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HomeMy WebLinkAbout0139 WARWICK WAY - Health 139 WARWICK WAY, CENTERVILLE A= 148 113 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 139 Warwick Way Centerville MA 02632 Owner's Name: Domnick Polorido F�E C VIE E D Owner's Address: Same Date of Inspection: August 15, 2001 A U G 2 3 20 01 Name of Inspector:(Please Print) James M. Ford TOWN OF BARNSTABLE Company Name: James M. Ford HEALTH DEPT. Mailing Address:' AQ.`-Boz•49 4 '. Map:"148 Osterville,MA 02655-0049 Lot. 113 Telephone Number: (508) 862-9400 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 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 Nee4 Further Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: _August 17, 2001 The system inspector shall submi 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 to the system owner and copies sent to the buyer,if applicable,and the approving authority:. Notes and Comments ****This'reporfonly describes conditions at the time of inspection and under the coiditions of use at that time. This inspection does not address how.the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 Page 2 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 139 Warwick Way Centerville, AM Owner: Domnick Polorido Date of Inspection: August 15, 2001 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 310 CMR 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 need to be replaced or repaired. The system,upon completion of the replacement 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 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. 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 pass inspection if (with approval of Board of Health): 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 - ass inspection.if with approval of.the Board of Health broken pipe(s)are replaced obstruction is removed ND explain- 2 Page 3 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION. (continued) Property Address: 139 Warwick Way Centerville. MA Owner: Domnick Polorido Date of Inspection: August 15, 2001 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 z.-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 seem 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: 3 Page 4 of 1 I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 139 Warwick Way Centerville, AM ° Owner: Domnick Polorido Date of Inspection: August 15, 2001 D. System Failure Criteria applicable to all systems: You must indicate either`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 '/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 SAS,cesspool or privy is below high ground water elevation. ✓ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ✓ Any portion of.a cesspool or privy is within a.Zone l.of.a gublic.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 than400.feet:butgreater 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-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.] No (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large System: 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) 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 11 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. 4 Page 5 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B �.x. .'..CHECKLIST Property Address: 139 Warwick Way Centerville. MA Owner: Domnick Polorido Date of Inspection: August 15, 2001 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? ✓ 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) ✓ Was the facility of;dwelling inspected:for signs of sewage back;up? ✓ _s,. Was the:site inspected for.signs,of.break out ✓ 3 _ .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: Yes No ✓ Existing information. For example,a plan at the Board of Health. ✓ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)]. 5 Page 6 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C .. ' SYSTEM INFORMATION Property Address: 139 Warwick Way r z Centerville, AM Owner: Domnick Polorido Date of Inspection: August 15, 2001 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Number of current residents: 2 Does residence have a garbage grinder(yes or no): No Is!aundry on a separate sewage system(yes ar no): No [if yes separate inspection required] Laundry system inspected(yes or no): Yes Seasonal use(yes or no): No Water meter readings,if available(last 2 years usage(gpd)): 2000-125,000 gals.; 1999 -64,000 gals. Sump Pump(yes or no): No Last date of occupancy: Currently occupied COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/person''/sgfft,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: Pumped in 2000-per owner Was system pumped as part of the inspection(yes or no): No is ycs,volume pumped: gallcrs--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) Tight Tank Attach a copy of the DEP approval _... Other(describe): _ Approximate age of all components,date installed(if known)and source of information: June 10, 1976-per as built card Were sewage odors detected when arriving at the site(yes or no): No 6 Page 7 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM 3 ' ..,, PART C "SYSTEM INFORMATION (continued) Property Address: 139 Warwick Way _'=z`i`•_. ____.._ _r i ...... - ' _ .