HomeMy WebLinkAbout0005 VISTA CIRCLE - Health 5 VISTA CIRCLE, CENTERVILLE
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TOWN OF BARNSTABLE
LOCATIONS V t t _ SEWAGE #
VILLAGE CSIJr ¢�J� ���. ASSESSOR'S MAP& LOT i T
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) (size) (e)00 D't"
NO.OF BEDROOMS
BUILDER OR OWNER_��►o. , cA 0.
SATE: O COMPLIANCE DATE:
Separation Distance Between the: 1
Maximum Adjusted Groundwater Table an °�� 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 • , �Feet
within 300 feet of leaching facility) ,
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Furnished by � ��.�
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COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENI'AI AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
ONE WINTER STREET BOSTON MA 02108(617)292-3500
RECEIVE®
S E P 2 2 2000
TOWN OF BARNSTABLE
ARGEO PAUL CELLUCCI HEALTH DEPT.
Governor
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORK
PART A
CERTIFICATION
Property Address: 5 VISTA CIRCLE CENTERVILLE YC•'
Name of Owner WALTER CHRISTIAN
Address of Owner: 5 VISTA CIRCLE CENTERVILLE MA.02632
Dale of Inspection: 917100
Name of Inspector:(Please Print)JOHN GRACI
I am a DEP approved system Inspector pursuant to Section 15.340 of Tide 5(310 CMR 15.000)
Company Name: TITLE V INSPECTIONS
Mailing Address: BOX 2119 TEATICKET MA.02636
Telephone Number: 564-6813
CERTIFICATION STATEMENT
'I certify that I have personally Inspected the sewage disposal system at this address and that the information reported below is true,accurate
and complete as of the time of inspection.The Inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems.The system:
X Passes The Inpectlon Is based on criteria defined in Title V
Conditionally Passes code 310 CMR 15.303.My findings are of how the system Is
Needs Further Ev luation By the Local Approving Authority performing at the time of the Inspection.My inspection does
Fails not Imply any warranty or guarantee of the longgevity of the
septic system and any of Its components useful life.
Inspector's Signature: Date:9/18/00
The System Inspector sha I submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 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 office of the Department of Environmental Protection.The original should be sent to the
system owner and copies sent to the buyer,if applicable,and the approving authority.
NOTES AND COMMENTS
o .
THE SYSTEM PASSES TITLE V INSPECTIONS.RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFULL LIFE.
RECOMMEND NOT DRIVING OVER THE SYSTEM THE COMPONENTS ARE H 10. It VEO
S E P 2 2 2000
_1MINOFSAANSTA&LE f
HEALTH DEPT,
�I
revised 912/98 Page 1 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 5 VISTA CIRCLE CENTERVILLE
Owner: WALTER CHRISTIAN
Date of Inspection:9/7/00
INSPECTION SUMMARY: Check A, B, C, or D:
A. SYSTEM PASSES:
I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist.Any failure criteria not evaluate
are indicated below.
COMMENTS:
System passes Title V inspection
B. SYSTEM CONDITIONALLY PASSES:
n1a One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system,upon completion of the
replacement or repair,as approved by the Board of Health,will pass.
Indicate yes,no,or not determined(Y,N,or ND).Describe basis of determination in all instances.If"not determined",explain why not.
nta The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate of
Compliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection;or
the septic P
tank whether or not metal 'P ,is cracked,structurally unsound,shows substantial infiltration or exfiltration,or tank
failure is imminent.The system will pass inspection if the existing septic tank is replaced with a complying P septic tank as
approved by the Board of Health.
Wa Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s)
or due to a broken,settled or uneven distribution box.The system will pass inspection if(with approval of the Board of Health).
broken pipe(s)are replaced
obstruction is removed
distribution box is levelled or replaced
Wa The system required pumping more than four times a year due to broken or obstructed pipe(s).The system will pass
inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
revised 9/2/98 Page 2 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 5 VISTA CIRCLE CENTERVILLE
Owner: WALTER CHRISTIAN
Date of Inspection:917/00
C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
_ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health,safety
and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 16.303(1)(b)THAT THE SYSTEM IS
NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT ThE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
_ Cesspool or privy is within 50 feet of surface water
_ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER.IF ANY)DETERMINES THAT THE SYSTEM IS
FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a
surface water supply.
