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Home My WebLink About0132 BUCKWOOD DRIVE - Health 132 Buckwood Drivo 272-079,:,... . . Hyannis s f a IL TOWN OF BARNSTABLE LOCATION . SEWAGE # VILLAGE_ I `f 44,10-1 S ASSESSOR'S rr & LOT -i 2-0 INSTA ME LLER'S NA &PHONE N0. SEPTIC TANK CAPACITY f` l5- -(it� LEACHING:FACILITY: (type) (size) CS T t�I Xdr NO.OF BEDROOMS ' BUILDER OR OWNER �— PERMITDATE: 3 y a COMPLIANCE DATE: Zf ®I Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet ..Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet .Edge of Wetland and Leaching Facility (If any wetlands exist within 300 feet of leaching facility) Feet Furnished by a s w O U4 TOWN OF BARNSTABLE LOCATION Z og rZ C dSEWAGE # A41I40¢T£ VMLAGE 4/y Zr&L'i ASSESSOR'S MAP & LOT Z7�— p INSTALLER'S NAME&PHONE NO. ( C 7'1 IV G SEPTIC TANK CAPACITY � : CO 2 LEACHING FACILITY: (type) )0 `7— (size) /6 NO.OF BEDROOMS -r- 7 7�� 70� BUILDER PERMTTDATE: COMPLIANCE DATE: Separation Distance Between the: ,L 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 feet of leach' fa "',, )( Feet Furnished by , YS�� N �w� � �--�� N � ^ ^ � �� o �� O 1 � _ �A� � ° � � �°S'r�� N - ' , � X . .� � '" � ' � � R d � � !3° � fv � � a � " � � � . <; - � -- -. r _.. +Y"••.....-..r--y._ ^j.. ..,-••-^;,•^ -"�«'}—,.� c. ,.aa^�^xr--s�-r"d-:.�-:,7c*,'-,,,...,,''. ,r- --"e....r..+-..'^�...� ,.-5,..^._�r�.r..--._.�.,,...-.,._ ti-,.-.. ..- TOWN OF BARNSTABLE BAR-W 4945 Ordinance or Regulation r;;O i ,o WARNING NOTICE -7 7& r '' Name of Offender/Manager I�61ot: � In,411 a.S Address of Offender '_ fkvc 4,jaA '% MA My/MB Reg.# N Village/State/Zip � 11 AAA O ? Go l Business Name . dam/'pm, on. 211 20v Business Address Signature of Enforcing Officer Village/State/Zip Location of Offense { ��r�"fjA !�r MA o76' Enforcing Dept/Division Offense 'ec j tM -7;-,, t f /A-.1X+04 C0c9e Facts f�ijt/r-,` +-0 r'C M QVC re L SC4y,M 'r" This will serve only as a warning. At this time "no legal action has been taken. It is the goal of Town agencies to achieve voluntary compliance of Town Ordinances, Rules and Regulations. Education efforts and warning notices are attempts to gain voluntary compliance. Subsequent violations will result in appropriate legal action by the Town. WHITE-OFFENDER CANARY-ORD./REG.-PROG. PINK-ENFORCING OFFICER GOLD-ENFORCING DEPT. .._ _:...,.--.._ --.. •-G,.°4ti;..-.--y,,.� ..hti,.n-...f+ .^'^''-^'r:..i.:N"....r+^^+y1L i - y ....-rY.w ,^Y`!/i�I�':.... ..y.P.r, 'rr.....i4'•..rvR...ywtr^v.-."'...a .-.. TOWN OF BARNSTABLE BAR-Wir " Ordinance or Regulation , , .. . r�� 7, WARNING NOTICE --7 ,, a Name of Offender/Mans er t m� t_ _7r�a�'►r . Y g Address of Offender 1AA MV/MB Reg.# Village/State/Zip `' '`a IAA 0 Business Name 1 1 am/pm, on -: 20•-) - Business Address —_� Signature of Enforcing Officer Village/State/Zip tt t ✓ 1 Location of Offense f Enforcing Dept/Division Offense rc , lei ,44/A wry,,: ,pjrj C04 Facts {� ' � rt, �,} , ►� re �ii M1�^ �•r k� ,.�f �:, �, -� F �- This will serve only as a warning. At this time'no legal action has been taken. It is the goal of Town agencies to ' achieve voluntary compliance of Town Ordinances, Rules and Regulations. Education efforts and warning notices are attempts to gain voluntary compliance. Subsequent violations will result in appropriate legal action by the Town. WHITE-OFFENDER CANARY-ORD./REG.-PROG., PINK-ENFORCING OFFICER GOLD-ENFORCING DEPT. Date: Q TOXIC AND HAZARDOUS MATERIALS REGISTRATION FORM NAMEOFBUSINESS: BUSINESS LOCATION: 1141191 MAILINGADDRESS: L�' 1-11� ASS Mail To: TELEPHONE NUMBER: �--� - Board of Health Town of Barnstable CONTACT PERSON: �X t9l P.O. Box 534 EMERGENCY CONTACT ELEPHONE NUMBER: Hyannis, MA 02601 TYPEOFBUSINESS: Does your firm store any of the toxic or hazardous materials listed below, either for sale or for you own use? YES NO . This form must be returned to the Bo rd of Health regardless of a yes or no answer. Use the enclosed envelope for your convenience. If you answered YES above, please indicate if the materials are stored at a site other than your mailing address: ADDRESS: TELEPHONE: LIST OF TOXIC AND HAZARDOUS MATERIALS The Board of Health has determined that the following products exhibit toxic or hazardous character- istics and must be registered regardless of volume. Please estimate the quantity beside the product that you store. NOTE: LIST IN TOTAL