HomeMy WebLinkAbout0084 WATERSIDE DRIVE - Health 84 Waterside Drive
Centerville P
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COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
RECEIVED
MAR 1 7 2003
TOWN OF BARNSTABLE
TITLE 5 HEALTH DEPT.
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 84 Waterside Drive
Centerville, MA 02632
Owner's Name: John Dewey
Owner's Address: North Hill A502-865 Central Ave.
Needham, MA 02492
Date of Inspection: March 5, 2003
Name of Inspector: (Please Print) James M. Ford
Company Name: James M. Ford
Mailing Address: P.O. Box 49 Map:227
Osterville,MA 02655-0049 Parcel. 165
Telephone Number: (508)862-9400 Lot. 17
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
Ne Further Evaluation by the Local Approving Authority
Fai s
Inspector's Signature: Date: March 5, 2003
The system inspector shall sub 't 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 report only describes conditions at the time of inspection and under the conditions 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: 84 Waterside Drive
Centerville, MA
Owner: John Dewey
Date of Inspection: March 5, 2003
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
pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain:
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Page 3 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 84 Waterside Drive
Centerville, MA
Owner: John Dewey
Date of Inspection: March S, 2003
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
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:
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Page 4 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 84 Waterside Drive
Centerville, MA
Owner: John Dewey
Date of Inspection: March S. 2003
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 1 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. [This system passes if the well water analysis,
performed at a DEP certified laboratory,for coRform 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.
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Page 5 of I 1
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 84 Waterside Drive
Centerville, MA
Owner: John Dewey
Date of Inspection: March 5, 2003
Check if the following have been done: You mast 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 or dwelling inspected for signs of sewage back up?
✓ Was the site inspected for signs of break out?
✓ Were all system components,excluding the SAS,located on site?
✓ _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition
of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum ?
✓ _ Was the facility owner(and occupants if different from owner)provided with information on the proper
maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has been determined based on:
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
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Page 6 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 84 Waterside Drive
Centerville, MA
Owner: John Dewey
Date of Inspection: March S. 2003
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: 1
Does residence have a garbage grinder(yes or no): Yes
Is laundry on a separate sewage system(yes or no): No [if yes separate inspection required]
Laundry system inspected(yes or no): No
Seasonal use(yes or no): No
Water meter readings,if available(last 2 years usage(gpd)): Unavailable
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/persons/sqft,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: Never pumped-per owner
Was system pumped as part of the inspection(yes or no): No
If yes,volume pumped: _gallons--How was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM
✓ Septic tank,distribution box,soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system(yes or no) (if yes,attach previous inspection records, if any)
Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be
obtained from system owner)
Tight Tank Attach a copy of the DEP approval
Other(describe):
Approximate age of all components,date installed(if known)and source of information:
Sep. 13184-per as built card
Were sewage odors detected when arriving at the site(yes or no): No
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Page 7 of 11
M'
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 84 Waterside Drive
Centerville, MA
Owner: John Dewey
Date of Inspection: March S. 2003
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: Approx. 16"
Material of construction: ✓ concrete _metal _fiberglass _polyethylene
_other(explain)
If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of
certificate)
Dimensions: 1000 gal.
Sludge depth: 2"
Distance from top of sludge to bottom of outlet tee or baffle: 30"
Scum thickness: 2"
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: 12"
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.):
Tees were present The liquid level was even with the outlet invert. There were no signs of leakage. Recommend pumping
every three years
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 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(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
SYSTEM INFORMATION (continued)
Property Address: 84 Waterside Drive
Centerville MA
Owner: John Dewey
Date of Inspection: March S. 2003
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: ✓ (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: Even
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.):
The D-box was level No solids were present
PUMP CHAMBER: None (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.):
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Page 9 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 84 Waterside Drive
Centerville, MA
Owner: John Dewey
Date of Inspection: March S. 2003
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 approximately 6"of water on the bottom The scum line was Y up from the bottom. There were no signs.of failure.
The bottom to grade was approximately 10' The cover was approximately 4'below grade. Recommend installing risers.
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 l l
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
. .PART C
SYSTEM INFORMATION (continued)
Property Address: 84 Waterside Drive
Centerville, MA
Owner: John Dewey
Date of Inspection: March 5, 2003
Map:227
Parcel: 165
SKETCH OF SEWAGE DISPOSAL SYSTEM Lot: 17
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.
