o K
leaching trenches,number,length:
leaching fields,number,dimensions:
overflow cesspool,mumber
innovative/altetnative system Type/name of technology:
Comments(note condition of soil,,signs of hydraulic failure,level S of n etc.): ding.damp soil,condition of vegetation,vie H c'/ po
�L'G.
H 11 qH � r
N
�� 1 G
CESSPOOLS:/!/ (cesspool must be pumped as part of'
m-spectionxlopte on site plan)
Number and conf gmabon:
Depth—top of liquid to inlet invert:
Depth of solids layer:
Depth of scum Dimensions of comes p 1
Materials of construction
Indication of groundwater mHow(yes or no):
Comments(note condition of soil,signs of hydraulic failure,level of ndin
Po &condition of vegetation,etc.):
PRWV-*/' pocate 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.):
f
Page 10 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
° PART C
SYSTEM INFORMATION(contimmo
Property Address;A. =Z��4�f
0WC11 )�o.-�
-evil,Owner. L�f
Date of Inspection; /O o p
SKETCH OF SEWAGE DISPOSAL,SYSTEM
Provide a sketch of the sewage disposal system inching ties to at least two permanat
m few
be=hmarkL Locate an wells within I00 feet.Locate where public water supply enters the landmarks or
building
O
J9-
e3 - �/
• Page 11 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAG
E DI
SPOSAL SYSTEM INSPECTION FORM
PART C
SYY- STEM INFORMATION(contimied) _
Property Address: 9 /"v�✓�?r yG•-h
Date of Inspection: a o O
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water (cr feet
Please indicate(check)all methods used to determine the high ground water elevation:
Obtained from system design plans on record-If checked,date of design plan reviewed
Observed site(abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Heaith-explain:
Checked with local excavators,installers-(attach documentation)
Accessed USGS database-explain:
You in descnbe ho youfished the higlhd water elevation:
N r!C-A►94 op
4 rNN/(I ems• Y `Ot*G.l7/C� ,
71*4G
w.✓ car
20 - -
r
r
J f
f
/ 90 D
f
T = 'BORTOLOTTI'CONSTRUCTION, INC r%olr ®�
45 INDUSTRY ROAD'VIARSTONS'MIL,LS MA 02648 '�oTT
508-771-9399` 508-428-8926 FAX: 508-428-9399
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
Property Address:
Date Of Inspection 6.4 / Inspector's Name: oe
Owner's Name and Address:
CERTIFICATION STATEMENT:
I Certify that I have personally Inspected the Sewage Disposal System at this address and that the Informa-
tion reported below is true,accurate and complete as of the time of Inspection. The Inspectioin was perform-
ed based on my Training and Experience in the Proper Function and Maintenance of On-Site Sewage Dis-
posal Systems.Thh system:
71/ Passes
Conditional) asses
Needs'Fu Eval on By-di e'L`ocal Approving'Authority{>
Failur
Inspector's Signature Date
TheSystem Inspecto shall submit a copy of this I .sr ction Report to the Approving Authority with Thirty
(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 Offie 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.
INSPECTION SUMMARY:
A) SYSTE PASSES:
VV I have not found any Information-bich indicates that the System violates any of the fail-
ure criteria as defined in 310 CMII 15.303. Any Failure Criteria not evaluated are indi-
cated below.
B) SYSTEM CONDITIONALLY PASSES!
One or more System Componenis need to be Replaced or Repaired. The System,upon
completion of the Replacement or Repair,Passes Inspection.
Indicate yes,nor,or not determined(Y,N,OR ND). Describe bases of determination in all instances. If"not
determined",explain why not.
The Septic Tank is Metal,Cracked,Structurally Unsound,shows Substantial Infiltration or exfil-
tration,or Tank Failure is iimminent. The System will Pass Inspection if Existing Septic Tank
is Replaced with a conforming Septic'Tank as Approved by the Board Of Health.