LIQUID VOLUME OR POUNDS. Quantity Quantity Antifreeze(forgasoline orcoolant systems) Drain cleaners NEW USED Cesspool cleaners Automatic transmission fluid Disinfectants Engine and radiator flushes Road Salt (Halite) Hydraulic fluid (including brake fluid) Refrigerants Motor oils Pesticides NEW USED (insecticides, herbicides, rodenticides) Gasoline, Jet Fuel Photochemicals (Fixers) Diesel fuel, kerosene, #2 heating oil NEW USED Other petroleum products: grease, Photochemicals (Developer) lubricants, gear oil NEW USED Degreasers for engines and metal Printing ink Degreasers for driveways & garages Wood preservatives (creosote) Battery acid (electrolyte) Swimming pool chlorine Rustproofers Lye or caustic soda Car wash detergents Jewelry cleaners Car waxes and polishes Leather dyes Asphalt & roofing tar Fertilizers X Paints, varnishes, stains, dyes PCB's Lacquer thinners Us�'Q Other chlorinated hydrocarbons, NEW USED (inc. carbon tetrachloride) Paint & varnish removers, deglossers Any other products with "poison" labels Paint brush cleaners (including chloroform, formaldehyde, Floor & furniture strippers hydrochloric acid, other acids) Metal polishes Laundry soil & stain removers Other products not listed which you feel (including bleach) may be toxic or hazardous (please list): Spot removers & cleaning fluids (dry cleaners) Other cleaning solvents Bug and tar removers WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS ,r F. No. A—/, -/ Fee +✓ THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION —TOWN OF BARNSTABLE, MASSACHUSETTS 01ppYication for �Dtgool *pgtem Con5tructton Vertu Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) El Complete System ❑Individual Components Location Address or Lot No ® O ra o-e� Owner's Name,Address and Tel.No. Assessor's Map/Parcel0-7 � � Q Installer's Name,Address,and Tel.No. 1 Designer's Name,Address and Tel.No. �e0L`Q0,�7E T)pe of Building: Dwelling No.of Bedrooms--31 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow �� gallons per day. Calculated daily flow w�� gallons. Plan Date Number of sheets Revision Date Title _ Size of Septic Tank cLr S"T1!J `- �-(�/J �V Type of S.A.S. Description of Soil Nature of Repairs or Alter tions(An er when applicable) 3 aC XZ— �i Date last inspected: DW- N ING C_N � v �� TIFV im STB�T Agreement: RITING THkSYSTEM N �N� The undersigned agrees to ensure the construction nd maintenance of the afgrede�9� - 1�- wage disposal system in accordance with the provisions of Title 5 of the E en a a of to place the system in operation until a Certifi- cate of Compliance has b 7 y rs of Hea Signed Date J Application Approved b A Date Application Disapproved for the following reasons Permit No. Date Issued ' - TOWN OF BARNSTABLE utiLOCATION i� �c►� �� a�`� SEWAGE # VILLA ��`� i4yr�-Z ASSESSOR'S. & LOT Z-1 2-=%�T INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY ��ti ! LEACHING FACILITY: (type) Cl G�� -F' L (size) TI X�a NO.OF:BEDROOMS j BUILDER OR OWNER_ _ �---E G,� PERMITDATE- 3 _ Z�' COMPLIANCE DATE: I �1 Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility (If any wetlands exist within 300 feet of leaching,facility) Feet Furnished by 00 a. 0 � j svilLi, :. . fi G A, •"A No. � d �d I Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: :`. Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS Z(pprication for Diopoear *pztem Construction permit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( `',) ,O Complete System 11 Individual Components ,A Location Address or Lot NoVI—Su C.K Lo(,x o O f i,*Q Owner's Name,Address and Tel.No. n u �� Assessor'sMap/Parcel � � �y "'�" (_� `— Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Grinder( ) Other Type of Building No.of Persons _ Showers( ) Cafeteria( ) Other Fixtures Design Flow `Z�i gallons per day. Calculated daily flow �� gallons. Plan Date Number of sheets Revision Date Title ° _ Size of Septic Tank � J Type of S.A.S. (-`'� I O tC ' - Description of So -rA-'w 1 Nature of Repairs or Alterations(Ans er when applicable) r - t " 11 a rt!_e_,&4jC �- Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage'disposal system in accordance with the provisions of Title 5 of the E rnentaYCod ` n , of to place the system in operation until a Certifi- cate of Compliance has beer�-issmd-by this �Heald . k Signed .