The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well.
_ The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well,
The system has a septic tank and soil absorption system and the SAS Is less than 100 feet but 50 feet or more from a
private water supply well,unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the
well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less
than 5 ppm,Method used to determine distance nLa-(approximation not valid).
3) OTHER
nLa
i
revised 9/2/98 Page 3 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 5 VISTA CIRCLE CENTERVILLE
Owner: WALTER CHRISTIAN
Date of Inspection:9/7/00
D. SYSTEM FAILS:
You must indicate either"Yes"or"No"to each of the following:
I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303.The basis for this determination is
identified below.The Board of Health should be contacted to determine what will be necessary to correct the failure.
Yes No
X Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool.
X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool.
X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
X Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow,
X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped nLa.
X Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation.
X Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
X Any portion of a cesspool or privy is within a Zone I of a public well.
X Any portion of a cesspool or privy is within 50 feet of a private water supply well,
X Any portion of a cesspool or privy is less-than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality
analysis.If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic ompounds,
ammonia nitrogen and nitrate nitrogen.
X The liquid level in the SAS.is over the.invert pipe,is in Hydraulic Failure.
E. LARGE SYSTEM FAILS:
You must indicate either"Yes"or"No"to each of.the following:
The following criteria apply to large systems in addition to the criteria above:
F.i
The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and
safety and the environment because•one or more of the following conditions exist:
Yes No
X the system is within 400 feet of a surface drinking water supply
X the system is within 200 feet of a tributary to a surface drinking water supply
X the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone II of a public
water supply well)
The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.30412).Please consult the local regional office of the
Department for further information.
revised 9/2/98 Page 4 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 5 VISTA CIRCLE CENTERVILLE
Owner: WALTER CHRISTIAN
Date of Inspection:9/7/00
Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following:
Yes No
X Pumping information was provided by the owner,occupant,or Board of Health.
X None of the system components have been pumped for at least two weeks and-the system has been receiving normal flow rates
during that period.Large volumes of water have not been introduced into the system recently or as part of this inspection.
X As built plans have been obtained and examined.Note if they are not available with N/A,
X The facility or dwelling was inspected for signs of sewage back-up.
X The system does not receive non-sanitary or industrial waste flow.
X The site was inspected for signs of breakout,
X All system components,excluding the Soil Absorption System,have been located on the site.
X The septic tank manholes were uncovered,opened,and the interior of the septic tank was inspected for condition of baffles
or tees,material of construction,dimensions,depth of liquid,depth of sludge,depth of scum.The size and location of the Soil Absorption
System on the site has been determined based on:
X Existing information,For example,Plan at B4O,H,
X Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable)
(1 5.302(3)(b)]
X The facility owner(and occupants,if different from owner)were provided with Information on the proper maintenance of
SubSurface Disposal Systems.
revised 9/2198 Page 5 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 5 VISTA CIRCLE CENTERVILLE
Owner: WALTER CHRISTIAN ,
Date of Inspection:917/00
FLOW CONDITIONS
RESIDENTIAL:
Design flow:11Q g.p.d./bedroom
Number of bedrooms(design): 3 Number of bedrooms(actual):I
Total DESIGN flow: 3.3.Q ,
Number of current residents:2
Garbage grinder(yes or no):NQ
Laundry(separate system)(yes or no): NO If yes,separate inspection required
Laundry system inspected(yes or no):M
Seasonal use(yes or no):JSLQ
Water meter readings,if available(last two year's usage(gpd): D&
Sump Pump(yes or no): NO {
Last date of occupancy: Wit
COM M ERCIAL/INDUSTRIAL
Type of establishment: Wa
Design flow: Wa gpd(Based on 15.203)
Basis of design flow: Wa
Grease trap present:(yes or no):JLQ
Industrial Waste Holding Tank present:(yes or no): MO
Non-sanitary waste discharged to the Title 5 system:(yes or no):MQ
Water meter readings.if available:nLa
Last date of occupancy: n& a
OTHER: (Describe)
nLa
Last date of occupancy: Wa
GENERAL INFORMATION
PUMPING RECORDS and source of information:
nLa
System pumped as part of inspection:(yes or no):lYQ
If yes,volume pumped Wit- gallons
Reason for pumping: Wa
TYPE OF SYSTEM
X Septic tank/distribution box/soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system(yes or no)(if yes.attach previous inspection records,if any)
I/A Technology etc.Attach copy of up to date operation and maintenance contract
Tight Tank Copy of DEP Approval
Other: Wa
APPROXIMATE AGE of all components,date installed(if known)and source of information:
1986
Sewage odors detected when arriving at the site:(yes or no): MQ.