+f'� Centerville, MA r Owner: Domnick Polorido Date of Inspection: August 15, 2001 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction: _cast iron ✓ 40 PVC _other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting;evidence of leakage,etc.): SEPTIC TANK: ✓ (locate on site plan) Depth below grade: 12" Material of construction: ✓ concrete _metal _fiberglass__polyethylene _other(explain) If tank is metal list age: Is age confirmed by a Certificate of Comphance,(yes.or no); (attach..a copy of certificate) _ . - _ _.._._._ ,3 Dimensions: 1000 gal. Sludge depth: 1" Distance from top of sludge to bottom of outlet tee or baffle: 30" Scum thickness: I" Distance from top of scum to top of outlet tee or baffle: 9" Distance from bottom of scum to bottom of outlet tee or baffle: 14" How were dimensions determined: Measuring stick Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): The inlet baffle and outlet tee were present. The liquid level was even with the outlet invert. There were no signs of leakage GREASE TRAP: None (locate on site plan) Depth below grade: Material of construction: _concrete _metal _fiberglass _polyethylene._other (explain): Dimensions: Scum thickness: Distance,from top pf.scum to,top of outlet tee or baf)le: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: ot- Comments(on pumping recommendations,inlet and outlet tee or baffle condition structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): 7 Page 8 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C i SYSTEM' '4NFORMATION (continued) Property Address: 139 Warwick Way - - Centerville, MA Owner: Domnick Polorido Date of Inspection: August 15, 2001 TIGHT or HOLDING TANK: None (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/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): -' 'DISTRIBUTION BOX:=``None '. if resent must.be opened) locate'on_site`. lan ( P ( P ) ' Depth of liquid level above outlet invert: Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): PUMP CHAMBER: .None (locate on site plan) Pumps in working crsler(yes or no): Alarms in working order(yes or no) Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): 8 Page 9 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM_ INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 139 Warwick Way Centerville, MA Owner: Domnick Polorido Date of Inspection: August 15, 2001 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type ✓ leaching pits,number: 6'x 6'(1000 gal.) leaching chambers,number: leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number: 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.): The pit had Y of water on the bottom The scum line was 4'uy from the bottom. There were no signs of failure.,»The bottom to was approximately 9. - CESSPOOLS: None (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 or no): Comments (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: None (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.): 9 _� , Page 10 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C , ';" ,SYSTEM:INFORMAT+ION4(continued) Property Address: 139 Warwick Way Centerville, MA Owner: Domnick Polorido Date of Inspection: August 15, 2001 Map: 148 Lot: 113 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. aA � a ,h I g, a3 a A@L- a8 ,3a- a9 f33- L/S Q 3 10 1 Page 11 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM_ INSPECTION FORM PART C SYSTEM INFORMATION,(continued) Property Address: 139 Warwick Way Centerville. MA Owner: Domnick Polorido Date of Inspection: August 15, 2001 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 25' feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked, date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) ✓ Checked with local Board of Health-explain:_topographic and water contours maps Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: The bottom ofthe leach pit to grade was approximately 9. Using the Barnstable topographic map and the Cape Cod Commission water contours map, the maps were showing approximately 25'+/-to groundwater at this site. This report has been prepared and the system inspected and passed as of the date of inspection. This report is not a warranty or guarantee that the system will function properly in the future. There have been no warranties or guarantees, either expressed, written or implied, relating to the system, the inspection and/or this report. 11 f L.av to I .