` Date Application Approved by Date 3- Z G Application Disapproved for the following reasons Permit No. Date Issued ' - --------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance - THIS IS TO CERTIFY, th the On-site Sewage is osal System Constructed( )Repaired( )Upgraded(V ) 0 Abandoned( )by cz✓ ) ✓"� at _ C)f i '6 has been constructed in acc rdance —' with the provisions of Title 5 and the for Disposal}System Construction Permit No."Z69 7/dated 3 Z G d Installer I Designer The issuance of thi&permit shall not be construed as a guarantee that the sy t will f nction'As d�gneV Date ?a Z �� r Inspector f - ———— ———————————————————— ——————————————— No. (�C�J / Fee f� THE COMMONWEALTH OF MASSACHUSETTS 4 PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS t lifSpooar *p$tem Construction Verna Permission is hereby granted o Construr.._c, ( ) epair(D )Upgrade )Abandon( ) System located at v�- oo and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Constructi n mu be completed within three years of the date of this h it. Date: 31?, a/ Approved by t' 1/6/99 NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. • i , CERTIFICATION-O'F-SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANS) � � �e7> hereby certify that the application for disposal works construction permit signed by me dated concerning the property located at meets all of the foil wing criteria: • is failed system is connected to a residential dwelling only. There are no commercial or business uses associated with the dwelling. • The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch. • here are no wetlands within 100 feet of the proposed septic system There are no private wells within 150 feet of the proposed septic system There is no increase in flow and/or chance in e us proposed There are no variances requested or needed. The bottom of the proposed leaching facility will not be located less than five feet above the maximum adjusted groundwater table elevation..[Adjust the groundwater table using the Frimptor method when applicable] • If the S.A.S.will be located with 250 feet of any vegetated wetlands, the bottom of the proposed leaching facility will not be located less than fourteen(14)feet above the maximum adjusted groundwater table elevation, Please complete the following: A) Top of Ground Surface Elevation (using GIS information) B) G.W. Elevation +the MAX. High G.W. Adjustment . 3 �r DIFFERENCE BETWEEN d B SIGNED : DATE: �� I [Please Sketch prop os plan of system o 'NOTICE Based upon the above information, a repair permit will be issued for bedrooms maximum. No additional bedrooms are authorized in the future without engineered septic system plans. q:health folder:cert GQ • F i n X�� 'fir Z,� a �� 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: 6111c4'woof A Ile, ,i9 O"o Owner's Name: 'Roww ej2'Row H Owner's Address: T.)- uNn i Date of Inspection: Name of Inspector: lease punt) Company Name: ypl O - G Mailing Address: PO eag ld- . Telephone Number: o k — — o 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 , Needs Further Evaluation by the Local Approving Authority i/ Fails Inspector's Signature: Date: The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer,if applica'ble1 and the approving authority. authority. �Owe,v�� Tp ��'`� Y 1�75 Tl'1 i c� fX Gi ct'1" S lei✓l Notes and Comments S ****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. I Page 2`of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A / CERTI/FICATION (continued) Property Address: 6-n 012co owner: Le Q Date of Inspe ion• 7—C—D/ Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: Al 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: Page 3 of 11 OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: i— / G 01 Owner: �--2 ✓� Date of Inspe ion: --O 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: f ,'Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 9q,"Jt/ Owner: Date of Inspection: O D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for AII 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 V Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or ' /cesspool V Liquid depth in cesspool is less than 6"below invert or available volume is less than%day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped y 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. y 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 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.] (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 Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd• You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) 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 R 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. l Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address:13'� c r c h- oo J a- ' d( o� Owner: 124¢ Date of p ction: .