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¢' Page 11 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 84 Waterside Drive
Centerville, MA
Owner: John Dewey
Date of Inspection: March S. 2003
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water 30 +/- 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:
Using the Barnstable topographic map and the Cape Cod Commission water contours map the maps were showing approximately
30'+/-to ground water 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
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F SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTIONkFORM
I
Address of, property (� T�QSide.drti�e Cent. met; oa6'3o1
Owner's •name
Date. of%:Inspection
J�� PART A
.,. CHECKLIST
- .' - 'y:• i �3 �r ,.ice ys_: E ,j:: .• - i.. . {;��- - p
.Check if thetfollowing ;have been done: 4.
Pumpingyinformation �was requested of the owneroccupant, and' Board of
Health -it
",,
L
None' of the ;system components have been pumped for atjeast two weeks
;and` he system,. has been receiving normal, flow rates�'during''that
`period. `.I'Large volumes of water have not been"-introduced. into" the
t,systemwrecently, or. as part of this inspection. �� 't
f •rid 4b p,{F ZS+� .i �. }v- YE t.l - r'
V 'As°#built 'plans -have been obtained and examined.
}f, Note if .they '.are''not
available 'with N/A. •
s a �
_ ,The. facilit orE;dwellin was inspected for signs- of ,sewa e,back-up.
t ✓ The site was inspected for signs of breakout.
x '
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,. v i .. F 7 i ".`....� � .5 .,rj,. >- E t�` s v, '' ,{ ;.: t1...;7.•. ex ..Y :. i '�
Al,lasystem_.components, excluding the SAS, have been located,'on the
� �b ,
The se ptic.tankxmanholes were uncovered, opened,_and 'wthe,,interior of
°;the':Iseptic(tank;was inspected for condition of baffles .or tees,.
material=;of);construction, dimensions, depth of, liquid, 'depth' of
sludge, Y,depth ,o f.. scum.I IT
The /size,*and location of the SAS on the site has' been determined based
on' existing.,Anformation or approximated by non-intrusive methods.
:•.3 i5 . ,t Js, xt.!C o$ + -r� _�-� ,.4• :- i; ,fit+,. ,�'. .. ..`.; , ,I
The facility owner,' (and occupants, if different from,;:owner) :were
provided with information on the proper maintenance of SSDS'.
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SUBSURFACE '.SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION
FLOW CONDITIONS.
If residential
_3 number of bedrooms
number. of current residents
- NO garbage grinder, yes or no'
_V!s laundry connected to system, yes or no
V0 seasonal use, .yes or no
If nonresidential, calculated flow.:
Water meter- readings,r
if available: >�
� Ig94 - 1g93
e�lang'
Last date of occupancy i
GENERAL INFORMATION1.41
Pumping records and source of information: ¢
Ash
- eystem .pumped as part of inspection, yes or no
if yes, volume pumped lDpQgAlloos.
Reason for pumping:
IY�A;n`�f#nc� • i; �
Tye of system
Septic tank/distribution box/soil absorption system
Single . cesspool •
Overflow;:cesspool.
Privy i
t►!O . Sharedsystem. (yes or no) (if yes, attach previous inspection
records, if any)
other (explain)
Approximate age .of all components. Date installed, if known. S.ource. 'of
information
I9%1
_V Sewage'.odors detected when arriving at the .site ': yes or no
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
~ SYSTEM INFORMATION continued
SEPTIC TANK:
(locate--on site plan)
depth below grade• Id'a
material of construction: concrete metal FRP other(explain).
dimensions:
Ir sludge depth
Xe distance from top of sludge to bottom of outlet tee or baffle
scum thickness,
_e distance from top of scum to top of outlet tee or baffle
Q&* 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 leakag recom ndations for repairs, etc. )
4nKS�cak+ jegn*. deme& ws pAA of znSp2�;e�l ta,•aS
DISTRIBUTION BOX:
(locate on site plan)
depth of liquid level above outlet invert
Comments:
.(note if level and distribution is equal, evidence of solids carryover,
evidence of :leakage into or out of box, recommendation .for repairs, etc. ) j
i
PUMP. CHAMBER:_ VA
(locate on site plan)
pumps in working order, yes or no
Comments:
(note condition of pump chamber, condition of pumps and appurtenances,
recommendations for maintenance or repairs,etc. )
J 44
I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ;
PART B
SYSTEM INFORMATION continued
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 b presen explain:
o�ge=�ed,n �
Type.
leaching pits and number _1- 6X19AMDO LQ,+chpi+ s•6odPArbA
leaching chambers and number
leaching galleries and number
leaching trenches, number, length
leaching fields, number, dimensions
overflow cesspool, number
Comments:
(note condition of soil, signs of hydraulic failure, level of' ponding,
condition of vegetation, recommendations for maintenance or repairs,etc. )
im+ %u Fail 6-16-9s
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, recommendations for maintenance or repairs,etc.)