r.<
revised 9/2/98 Page 6 of 11
f
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION('continued)
Property Address: 5 VISTA CIRCLE CENTERVILLE
Owner: WALTER CHRISTIAN
Date of Inspection:917/00
BUILDING SEWER:
(Locate on site plan)
Depth below grade: J2 r
Material of construction:_ cast iron X 40 PVC _ other(explain)
Distance from private water supply well or suction line: nLa
Diameter: nLa
Comments: (condition of joints,venting,evidence of leakage,etc.)
THERE IS TOWN WATER
SEPTIC TANK: X
(locate on site plan)
Depth below grade: U
Material of construction:X concrete_ metal_ Fiberglass _ Polyethylene _ other(explain)
. nLa
If tank is metal,list age Is age confirmed by Certificate of Compliance(Yes/No): MQ
Wit
Dimensions: L 8'6"H 5'7"W 4'10"
Sludge depth: 1"
Distance from top of sludge to bottom of outlet tee dr-baffle:
Scum thickness:-nLa iA
Distance from top of scum to top of outlet tee or baffle:6
Distance from bottom of scum to bottom of outlet tee or baffle: nLa
How dimensions were determined: MEASURED
Comments:
(recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage,
etc.)
SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND RECOMMEND PUMPING EVERY TINO YEARS
GREASE TRAP:
(locate on site plan)
Depth below grade:
Material of construction:_concrete_ metal_ Fiberglass _ Polyethylene_other(explain)
nLa
Dimensions: nLa
Scum thickness: nLa
Distance from top of scum to top of outlet tee or baffle.,_nLa
Distance from bottom of scum to bottom of outlet tee or baffle n/a
Date of last pumping: Wa
Comments:
(recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage,
etc.)
n&
!Es i
revised 9/2/98 Page 7 of 11
f
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 5 VISTA CIRCLE CENTERVILLE
Owner: WALTER CHRISTIAN
Date of Inspection:917/00
TIGHT OR HOLDING TANK: NQ (Tank must be pumped prior to,or at time of,inspection)
(locate on site plan)
Depth below grade: n/a
Material of construction:_ concrete_ metal_ Fiberglass _Polyethylene_ other(explain)
n/a
Dimensions: n/a
Capacity: n/a gallons
Design Flow: n/a gallons/day
Alarm present: NO
Alarm level:j2L& Alarm in working order:Yes_No_ NO
Date of previous pumping: n/a
Comments:
(condition of inlet tee,condition of alarm and float switches,etc.)
n/a
DISTRIBUTION BOX: _
(locate on site plan)
Depth of liquid level above outlet invert:n/a
Comments:
(note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.)
n&
PUMP CHAMBER: NQ
(locate on site plan)
Pumps in working order:(Yes or No): NQ
Alarms in working order(Yes or No): NO
Comments:
(note condition of pump chamber,condition of pumps and appurtenances.etc.)
Wa
revised 9/2/98 Page 8 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 6 VISTA CIRCLE CENTERVILLE
Owner: WALTER CHRISTIAN
Date of Inspection:917/00
SOIL ABSORPTION SYSTEM(SAS): X
(locate on site plan,if possible;excavation not required,location may be approximated by non-intrusive methods)
If not located,explain:
nLa
Type:
leaching pits,number: 6'X C LEACH PIT
leaching chambers,number: _nLa
leaching galleries,number: ji&
leaching trenches,number,length: n&
leaching fields,number,dimensions: nla
overflow cesspool,number: nLa
Alternative system: nLa
Name of Technology: _n&
Comments:
(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.)