-0/ Check if the following have been done.You must indicate`yes"or"no"as to each of the following: Ye No Pumping information was provided by the owner,occupant,or Board of Health /Werean of the stem components um out in the previous two weeks Y system Ixi pumped 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 u � l� g p Was the site inspected for signs of break out Z7Were all system components,excluding the SAS,located on site v _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition 7oft 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 i maintenance of subsurface se*age disposal systems The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Y� no ( no Existing information.For example,a plan at the Board of Health 1/ Determine in the field if f h failure criteria _ _ d tl ( any o the a ure cute a related to Part C is at issue approximation of distance Ts unacceptable) [310 CMR 15.302(3)(b)) I Page,6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: D a,--, equcvo� Owner: lrPi Date of Inspe tion: 3 fl 6-0 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): Number of bedrooms(actual): DESIGN flow based on 310 Cb f 15.203(for example: 110 gpd x#of bedrooms):Y30 Number of current residents:,- Does residence have a garbage grinder(yes or no): /1 O Is laundry on a separate sewage system(yes or no):IO[if yes separate inspection required] Laundry system inspected(yes or no): li'O Seasonal use: (yes or no): AV Water meter readings,if available(last 2 years usage(gpd)): Sump pump(yes or no): /VO Last date of occupancy: COMMERCIALANDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no): Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records /` Source of information: ( - 1,,t4e Was system pumped as part of the inspection(yes or no): iVo If yes,volume pumped:_gallons--How was quantity pumped determined? Reason for pumping: V 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/Altemative 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 install J if known)and source of information: `f , Were sewage odors detected when arriving at the site(yes or no): /f/,O Page 7 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner: &-4e v- Date of Inspection: .7 6-0 BUILDING SEWER(locate on site plan) Depth below grade: /-f 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: Zocate on site plan) Depth below grade: 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: J Sludge depth: �'" �ti�`l�e C� Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: Distance from top of scum to top of outlet tee or baffle: D Distance from bottom of scum to bott f outlet t e or baffle•_o How were dimensions determined: o e s 2 i, Comments(on pumping recommendations,inlet tee or baffle condition,structural integrity,liquid levels a elated to outlet iiivq,evidence o 1 ge,etc.): , ,cod 4,1 o'. ,0�1 . AT GREASE TRAP: Kocate on siteplan) 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.): Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C 77) SYSTEM INFORMATION(continued) Property Address: �J� nvvp61a_ O� Owner: Date of Inspection: 1 —Q/ T TIGHT or HOLDING TANK: /L' (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:A(if present must be opened)(locate on site plan) 1,�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.): / 0 � - �x P •W(locate UMP CHAMBER. 