PRIVY: ;
(locate on site plan)
materials of construction 3 {
dimensions
depth of 'Solids
Comments: ,
(note 'Condition -.of soil, .signs of hydraulic failure,,.level oftponding,
condition of vegetation, recommendations for maintenance," or repairs,-etc. )
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SUBSURFACE SEWAGE DISPOSAL, SYSTEM INSPECTION ;FORM
PART B
SYSTEM INFORMATION continued'
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at - least two permanent references landmarks' or=benchmarks
locate all wells within 100 ' r
\\do
10
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DEPTH TO GROUNDWATER
depth to groundwater
method of determination or approximation: F
JeO hoe_ is y- 131 .
12
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION'FORM-
PART C
FAILURE CRITERIA
Indicate yes, ,no, or not determined (Y, N, or ND) ; Describe. basis of
determination in all instances. If "not determined", explain why not)
MO Backup of .sewage into facility?
WO Discharge or ponding of, effluent to the surface* of the ground or.
surface waters?
Static liquid level in the distribution box above outlet invert? :
_ Liquid depth in cesspool <6" below invert or available volume< 1/2 day
flow?
@�0 Required pumping 4 times or more in the last year?
number of times pumped
Imo_ Septic tank is metal? cracked? structurally unsound? 'substantial
infiltration? substantial exfiltration? tank failure-
.,imminent?
Is any portion of the SAS, cesspool or privy:
below the high groundwater elevation?
-_ within 50 feet of a surface water?
AL within 100 feet of a surface water supply or tributary to a surface
water -supply?
i
within. a Zone I of a public well? •
`JO within 50 feet of a bordering vegetated wetland or salt marsh
(cesspools and privies only, not the SAS) ?
MR within 50' feet of a private water supply well?:
less than 100 feet but greater than 50 feet from a:`private water
14 supply well with no acceptable water quality analysis? If the well
has been analyzed to be acceptable, attach copy of•�well water4nalys,_ 1
.for coliform bacteria, volatile organic compounds, 'ammonia nitrogen
and nitrate nitrogen.
• I
... .. -- — - - - -
.�`.:-��-- -�---- ----=------------------------TOWN OF-----Grafnj0hiQ.----- BOARD OF HEALTH
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART D.- CERTIFICATION
-TYPE OR PRINT CLEARLY-
PROPERTY INSPECTED
STREET ADDRESS j;LI WA IC��
ASSESSORS MAP, BLOCK AND PARCEL #
OWNER' s NAME GCD5S
PART D - CERTIFICATION
NAME OF INSPECTOR �oWmr�
COMPANY NAME R06(uon Septic kruic-t
COMPANY ADDRESS 41 CAPT C 1(6 �ArAc- 1-noli3 M6 0•2ro/
Street Town or City State LIP
COMPANY TELEPHONE ( Sob ) 7157 -79g�, FAX
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposa7.' system at
this address and that the information reported is true , accurate , and
complete as of the time of inspection . The inspection was performed and any
recommendations regarding upgrade , maintenance , and repair are consistent
with my training and experience in the proper function and maintenance of on-
site sewage disposal systems.
Check one:
System PASSED
The inspection which I have conducted has not found any information
which indicates that the system fails to adequately protect public
health or the environment as defined in 310 CMR 15 . 303 . Any failure
criteria not evaluated are as stated in the FAILURE CRITERIA section of
this form.
System FAILED*
The inspection which I have conducted has found that the system fails to
protect the public health and the environment in accordance with Title
5 , 310 CMR 15 . 303 , and as specifically noted on PART C - FAILURE
CRITERIA of this inspection form.
Inspector Signature G(Jt.�ir���f)1i71ia Date 4-/0-95
One copy of this certification must be provided to the OWNER, the BUYER
(where applicable) and the BOARD OF HEALTH.
* If the inspection FAILED, the owner or operator shall upgrade the system
within one year of the date of the inspection, unless allowed or required
otherwise as provided in 310 CMR 15 . 305 .
partd.doc
)/ TOWN OF BARNSTABLE
LOCATION A/LUfi` rside_ dov, SEWAGE #
VILLAGE Ge n f• ASSESSOR'S MAP &LOT
INSTALLER'S NAME&PHONE NO. R01 06n 7 7S 7`'86
SEPTIC TANK CAPACITY 1000
LEACHING FACILITY: (type) 1000 CD (size)
NO.OF BEDROOMS .3
BUILDER OR OWNER 907,t KraX-S
PERMTTDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and 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 feeJ2w �iaY!
lea ching facility) /L4
Feet
Furnished by '(� -M 'f
yS
�1
S �
BOARD qF HEALTH
Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal
System at:
j lie
Location-Address or Lot No.