THE LEACH PIT IS STRUCTURALL SOUND AND FUNTIONwG PROPERLY THE PIT HAS NOT HAD MORE THAN 8"OF WATER IN IT,
CESSPOOLS: _
(locate on site plan)
Number and configuration: Wa
Depth-top of liquid to inlet invert: nLa
Depth of solids layer: n&
Depth of scum layer. n&
Dimensions of cesspool: Wa
Materials of construction: WA
Indication of groundwater: n& inflow(cesspool must be pumped as part of inspection)n&
Comments:
(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.)
Wa
PRIVY: _
(locate on site plan)
Materials of construction:Wa Dimensions:nLa
Depth of solids: n&
Comments:
(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.)
nta
a`
revised 9/2/98 Page 9 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 5 VISTA CIRCLE CENTERVILLE
Owner: WALTER CHRISTIAN
Date of Inspection:917/00
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent reference landmarks or benchmarks
locate all wells within 100'(Locate where public water supply comes into house)
n/a
IA
IL
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A
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p C
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AO M
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revised 9/2/98 Page 10 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 6 VISTA CIRCLE CENTERVILLE
Owner: WALTER CHRISTIAN
Date of Inspection:9/7100
NRCS Report name: nta
Soil Type: Wit
Typical depth to groundwater: nLa
USGS Date website visited: nLa
Observation Wells checked: NO
Groundwater depth:Shallow _ Moderate _ Deep _
SITE EXAM _ Slope
_ Surface water
_ Check Cellar
_ Shallow wells
Estimated Depth to Groundwater 12 Feet
Please indicate all the methods used to determine High Groundwater Elevation:
_ Obtained from Design Plans on record
_ Observed Site(Abutting property,observation hole,basement sump etc.)
Determined from local conditions
Checked with local Board of health
_ Checked FEMA Maps
_ Checked pumping records
_ Checked local excavators,installers
X Used USGS Data
Describe how you established the High Groundwater Elevation.(Must be completed)
USGS MAPS AND CHARTS
revised 9/2/98 Page 11 of 11
I ,
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENT F w�Q
DEPARTMENT OF ENVIRONMENTAL O I CTII
ONE WINTER STREET, BOSTON MA 02108 (617) 29 =5500
� *rnNN OF BARNSTABIE
WILLIAM F. WELD TRUDY CORE
Governor Secretary
ARGEO PAUL CELLUCCI AVID B. STRUHS
Lt. Governor Commissioner
�p�t SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM\ ' CA
SUBSURFACE PART A.
LOB-_ as e CE�R"TIFICATION
Property Address: IST� QJQ,CiI�, I `+CiWr-Q,4t}�11�V Address of Owner: �i\,l h�►✓� \C �cti�
Date of Inspection: 4r ?w 1 q (If different)
Name of Inspector: M i i,-.r�i��T1e�1�(� gV�t,��•.�Q�`O�'U t v�j�
I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000) 1
Company Name: L_
Mailing Address:'7.C—) .5i"r,h a.<or,Zr
Telephone Number:
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and
complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance
of on-site sewage disposal systems. The system:
• Passes
_ Conditionally Passes
Needs Further Evaluation the Local Approving Authority
Fai
Inspector's Signature: Dater `l
The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (30) days of completing this inspection.
If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the
appropriate regional office of the Department of Environmental Protection. The original'should be sent to the system owner and copies sent to the
buyer, if applicable, and the approving authority.
INSPECTION SUMMARY: Check A, B, C, or D:
A] SYSTEM PASSES:
I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any
failure criteria not evaluated are indicated below.
COMMENTS:
B] SYSTEM CONDITIONALLY PASSES:
One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon
completion of the replacement or repair, as approved by the Board of Health, will pass.
Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain why not.
The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of
Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection: or the
septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure
is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved
by the Board of Health.
(revised 04/2.5/97) Page I of 10
A
a
c
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued) .
Property Address:
Owner:
Date of Inspection:
B) SYSTEM CONDITIONALLY PASSES (continued)
_ Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or
due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health).
Describe observations:
broken pipe(s) are replaced
obstruction is removed
distribution box is levelled or replaced
The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection
if(with approval of the Board of Health):
broken pipe(s) are replaced
obstruction is removed
C) FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
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 FUNCTION NG IN A
• MANNER WIUCH "'ILL 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 "'ILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE)
DETERMINES THAT THE SYSTEM IS FUNCTIONLNG IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND
SAFETY AND THE ENVIRON'1V1ENT:
The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet to a surface water supply or
tributary to a surface water supply.