— �Ci SD,,,, as3 Zone � G�au•,�w��'ci L_t,v 1 i t Commonwealth of Massachusetts Executive Office of Environmental Affoirs Department of Environmental Protection Wflllam F.Weld Governor Trudy Coxe Secretary,EOEA David B.Struhs Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM (( / PART A (� 3 CERTIFICATION �r Property Address: 13g WAY'i(A.LU A.y (0d�_0e1-01 k�e, Address of Owner: 1 v,�A wk— �-0Ao&)'tI&Uc_ Clu% Date of Inspection: 16-140 (If different) Name of Inspector IQ r,� � 5 Company Name, Address aA Telephone Number: &0 'C'e- (W- .f AVM ri 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: ZPasses tit _ Conditionally Passes Needs Further Evaluation By the Local Approving Authority f' Fails Inspector's Sign I Date: The System Inspector shall sub it 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 sen tc 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: V I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303, Any failure criteria not evaluated are indicated below. B] SYSTEM CONDITIONALLY PASSES: One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair, passes inspection. Indicate yes, 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, cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 8/15/95) 1 One Winter Street a Boston,Massachusetts 02108 a FAX(617)556-1049 a Telephone(617)292-5500 ice,Printed on Recycled Paper 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Addrests-. ( `3n'q (uGc,ricA ,LA'Y"( C'ev.Ti, Owner: �1Gu(r+'— t-v g06t:"t pub G2v\t�tN Date of Inspection: a--I 19A(o B] SYSTEM,,CONDITIONALLY PASSES (continued) Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed C] FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: 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 SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: _ the wstem has a septic tan anu soli absorption system and is w it!Lli 00 ICci to a sulidce Vraici 5upp!) of tributai) to a surface water supply. The system ha, a septic tank and soil absorption system and is within a Zone I of a public water supply well. _ _ The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. The systen, has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water _ supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm• D] SYSTEM FAILS: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. (revised 6/15/95) 2 .�a SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Lo,-`rIJILW A"/ CieK' r Owner: *\A,,k. Q\} ctN Date of Inspection: D] SYSTEM FAILS (continued): IStatic 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. L 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: The following criteria apply to large systems in addition to the criteria above: The design flow- of system is 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: the system is within 400 feet of a surface drinking water supply the system is 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 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 8/15/95) 3 •s SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: •SIR U�l�`r�L� L.V'"l Ce1-'T� Owner: ll)A"r'19- Qv'A tYN Date of Inspection: t Check if the following have been done: iz Pumping information was requested of the owner, occupant, and Board of Health. None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. _ZAs built plans have been obtained and examined. Note if they are not available with N/A. 2The facility or dwelling was inspected for signs of sewage back-up. vThe system does not receive non-sanitary or industrial waste flow ✓fhe site was inspected for signs of breakout. V 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. Y/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. he facili;? o..".-c'- ;3 : ' occupa"t if d f?cre from owne-? were provided with information on the proper maintenance of Sub- Surface Disposal System. (revised 8/15/95) 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: mar%ck-w i.Y Cek7i . Owner: V4\ccw(L-- Cis v "N Date of Inspection: FLOW CONDITIONS RESIDENTIAL: Design flow: `�4—V allons Number of bedrooms: Number of current residents: Garbage grinder (yes or no):1( Laundry connected to syste (yes or no):1— Seasonal use (yes or no): Water meter readings, if available: 000 Last date of occupancy:R ti COMMERCIAUI NDUSTRIAL: Type of establishment: Design flow:_gallons/day Grease trap present: (yes or no)_ Industrial Waste Holding'Tank present: (yes or no)_ Non-sanitary waste discharged to the Title S system: (yes or no)_ Water meter readings, if available: Last date of occupancy: OTHER: (Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: ll)A NLC V" aL 9?; h,1 IQ-f 6 Clio System pumped as part of inspection: (yes or no)_ if yes, volume primped: gallons Reason for pumping: TYPE Off,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) and source of information: '14 Sewage odors detected when arriving at the site: ( es or no). 