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.): Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: ")— moo/ Owner:��4 Date of Inspedion: SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why: T e / leaching pits,number:_ )o 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,lev of ding,damp soil,condition of vegetation, etc.): // r 0 v►JI'l U fa• t� o rM 2 Y CESSPOOLS:Z(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: (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.): Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: r 1 14 1-"O Owner: - Date of Insp ction: 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. Av povs 3� v . Page 41ofII OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: / � Owner: L- ^O Date of Insp ion• �- SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water ��+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) hecked with local Board of Health-explain: +i1 a�s Checked with local_excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: -gam c� w 20V"'� t Commonwealth of Massachusetts (9f ab S L)ILExecutive Office of Environmental Affairs 1 2 1 ' A P R l 2 1996 , Department of i Environmental Protection I'm f - 44 William F.Weld `! Goremw Trudy Coxe 9 N,EOEA David B.Struhs oomm"ioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: i3 - �2 dress of Owner: Date of Inspection: Z11 Z - q L^, Of different) Name of Inspector: T1' 111ok t?J Compan Name, Address and Telephone Number: -7 5 s 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: _Z'Passes _ Conditionally Passes Needs Further Evaluation By the Local Approving Authority _ F Inspector's Signature:' Date: 7 .2- -9 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. Bj 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) One Winter street a Boston,Massachusetts 02106 a FAX(617)SSG-1049 a Telephone(617)M-SW 10 Printed on Recycled Pape SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Owner: Date of Inspection: B] SYSTEM CONDITIONALLY PASSES ( ntinued) 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): brten pipe(s) are replaced obst uction is removed distri tion box is levelled or replaced The system required pumping more an four times a year due'to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Bo d of Health): broken pi (s) are replaced / obstruction removed / C] FURTHER EVALUATION IS REQUIRED BY THE BOARD O EALTH: Conditions exist which require further evaluation b he oard 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 HE LTH DETER NES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC H TH AND SAF AND THE ENVIRONMENT: _ Cesspool or privy is within 50 eet of a surface water _ Cesspool or privy is within 5 feet of a bordering vegeta ed wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE OARD OF HEALTH (AND PUBL C WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING N A MANNER THAT PROTECT T\ E PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a otic tank and soil absorption system and is within 100 feet to a surface water supply or tributary to a surface water su ly. _ The s�step. ha, septic tank and soil absorption system and is within a Zone I of a public water supply well. _ The system h a septic tank and soil absorption system and is within 50 feet of a private water supply well. _ The system as a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water supply wel , unless a well water analysis for coliform.bacteria and volatile organic compounds indicates that the well is free from ollution 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 dete ned that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this dete ination 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 8/15/95) 2 F! SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Owner: Date of Inspection: D)SYSTEM FAILS(continued): Static liquid level in the distribution box above outlet invert due to an overloaded or dogged SAS or cesspool. Liquid depth in cesspool is less than 6" below invert or available volume is less than 112 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 %J thin 100 feet off a;:nrface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is wit 'n a Zone,4 of a public well. Any portion of a cesspool or privy is within feet of a private water supply well. Any portion of a cesspool or privy is ss than 100 feet but greater than 50 feet from a private water supply well with no acceptable water qualify analysis. the well h s been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile org c compounds, monia nitrogen and nitrate nitrogen. Ej LARGE SYSTEM FAILS: The following criteria ap y to large systems in addition to the cr feria above: The design floe. of ystem is 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety and the environ ent because one or more of the following conditions exist: t 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 If 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 t' 'r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 1?j,/am Owner: t� f va j. Date of Inspection: Check if the following have been done: �/umping information was requested of the owner, occupant, and Board of Health. /one 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. A�As built plans have been obtained and examined. Note if they are not available with N/A. L-T'he facility or dwelling was inspected for signs of sewage back-up. �e system does not receive non-sanitary or industrial waste flow 1-�The site was inspected for signs of breakout. system components, excluding the Soil Absorption System, have been located on the site. 