_ The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well.
_ The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well.
_ The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private
water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is
free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm.
Method used to determine distance (approximation not valid).
3) OTHER
(revised 04/25/97) Page 2 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:
Owner:
Date of Inspection:
D] SYSTEM FAILS:
You must indicate either "Yes" or "No" as to each of the following:
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.
Yes No
Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool.
Discharge or ponding of effluent to the surface of the ground or surface waters due to an 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 1/2 day flow.
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped —
Any portion of the 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:
You must indicate either "Yes" or "No" as to each of the following:
The following criteria apply to large systems in addition to the criteria above:
The system serves a facility with a design flow of 10,000 gpd or greater (Large System) and the system is a significant threat to public
health and safety and the environment because one or more of the following conditions exist:
Yes No
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 U of a public
water supply well)
The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program
requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.
(revised 04125/97) Page 3 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 5 V
Owner: N k,e_ �yS
Date of Inspection:
Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following:
No
Xs Pumping information was provided by the owner, occupant, or Board of Health.
None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates
during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection.
As b ink-plans have been obtained and examined. Note if they are not available with N/A.
_ The facility or dwelling was inspected for signs of sewage back-up.
The system does not receive non-sanitary or industrial waste flow.
x _ The site was inspected for signs of breakout.
_ All system components, excluding the Soil Absorption System, have been located on the site.
The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or
tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum.
The size and location of the Soil Absorption System on the site has been determined based on:
The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of Sub-
Surface Disposal System.
_ Existing information. Ex. Plan at B.O.H.
_ Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable)
(15.302(3)(b)]
(revised 04/25/97) Page 4 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
p SYSTEM INFORMATION
Property Address:
Owner:
Date of Inspection:
FLOW CONDITIONS
RESIDENTIAL:
Design flow:?` Q_g.p.d./bedroom for S.A.S.
Number of bedrooms:675
Number of current residents:
Garbage grinder (yes or no):_
Laundry connected to system (yes or no):
Seasonal use (yes or no):_
Water meter readings, if available (last two (2) year usage (gpd):
Sump Pump (yes or no): NO
Last date of occupancy: U%YN jZ,
COMMERCIAL/INDUSTRIAL:
Type of establishment:
Design flow: ¢allons/day
Grease trap present: (yes or no)_
Industrial Waste Holding Tank present: (yes or no)_
Non-sanitary waste discharged to the Title 5 system: (yes or no)_
Water meter readings, if available:
Last date of occupancy:
OTHER: (Describe)
Last date of occupancy:
GENTERAL INFORMATION
PUMPING RECORDS and source of i formation:
Ar
System pumped as part of inspection: (yes or no)
If yes, volume pumped: eallons
Reason for pumping:
TYP 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)
I/A Technology etc. Copy of up to date contract?
Other
APPROXIMATE AGE of all components, date installed (if known) and source of information:
Sewage odors detected when arriving at the site: (yes or no)j
(revised 04/25/97) Page 5 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: Ski,st A-I
Owner: P1 Chd`"-(5
Date of Inspection: 713okei-
BUILDING SEWER:
(Locate on site plan)
Depth below grade:
Material of construction: _cast iron_40 PVC _other (explain)
Distance from private water supply well or suction line
Diameter
Comments: (condition of joints, venting, evidence of leakage, etc.)
SEPTIC TANK:
-141-5
(locate on site plan)
Depth below grade: �
Material of construction: oncrete _metal _Fibergla
,c ss _Polyethylene _other(explain)
If tank is metal, list age _ Is age confirmed by Certificate of Compliance _(Yes/No)
Dimensions:-1000
Sludge depth: @S'Z
Distance from top of slpdl;e to bottom of outlet tee or baffle:
Scum thickness:_ `1
Distance from top of scum to top of outlet tee or baffle: it
Distance from bottom of scum to bottom of outlet tee or baffler_
How dimensions were determined: tJ'9W UnAA
Comments:
(recommendation for pumpi"condition inl and outlet tees or baffles, depth of liquid level in relation to outlet invert. ructural int city,
evidence of leakage, etc.) C
GREASE TRAP:
(locate on site plan)
Depth below grade:
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:
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity.
evidence of leakage, etc.)