8 g Y 11 (revised 8/15/95) 5 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: (Ut!k— Date of Inspection: SEPTIC TANK: (locate on site plan) It Depth below grade: Material of construction: concrete _metal _FRP—other(explain) Dimensions: Sludge depth: Z;t' _ 4a rt Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: 1i Wt Distance from top of scum to top of outlet tee or baffle:_ Distance from bottom of scum to bottom of outlet tee or baffle:_ Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) 4.t�v O f.LS GREASE TRAP: (locate on site plan) Depth below grade: Material of construction: _concrete _metal _FRP _other(explain) Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: f ista^ce from bottom - cat,, t, hot!om oi owlet tee 0, bat!ie- 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 8/15/95) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION.FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: M61"' Date of Inspection: t f TIGHT OR HOLDING TANK: (locate on site plan) Depth below grade: Material of construction: _concrete_metal _FRP—other(explain) i Dimensions: Capacity: gallons Design flow: gallons/day Alarm level: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX:_V (locate on site plan) Depth of liquid level above outlet invert: Letj Comments: (note if levei ano distributiui, r tea;, e�;dence of;olid_ co;r�o�er, evidence of leakage into or out of box etc. U g ) PUMP CHAMBER: (locate on site plan) Pumps in working order:(yes or no) e Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) (revised 8/15/95) 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: (A,?Cd,ne,1fZ,t"" (.,ett:,r i Owner: 4%--v k. KIN Date of Inspection: a—k G y�fP SOIL ABSORPTION SYSTEM (SAS): (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: Type: 1 leaching pits, number: leaching chambers, number:_ leaching galleries, number: leaching trenches, number,length: leaching fields, number, dimensions: overflow cesspool, number: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,etc.) © ,,n a o_� CESSPOOLS: �I (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: (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) (revised 8/15/95) B SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 13c1 UU Owner: Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells withi 100' ,' G DEPTH TO GROUNDWATER OC� 'r C Depth to groundwater: , Nfeet vv,, *X 40eq—GIFT A16V-r-- method of determination or approximation: cIs✓hfN73' (revised 6/15/95) 9 p, TOWN OF BARNSTABLE LOCATION i 3 1 G SEWAGE # VILLAGE C1e+z t,(J,�t� ASSESSOR'S MAP & LOT JNSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY I O.Orb GAI- LEACHING FACILITY: (type) tT (size) /MV 6AL NO. OF BEDROOMS 3 D BUILDER OR OWNER 00rAt-lick Y CI[or?do \ PERMITDATE: 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) r Feet Furnished by 15 -4(. �k A l- • �B a3 77 1 Aa- a8 aa- a8 a A3- 3� O 3 Y LOCATION ' 5E-\"O C;E PERMIT UO. G - IhISTA LER 5 W ADDRESS BUILDER 'S Q A,V4E ADDRESS DATE PERMIT ISSUED '" DATE COMPLI W-ACE ISSUED : r ' b eC � .-� �-r- b �� � •� t' `� i » � • �� . � . ��� --- �s r' �� �� ��. Ff i f� 1w� LOCATION 5EW6,C,E PERMIT 1.JO. 1h1 T QLLER•5 1 &M DDRESS 5 LDER 5 &"E ADDRESS -Dl.S,TE PERMLT- ISSUED D ATE COKAPLI W-ACE ISSUED ; �� "' II - i A Ae yY Q No.......��_..---•• Fs$...1........ . T COMMONWEALTH OF MASSACHUSETTS BOARD F H H _ _....1 . . . ..........OF... .. ................................-------------------------------- - ............. z Appliratinn -fur Biipuiittl Workii Tnnitrnrtinn Prrnitt Application is hereby made for a Permit to Xonstruct ( or Repair ( ) an Individual Sewage Disposal System at -------•-�3--------------------•-----•-••-- ------------ Location•Addre --•-•-L-ot----N--o. ;--•--••----------------------------- ---- `//�/, r Owne d s i a .................. ----- --........•. ... ................... ............ •.: ........................••.. ................................... In taller Address Q Type of Building Size Lot../.�,,5_/..Oao----Sq. feet U Dwelling—No. of Bedrooms--------- --------------------------------Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building -_--.-____________________ No. of persons............................ Showers ( ) — Cafeteria ( ) Otherfixtures ...................................................... W Design Flow--_..-_-_--_-SM-----_•_______________gallons per person per day. Total daily flow----------------------------------------.---gallons. WSeptic Tank—Liquid cap,-_A�---gallons Length--------_------ Width------.......... Diameter................ Depth.-_.--_-____._. x Disposal Trench—No- -------------------- Wi 11 - -------- ---- Tot Length... .....�1 leaching area ®'t __sq. ft. Seepage Pit No........ i ;a_&_ .. l th le,/ .-- - ---.-- al leaching area------------------sq. it. Z Other Distribution box ( ) Dosing tank ( ) o�L �0G1)k,_ 3'• �- L, Percolation Test Results Performed by------- --------------------------•......--•--------.....---------------- Date------------------------------------._.. Test Pit No. 1................minutes per inch Depth of "lest Pit.................... Depth to ground water_..-.-_----..--.--.-.._. (14 Test Pit No. 2................minutes per inch Depth of Test Pit_----------------- Depth to ground water.-._._.--____.._-_--.__. 9 -----+e ----- =er, I1 --2- !- /-- a r _ � _ Description of Soil 0•� (! . ••--a"..... ,. Via__. 2------- y x --------- _ - c.� '!tip 7 �} W 7- � ---------------------------------------------------------------------------------- V 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 Article XI of the State Sanitar Co e— un rsigned further agrees not to place the s stem in operation until a Certificate of Compliance has en ssue t oard of health. � Sig -q Date Application Approved By....... . ..... --------- ---- vtr �' 7 Date Application Disapproved for the following reasons----------------------------•-------......