Address
Installer Address
Type of Building Size Lot...�azqr DQ.Q....Sq. feet
Z Other Distribution box (&/) Dosing tank ( .) -
Test Pit No. I------i� minutes per inch Depth of Test Pit...... ...... Depth to ground water.AQ---
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TLITLE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has beer)4ssued by�te bo%rad of health.
Date
____________
Date
PermitNn......................................................... Issued.......................................................
— —
No. .2..-_.. Z. 7 �'�J
THE COMMONWEALTH OF MASS`AC14USETTS
BOARD OF HEALTH
............ ..............................OF........................................
.._...._..............................
Appliration for Disposal Works Tonstrurtion rrrmit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
................-........_...................................................................... •-•-•••.......---._...----•••••----••••---•-•••-•-••---•••-•-••-•-•••.............---•............
Location-Address or Lot No.
Owner Address
W
Installer Address
UType of Building Size Lot............................Sq. feet
►� Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
a`4 Other—T
YPe of Buildin g ---•-----•------------------ No. of persons............................ Showers ( ) — Cafeteria.(...__>.
P4 Other fixtures
w Design Flow..............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity.:._.......gallons Length................ Width................ Diameter________•-___- Depth................
x Disposal Trench—No. ........................ Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test-Results Performed by.......................................................................... Date........................................
i...7
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water-.___-_-______---_-_---.
44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
a •--••-•--•-•-----------••.............•-•••••--•-•••-••••--••-•-•••-•.....-•••-•-------•••-•._...•••.......................................
-....
.------_-----
0 Description of Soil........................................................................................................................................................................
x
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 TITLL 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health.
y�ignec ----------------•-------------------------------•-•---------...----------•---•----- ....... Da-tZ
Application Approved BY• c -----------,,.. ... ....._..._.. -r✓ r ! _.._..__
.....•-• •- .
Date
Application Disapproved flr-,;the (owing reasons:--•-••------•-•------------•--•-----•-----------------------•------------------•-----------------•----•-----•...
------------------------•-•---•----•--•-------...---••--••---••••••-••••--•--•............................................................
Date
PermitNo......................................................... Issued-.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..........................................OF.....................................................................................
Tntifiratr of Tompliaurr
THI�' IS T IFY, That the Individual Sewage Disposal System constructed ( or Repaired ( )
;<
b .....-- /--="_•`......• -!rE. '-=4i---------------------•-•-•--•---------...---•--.........-----...........
V` •,Instiller
has been installed in accordance with the provisions of TIT .F 5 of h State Sanitary Code as described in the
application for Disposal Works Construction Permit No..... �Tr
:___ ._.._.... dated-...............................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE.......................................................1,.----1-1-.6�. Inspector....................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
-12,
No. ..�...._.7 �..:. FEE....s
�71,
Permission is hereby ranted...._�._.�:4 �"
................ .......... • • ............•.........................................................
to Construct (✓)�ox�'Rep ' f an,.Individu T e-, is a1 System
e?_ ------------------•---------------•----------•-----------------------••-•.......•-•-•-
at No. ...= -= Street
as shown on the application for Disposal Works Construction Permit No.... �Y ate ..........................................
- -------------------------------------
Board o ealth
DATE..................................................
FORM 1255 A. M. SULKIN, INC.. BOSTON
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TOWN OF BA`RNSTABLE u
LOCATION 11 ��J CrS► 4�r. SEWAGE #
VILLAGE CG.►Tkrt ,. ASSESSOR'S MAP & LOT
INSTALLER'S NAME&PHONE NO.
SEPTIC.TANK CAPACITY UVO
LEACHING FACILITY: (type) �� (X (size) I&D !41
NO.OF BEDROOMS 3
BUILDER OR OWNER �O�n
PERMTTDATE: 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 leachin facility) �--�— Feet
Furnished by �/l S .7
y -
r
� 3 �
9 a3
a 2
O
3 3y 3-7
dy-- I3,7
LO- CAT ION y' SEWAGE PERMIT N0.
` VILLAGE
.INSTA L ER' N ME i ADDRESS.
A//s
EUILDER OR OWNER
DATE PERMIT ISSUED
DAT E COMPLIANCE ISSUED
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