(revised 04/2$/97) Page 6 of 10
I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: S �STA
Owner:
Date of Inspection: I s
TIGHT OR HOLDING TANK:—L—O(Tank must be pumped prior to, or 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/day
Alarm level: Alarm in workine order _ Yes; _ No
Date of previous pumping:
Comments:
(condition of inlet tee, condition of alarm and float switches, etc.)
)ISTRIBUTIOti BOX:�(L.�
(locate on site plan)
Depth of liquid level above outlet invert:-<�J='"`
Comments: p
note if leve and distribution is equal, idence of soli carryover, evidence of leakag in or-out of box, etc.)
O t-,
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 appurtenances, etc.)
(revised O4/25/97) P2ge 7 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
` r SYSTEM INFORMATION (continued)
v
Property Address: I s1 A
Owner: N1C_Va`�����
Date of Inspection:
SOIL ABSORPTION SYSTEM (SAS):_4
(locate on site plan, if possible: excavation At required, but may be approximated by non-intrusive methods)
If not determined to be present, explain:
Type:
leaching pits, number: to K 1
leaching chambers, num er:_
leaching galleries, number:
leaching trenches. number,length:
leaching fields. number, dimensions:
overflow cesspool, number:
Alternative system:
Name of Technology:
Comments:
(note condition of soil, igns of hydraulic failure, level o pond condi n.of ve tion c.) Vl,
CESSPOOLS:..
(locate on site plan)
Number and configuration:
Depth-top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater:
inflow (cesspool must be pumped as part of inspection)
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
PRIVY: !"V
(locate on site plan)
Materials of construction: Dimensions:
Depth of solids:
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
(revised O4/25/97) Page 8 of 10
I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: �v�s
Owner: RI CLhO\US
Date of Inspection: 1
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100' (Locate where public water supply comes into house)
S
I
LS
CD
f�3-3
(revised 04125/97) Page 9 of 10
I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
Owner: OX-InA 4S
Date of Inspection: -1 so�CI�
Depth to Groundwater�X Feet
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from Design Plans on record
Observation of Site (Abutting property, observation hole, basement sump etc.)
Determine it from local conditions
Check with local Board of health
Check FEMA Maps
Check pumping records
Check local excavators. installers
Use USGS Data
Describe in your own4vords howYQk established the High Groundwater Elevation. (Must be completed)
U►s� fol
(revised O4/25/97) Page 10 of 10
APPLICATION FOR PERCOLATION TEST AND OBSERVATION PITS
LOCATION LAKEVtWW rs- .; 17 NO.
VILLAGE CENTERVILLE DATE
APPLICANT R. ARTHUR WILLIAMS, INC. FEE $15.M
ADDRESS # 2 OAK STREET, CENTERVILLE TELEPHONE NO. 428-5717 (Non-refundable)
ENGINEER BAXTER & NYE _TELEPHONE NO._428-9131
DATE SCHEDULED_JANUARY 8. 1986 0930
(Applicant' s signature)
! • • • • • • e • • • • s e • o • e e e e e e e o o • • • e e e • 0 0 0 • • • • • • 0 • • • 0 • • • o • • • • 0 0 0 0 • • • • • • • 0 • 0 • • • 0 0 • 0 • • • • • •
SOIL LOG
SUB-DIVISION NAME LAKEVIEW DATE JANUARY 8. 1986 TIME
EXPANSION AREA: YESNO S VAL '&x7,e& K,46 _ENGINEER
TOWN WATER_X_PRIVATE WELL -, C.�C ,.� BOARD OF HEALTH
ALFR .D FULLER EXCAVATOR
SKETCH: (Street name,etc. ,dimensions of lot, exact location of test holes and
percolation tests, locate wetlands in proximity to test holes )
NOTES:
i 17- 5-G74
Lol-
160
�- 5767Z
N
76
7
3U-
�►
`09
LL p t
PERCOLATION RATE: GZOA(tAj ?ev- k k)C4
TEST HOLE NO: ELEVATION: TEST HOLE NO: ELEVATION:
1 C�D Loo�uca��C� 1
2 2
3 3
5 RCD 5
6 ff 6
7 Jac�� 7
8 8 -
9 9
10 10
11 11
12 12
13 (�0 13
i
14 U5r LoT 1k �- AG Ll 14
15 15
16 Ir--40 . �ZO
16
SUITABLE FOR SUB-SURFACE SEWAGE: LEACHING FIELDK LEACHING PITS X
LEACHING TRENCHES X
'I UNSUITABLE FOR SUB-SURFACE SEWAGE. REASONS:- -"
NOTE: ENGINEERING PLANS MUST SHOW NUMBER ASSIGNED ON PERC TEST APPLICATION
ORIGINAL: COMPLETED IN ENTIRETY BY P. E. AND RETURNED TO BOARD OF HEALTH
COPY: RETAINED BY APPLICANT
6S N�tiJ;de br
E M E A
KEEPING YOU ORGANIZED
No. 12534
2-153LOR
SUSTAINABLE
FORESTRY MIN.RECYCm
INITIATIVE CONTENTIG%
CordfiedR6erSoeroin0 POST-CONSUMER®
wvwAprommarp
$Rolm
MADE IN USA
GET ORGANIZED AT SUE AIM
ASSESSORS MAP N0: 2 =<
y ,
No ���� - PARCEL NO.: a Fss... ...........