------------------..............------------..........----------------- -------•------------•----------------------------------------------------------•-----------------------•-----------------------------------------------•-------------------•----------•--------------- Date PermitNo......................................................... Issued........................................................ Date No....... F ..✓..................... BOARD COMMONWEALTH OF f lOFLMASSACH MASSACHUSETTS es$. ' ....._a .................OF.../. � H................................. 3 . .. ..... AVV irtttiun -fur Binpuutti 10orkii Tomitrnrtinn Vrruift Application is hereby made for a Permit to Construct (�or Repair ( ) an Individual Sewage Disposal System at: .....................• -I- al!t.................................... - - - c, CPS Location•Addre or Lot No. :�� W - -------------/ Owne �... Installer Address Q Type of Building Size Lot..%o!'f,, y.. 2—to-__-Sq. feet U Dwelling—No. of Bedrooms........ . ...............................Expansion Attic ( ) Garbage Grinder ( ) PA Other—Type of Building ---------------------------- No. of persons---------------------------- Showers ( ) — Cafeteria ( ) QI Other fixtures --------------------------------------- -- -- W Design Flow............ ......................gallons.per person per day. Total daily flow---------------------------------------.....gallons. WSeptic Tank—Liquid cap�ltyVZ)---gallons Length---------------- Width................ Diameter---------------- Depth.-_---_-.----- x Disposal Trench—No. .................... Wmil ............._.. Tot Length____ ,___..........Total leaching area-.�o-.�._.sq. ft. Seepage Pit No....... . i2f _ ____ D4th l�l9w�itle -�c����.�otal leaching area..........:......sq. ft. Z Other Distribution box ( ) Dosing tank ( ) c,0. aPercolation Test Results Performed by------ ------------------------------------------------------------------- Date---------------------------------- Test Pit No. 1----------------minutes per inch Depth of "Pest Pit-------------------- Depth to ground water....---.--._._.--...-_-. fZ4 Test Pit No. 2----------------minutes per inch Depth of Test Pit.................... Depth to ground water.-.-.----_--_-_---.-.... =_ t _' -t- u----------------- - ------------=--------- - ------------ -- x Desc> pt}on of Soil /O r '�-r,�""' 1_.. ram ' /..1 - �lf1z �_5� .-`lj f � � �1 -•-- U (G x --------7--------�2--------- t t t� >� �J- ------------------------------------------------------------ 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 Article XI of the State Sanita Co e—TiYi undersigned further agrees not to place the system in operation until a Certificate of Compliance has -e issue by t board of health. Sign ---•---•--�'�- ----------------------------------------- J Date Application Approved BY --•• --•- 6r�(./!.!I. . ..-•••--......--- ---- ! / l. Date Application Disapproved for the following reasons-------------------------•-------•------•-------.............-•--•--•----------------•---------••-•..._--••--••-- -------------------•------.-.---------••--•--••------•----------------------•---•-•----•------•----------------•-----------------------------------•-----------•-----------•-•--•---•------------------- Date PermitNo......................................................... Issued..................... .................................. Date THE COMMONWEALTH OF MASSACHUSETTS BOARDS, F HE Trrtifirate of "ft ampliatta THIS IS TO CERTIF�,,.That the IndividualSewa e Disposal System constructed ( r Repaired ( ) I tall ; has been installed in accordance with the provisions of <' "ticle XI of he State Sanitary Code as described in the i application for Disposal Works Construction Permit NoO�J.4:__/------------------ dated...__!�—_.L.Z-_.. _.. ---------- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WIU FUNCTION SATISFACTORY. DATE. ------...��..........•-••--•-••--. Inspector -- ------ ------- s E COMMONWEALTH OF MASSACHUSETTS ,6 f BOARD O HEAL H f .� lam,. O F......� c--ew. . . No................... ---• FEE.. DitiVniial nrk-o Clun,itrugiun Vrrmit Permission is eby granted---•— ------------------•-•-•------------••-•-------•---••------• .... to Construct ( or Wep h (� ) an Individual Sewage ,isposal y/em at No. ------------- ! a --( -/�----------- <!� ------------------------------------- Street as shown on the application for Disposal Works Construction P� 't NoA.�, _' ---------- Dated-_-.- J -------•----------------------- d of H`ealt DATE------. ........................................... FORM FORM 1255, HOBBS & WARREN, INC.. PUBLISHERS x * rho e T � e 3 A N pJi v, ,4 a� rt p+i. FW ,�� t a i x 5 "\ k_ is , .n SW !r. yx, 41 AM 17 t 5 �..ti1 GvT ' i a � ��• 'Z i G/o,/Ep. G'V /:/CiZ/'�N�` d`<'� �r �a�'y>JY y `✓ !y!•c�✓ <-d'/ti.J Fes""� 2"'L '�t h # tea;. y e�ahw,I�'✓ ®.�vey�h+i� w1L, Loeq�r/�®+ cr A/ 71a� t .l � FRO.01 .•.0947 470WeY.i NV/ H400®0^1 IQ"V ♦a oq /7" `;'.i h.. 1 n 'T ,i z•j. r r s La r h. 74wrL ® CAT t' /�tlr+Anffi QJ�/s7TiE�C/C."f�i�T•Ya r tqf ? ait SC/@1/43Y10Ad78L76 _L M