Sewage Backup or Breakout or High State 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):
-1-
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
CERTIFICATION(continued)
Broken pipe(s)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:
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 PROTECT THE
PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
Cesspool or privy is within 50 Feet of a surface water
Cesspool or privy is within 50 Feet of a bordering vegetated wetland or a'salt marsh.-
2)SYSTEM WILL FAIL UNLESS THE BOARD'OF HEALTH (AND PUBLIC WATER
UPPLIE IF APPROPRIATE DETERMINES THAT THE SYSTEM IS FUNCTION-
S )
ING IN AMANNER THAT PROTECT THE PUlkIC"HEALTHAND'SAFETY AND THE
. ENVIRONMENT•-� . .. . ::... , . . , _
m h tic tank and soil abso don <stem and'�s within 100 Feet to a surface
The syste as a septic rp sy _ . . ,
water supply or tributary to a surface water supply.'
The system has a seplic'tank and soil absorption system andis with a Zone I of a public
water supply well.
The system has a septic tank and soil absorption system and is within 50 Feet of a' rivate
Water supply well.
The system 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
the,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 efluent to the surface of the ground or,surface waters due to an
overloaded or clogged SAS or cesspool:_
Staticalquid level jn the distribution_box above outlet mvertdq to an oyerloaded.or clog-
Pged SAS oricesspool , V-`,00t
r ,T
,g Liquid depth.in)cesspooI is less_than 6",below invert or available volume-is less than 1/2-
day flow. a x
Required pumping more than;4 times in the last year._'aye io clogged or obstructed
pipe(s). Number of times pumped
-2-
s.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued) .
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.
Any portion of a cesspool or privy is within 50 Feet of a private water supply well.
Any portion of a cesspool or privy is less than 100 Feet but greater than 50 Feet from a private
water supply well with no acceptable water quality analysis. 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.
E)LARGE SYSTEM FAILS:
The following criteria apply to a large system in addition to the criteria above:
The design flow of a 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
w conditions exist
The system is within 400.Feet of a4surface.drinkingvater supply "
The system is within 200 Feet of a tributary to a surface drinking water supply;
f.,. ., The system is located iqa nitrogen sensitive area.Interim Wellhead Protection Area
(IWPA)or a mapped Zone I1 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.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Check if the following have been done:
t/ pmg information was requested of the owner,occupant,and Board of Health.
one of the system components have been pumped for atleast 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.
_:S-built plans have been obtained and examined. Note if they are not available with N/A.
'ne facility or dwelling was inspected for signs of sewage back-up.
e system does not receive non-sanitary or industrial maste-flow.
The site was inspected for signs of breakout.
All system components,`exciuding.the Soil Absorption System,have been located on site.
The septic tank manholes were uncovered,opened,and the'interior of the septic tank was in-
for`condition-of baffles or tees,material of construction'dimensions,_depth of liquid,
depth of sludge,depth of scum.
The size and location of•the Soil Absorption System on the site has been determined based on
existing information or approximated by non-intrusive methods.
-3-
n.l; {.;�:r v'1.
I
SUBSURFACE-SEWAGE D'ISPOSAL'SYSTEIVI INSPECTION FORM
PART B.
CHECKLIST(continued)
The facility owner(and occupants,if different from owner were provi
ded with information on
the proper maintenance of Subsurface Disposal System
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
_ SYSTEM INFORMATION
FLOW CONDITIONS
RlZSIDENTL6
Design Flow:S�gallons Number of Bedrooms: Number of Current Residents:_
Garbage Grinder: Laundry Connected To System: Seasonal Use:/yi,�j—
Water Meter Readings,if a ailable:
Last Date of Occupancy: -
COM�_ . . CULIINnUsT
I*of Establishment: r -
Desi Flow. sallons/day Grease Trap Present:'(yes or no)1p!,
Industrial Waste Holding-Tank Present:
Non-Sanitary Waste Discharged To The Title V System: -
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: If yes,volu um lone
P P��
Reason for pumping:
TYPE,OF SYSTEM:
Septic Tank/Distribution Box/Soil Absorption System
Sine Cesspool
Overflow Cesspool
Privy
Shared System,(If yes,,attach previous inspection records,if any)
Other(explain):
ROXIMATE GE of all componen ,date in talled(i o n)and source of information:
r _ -n_ - a. ,.. '77
Sew e.odors detect w arriving at the site: y`/�
-4-.