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
...................OF.....-.......... � � ............................
Appliratiun for Uispuuttl Works Tunutrurtiun rumit
Application is hereby made for a Permit to Construct (X) or Repair ( ) an Individual Sewage Disposal
S stem at: n
�1a' "^ .................................... `�-----•----d_.. .._.�.. �: _ d; 6�ar.�.......
Location ddress _/ port No. /
................................. . ..7/.:c 2=t.k.6,-.b e ri�Ae`.�aZ.r _�}_._..t 4:2"�lluL�r1K"...........---
W Owner Ad, s
................................................ R,,�-
c r+
Installer Address C,T
UType of Building �- _ Size Lot.... ....Sq. feet
Dwelling—No. of Bedrooms.__..1 _I A. ___________________Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building No. of ersons____________________________ Showers
a g ---------------------------- P ( ) — Cafeteria ( )
Otherfixtures ------------------------------------•------•--------......-------•------•----._...-•-----•---._...._...----•------.....-•---._.....---............---•
W Design Flow................................,..___gallons per person per day. Total daily flow.. . 4..........................gallons.
WSeptic Tank—Liquid capacity_F lNnh__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,><r Dosing tank ( )
aPercolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. 1________________minutes per inch Depth of Test Pit.................... Depth to ground water..___..____._.__._.____.
f14 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
a ........................
.•-•-•----•--•----•--- ---------------
•--------
•-----------•-----------•-------
-----------
•••-------
•-••••--------
•-.._......
0 Description of Soil........................................................................................................................................................................
W
UNature of Repairs or Alterations—Answer when applicable...............................................................................................
--•-•--•-••-------------------------------------------•--------------------------------------------._..._•----
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of iIHE 5 of the State Sanitary Code—.The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has be ed y the b and of health
Signed--- � '1�. f-'-c%_._...----
__________ ______ „Y. ....
ate
*Application Approved BY................................... ---•--- ..............•. ---•--_-- -
bate
Application Disapproved for the following reasons: -------------------<-� --------------------------------------------------
--••-•••---------•---•---•••-------•--•-••-•-•-•••---••-----•--•--•---•----------------•---•--------....-•---•----=----....-----••----------•--------•----••••--•------------•-----------•--•--••-----•-
//-��ii Date
Permit No.._ 4Q2S.............. Issued.......................................................
Date
No. ..64Z r FIZIM ../... ��..�✓ ....
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
a_ ....................OF................. ::���-...,c/.: f� �.,.
Appliratiun for Disposal Warks Tonutrurtion Vrrutit
Application is hereby made for a Permit to Construct (X) or Repair ( ) an Individual Sewage Disposal
System at:
1 /
....5 i:',;{ter f/:Ic%-_,...!./:�........---•--•------------------•--•-----..... -----••--•---f..r.� ........ r_.:�= - "•--!:.i .`.. ......
Location-/Address _ / ` or Lot No. -
1 .............•--•-.........•... / .%.. `:...1'�A 1,r�_�t�<;/ ... __: {_., _l Glsl......_-----
( Owner 1/,Address le,
Installer Address
d Type of Building Size Lot..... �> .-:`.I/....Sq. feet
Dwelling—No. of Bedrooms....--1-.E-�-:...................Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
dOther fixtures ------------------------------------•--------------......----------------------------------------•---•---...........-------•---._........._..........
WDesign Flow.................................: .:: gallons per person per day. Total daily flow... ?? .._....._.__._.....______.gallons.
WSeptic Tank—Liquid capacity..!t°r.-P.gallons Length................ Width................ Diameter................ Depth................
x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No.__!`_41�_ '_.__.. Diameter.....f............. Depth below inlet....k.1......... 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........................
44 Test Pit No. 2................minutes per inch Depth of Test Pit............_....... Depth to ground water........................
a •-•-•••••-••---------•-•••--••---•...••••...•••••••--•••.....•••••.....-•-•••......--•---••----..............................................................
0 Description of Soil........................................................................................................................................................................
W
U -•••-••••••••-•-••-••-•••-•••••••--•-•-••-•••-•-•••.....---•••-•--------•••-•--•...............•-••-••••••-......-•••••-•--••......----••-••••••--•--•••••-•-•-•-••--••••............-•..........----•-
W
-----------------------------------------------•------------------------------------------------•--------------------------------------------------.........----------•-----------•••••......•---•_....
U Nature of Repairs or Alterations—Answer when applicable.........................................................:..:..................................
------------------------------------------------•------•---.......--------••-•---....--•------•--•---.........-----------------•--•-•-----•-•--...--------...._..........................•-•-••.......
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITL% 5 of the State Sanitary Code—.The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been--ssued by the board of health.
�'G%1/
'� '`�f G Signed---- { .,:.,j1. .-� � ! ..r 11...i„= :._. '�rw....
r� r
.=t
` ate
Ilcation Approved B ` '=I �� r Zs
PP PP Y••--•- - ........ 1 ..
�'-~`_1--`.1—`__ ate
Application Disapproved for the following reasons: ................. _
....................•---•-----..........-----•----------•----•-------------------•------.................._...........--•------------------•-----...-----------------•--•--------------------......._....
Date
Permit No..... :.....-_�-� �� //�l.1. - Issued_.......................................................
Date
OIv THE COMMONWEALTH OF MASSACHUSETTS
A BOARD OF HEALTH
.... ................. ... ....................................
Trrtifiratle of Toutplinurr
TH�S IS TO CERTI-FY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
by 51• __(\�_�_:=� .... L A, ............
• =- - ..... ......
f J Installer
ato(_ r- f- ==i ......_.-....................e.....---•---------•-----------...---.................----------------......•.........------ ..•....------------.
has been installed in accordance with the provisions of TITLE 5 of, The State Sanitary Code as de cribed in the
application for Disposal Works Construction Permit No....... .. ..... t...r�..._..._._. dated............ ?�...t.U�'
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUN TION ATI'SFACTORY. 1.._7_��
f .
DATE............... Inspector....................................................................................
t OMMONWEALTH OF MASSACHUSETTS
[ BOARD OF HEALTH
f r /. .
! r ':..:.::....................OF........... �_.*t...... ......... .:.....................
No.:,.:..:�_......:..:.r` FEE...••...................
Disposal Works Tonotrortion ;ermit
Permission is hereby granted.......:.1_.}.r a
to Construct S ) or Repair, ( ) an Individual Sewage Disposal System
��,
Street
as shown on the application for Disposal Works Construction Permit No�&_ �!'. . Dated...:. ! C�
....
21.
_ .............................
DATE...... .......... -
f rZ�---- t Board of Health
f ...--••••••• •...........••....
FORM 1255 A. M. SULKIN, INC., BOSTON
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TOWN OF BARNSTABLE °
LOCATION J SEWAGE # ''
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VILLAGE , ASSESSOR'S MAP & LOT
o®INSTALLER'S NAME & PHONE NOagd WJ4 � C�
EPTIC TANK CAPACITY / o-
P°LEACHING FACILITY:(type) (size)
4::: 'NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER
OBUILDER OR anvil_ 2.�
DATE PERMIT ISSUED:
DATE .COMPLIANCE ISSUED: J;z o
VARIANCE GRANTED: Yes No ,,-�—