5UBSURFACE,SEWAGE DISPOSAL 5YS'rEM INSPECTION FORM
PART C
GENERAL'INFORMATION (continued)
SEPTIC TANK:
Depth below grad Material of Construction: t,-"concrete metal FRP Other
(explain)
Dimisions:/0%9, I Y Y-61 Sludge Depth:c �/ Scum Thickness:
Distance from top of sludge to bottom of.outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle: 6
Comments:(recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid
level in lation tomittlet i vert,structural integrity,eviden a of leakage,etc.) /
i�
i
GREASE TRAP:
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: 4 .
Comments: (recommendation for pumping,condition of inlet and outlet tees or:baflles,'depth of liquid
level in-relation Ato outlet,invert_ siru wffil'integrity,:evidence of leakage;etc.)
TIGHT OR HOLDING TANK:0
Depth Below Grade: Mat rial 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: y
Depth of liquid level above outlet,invert:
Comments: (note' el and distribution is equal,ev' en o solids carryov r,evidence of leakage into
or out of box,etc. /
PUMP CHAMBER:
-Pump is in wtrkin g order.
,.
Comments: (note condition of pump chamber,condition of pumps and appurtenances,etc.)t
.,• , ,-,.SUBSURFACE SEWAGE DISPOSA --SYSTEM`INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
SOII,ABSORPTIO14 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,number: Leaching chambers,number: Leaching galleries,number:
Leaching trenches,number,length:
Leaching fields,number,dimensions:
Overflow cesspool,number:
Commen : (note condition of soi signs of)iydrau is failure level of ponding,condition of vegetation,
CESSPOOLS:
Number and oonfi gutation: _ 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 soilk, signs of hydraulic failure, level of ponding,condition of vegetation,
etc.)
PRIVY:"' .
Materials of construction: Dimensions:
Depth of Solids:
Comments:(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,
etc.)
-6-
" SUBSURFACE SEWAGE'DISPOSAL` SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
SKETCH OF SEWAGE DISPOSAL SYSTEM:
Include ties to atleast two permanent references, landmarks or benchmarks.
Locate all wells within 100 Feet.
AU
' 1
DEPTH TO GROUNDWATER:
Depth to groundwater: Feet
Met4od of Determination or App oximatio : /�.�}`j�iyl0�
Y�/^> o
lc i
-7-
• TOWN OF BARNSTABLE
LO.^_A'Y'ION q,? A0 W4 V SEWAGE # 7 ��
VILLAGE L A0,11,t�r Ille ASSESSOR'S MAP&LOT
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY /,
LEACHING FACILITY: (type)1-�t�6 ftis�as 60 (size) /O X 3-0 D�
NO.OF BEDROOMS 3
BUILDER ORCW_N1 ®✓ d'i�l�/�
PERMIT DATE: Z—ZJ > COMPLIANCE DATE: 4
Separation Distance Between the: �
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility J` t Feet
Private Water Supply Well and Leaching Facility (If any wells exist Feet
on site or within 200 feet of leaching facility)
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) A Feet
Furnished by
tAg fa/-
S
as
00
�u
TOWN OF BARNSTABLE
LOCATION " SEWAGE #
VILLAGE ASSES SO 'S MAP & LOT 0.09J
PR's�NAME&PHONE NO. pp T � t�
01
SEPTIC TANK CAPACITY /mil� iZ�id�
LEACHING FACILITY: (type) 7 2V YA&X 74 (size) l o X'3� 'Y
NO. OF BEDR00_ S
BUILDER 0 OWNER
PERMIT DATE: COMPLIANCE'DATE: '
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
ii
No. Fee y
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
ZIpprica.tion for Mi.5pogar *p5tem Construction Perron
Application for a Permit to Construct( )Repair( )Upgrade( VAbandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. ��t���® „vv/®�� wner's Name,Address and Tel.N
Assessor's Map/Parcel 7 A/����
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
Type of Building:
Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Grinder(-W
Other Type of Building No. of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow 33e::51 gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S. �Zz z/
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) T e°
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to pla. ce the system in operation until a Certifi-
cate of Compliance has been issue by thi ar H
Signed Date l!�
Application Approved by Date
Application Disapproved for the following reasons
Permit No. Date Issued
TOWN OF BARNSTABLE
LOCATION q Wa y SEWAGE #
VILLAGE ���� ASSESSOR'S MAP & LOT If
INSTALLER'S NAME&PHONE NO. E/D1�7�4`D � �6 771J`jZ'_
SE TANK CAPACITY l ADD�f L
LEACHING FACILITY: (type)
(size) /O X'30 04A
NO. .. BEDROOMS 3�
BUIL OR W1v1iRR� /�d✓ �i�lQ/� q _
PERIviTTDATE: Z� 7 COMPLIANCE DATE:
Separation Distance Between the:
Maaimutri Adjusted Groundwater Table and Bottom of Leaching Facility
St ` Feet
Private.Water Supply Well and Leaching Facility (If any wells exist
on site or within elle
200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist J�f Feet
within 300 feet of leaching facility)
Furnished by
`f
Qea
�y6
00
�N1 '
3�1
Me-7 � e G•..aw.. ''il
' O�.
No. Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS
2pplication for Oigpoml *pgtem Congtruction Vermit
Application for a Permit to Construct( )Repair( )Upgrade( /Abandon( ) El Complete System ❑Individual Components
Location Address or Lot No. Owner's Name,Address and Tel.N .
Assessor's Map/Parcel.
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
a q
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder(--Co
Other Type of Building i o No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow //:2 gallons per day. Calculated daily flow 33e!!2 gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank_ / 4 4- 4 Type of S.A.S. /a 2a a Y, ✓-`s��ii�fii�y,�i"S
Description of Soil
1�
Nature of Repairs or Alterations Answer when applicable).
P q IG
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issue by thi and f He /
Signed Date 6/il 3P/7
Application Approved by Date
Application Disapproved for the following reasons
Permit No.�1 � Date Issued
---------------------
THE COMMONWEALTH OF MASSACHUSETTS l j'D ®Dy
BARNSTABLE, MASSACHUSETTS
Certificate of Comphance
THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired ( ) Upgraded
Abandoned( )by Anc ✓ % e� v
at !.t/ e has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. dated
Installer // Z291 % Designer
The issuance of this permit shall not be nstrued as a guarantee that the system w' function as designed.
Date 4�0 � Inspector
No. ------------/�----/ Fee
THE COMMONWEALTH OF'MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS
'Wigpogar *pgtem Congtruction Vermit
Permission is hereby granted to Construct( )Repair( )Upgrade(V �Abandon( )
System located at CPh YeY//
ICDY'�VN/Y�1
and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to
comply with Title 5 and the following local provisions or special conditions.
Provided: Construction must be completed within three years of the date of this permit.
Date: 7 Approved by
Fes" P 1
.tea fi.lm
M
rr ssR " $
,r 3L 'E!'ri.
...`.iirs 4♦�4•�..-•y -�i."'f •t,/•S.. cr "' •¢+"4 �y
NOTICE: This Form GIs �o Be Used For the Repair.:Of Failed
Septic Systems Only.
CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL
WORKS CONSTRUCTION PERMIT OMHOUT DESIGNED PT AN�
Alr;� o /, herebv certify that the application for disposal works
construction permit signed by me dated ' l o"-h' concerning the
property located at D�I' 0/' G!/� meets ail of the
following criteria:
ere are no wetland wit
hin tthtn�00 fz.._t of the he or000sed septic system
�There are no private weils within i 50 ee[of the proposed septic system
+ tie observed zroundwa[er tabie is i z:[or ?reater beiow the eottom of:he ieachin,2'ac;lir,
ere s no increase in :low and/or c�anse m use or000sed
._per_ _... ..o va.-a,:ces t.,cu.st.,d ,. ::z....'-d.
]
SIGNED : DATE:
LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER
[Attach a sketch plan of the proposed system.Also if the licensed uisttaller posesses a certified plot plan,
this pfan s9W&be submitted].
z
------------
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