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. e 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. The faciiit� ov ner (and occupants, if different from ov�ner; were provided with information on the proper maintenance of Sub- Surface Disposal System. (revised 8/15/95) 4 :J • SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 132 p2 f�� Owner: 'E"t N fie,. Date of Inspection: FLOW CONDITIONS RESIDENTIAL: Design flow: �L) lions Number of bedrooms: -2� Number of current residents: Li Garbage grinder (yes or no):/ Laundry connected to system (yes or no): 4 Seasonal use (yes or no): 1 Water meter readings, if available: 33 _O dp Last date of occupancy:- .a COMMERCIAUINDUSTRIAL• Type of establishment: Design flow: gallons/day Grease trap p sent: (yes or no)_ Industrial Waste Tank present: (yes or no)— Non-sanitary waste discharged itle 5 system: r no)_ Water meter readings, if available: Last date of occupancy: OTHER: (D nbe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: 7u-u-�''YI — ivtl�+t I System pumped as part of inspection: (yes or no)&_�J If yes, volume pumped Rallons Reason for pumping. TYPE OF SYSTEM y Septic tank/diA4bat+eR-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: Ill/ - a Sewage odors detected when arriving at the site: (yes or no)ZV (revised 8/15/95) 5 r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: Date of Inspection: SEPTIC TANK: (locate on site plan) G Depth below grader Mtaterial of construction: L-toncrete _metal _FRP_other(explain) 0 Dimensions: Sludge depth: G Z Distance from top of sludge to bottom of outlet tee or baffle: 3 Scum thickness: 0 Distance from top of scum to top of outlet tee or baffle: rJ& Distance from bottom of scum to bottom of outlet tee or baffle:_ Comments: trecommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in rel ion to outlet invert, structural integrity, evidence of leaka e, etc.) ✓i 4 �`'1'e' � d��7rL -GREASE TRAP:_ ;locate on site plan) Depth below grade: Material of construction: _con\ metal _FRP other(explain) Dimensions: Scum thickness: Distance from top of scup, to top of outlet affle: D!Stance from bottom �i ��orn t^ hn of outlet a or baffle: Comments: (recommendation fo umping, condition of inlet and out s:orbafles, depth.of liquid level in relation to outlet invert, structural integrity, evide of leakaee. etc.) (revised 8/15/95) 6 tt SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM . PART C SYSTEM INFORMATION (continued) Property Address: Owner: Date of Inspection: TIGHT OR HOLDING TANK:_ (locate on site plan) Depth below grade: Material of construction: _concrete_metal _FRP—other(explain) Dimensions: Capacity: Rallons / Design floe: aallons/daq Alarm level: Comments: (condition of inlet tee, ition of alarm and float switches, etc.) DISTRIBUTION BOX:Z_11dA / (locate on site plan) Depth of liquid level above outlet invert: Comments: (note if level and dist:ibution i, equal, evidence of solid: ca-•o\,er, evidence of leakage into or out of box, etc.) PUMP CHAMBER:_ / (locate on site plan) Pumps in working order:(yes or no) Comments: (note condition of pump chamber, condition of pumps and appurtenanc�, etc. (revised 8/25/95) 7 ,1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM 'a PART C SYSTEM INFORMATION (continued) Property Address: Owner: Date of Inspection: 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: 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 hydraulc failure, level of pondin condition of vegetation,etc.) CESSPOOLS: _ (locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth.of solids layer. Depth of scum layer: Dimensions of cesspool: Materials of construction: indication of groundwater: inflow (cesspool must pumped as part of inspection) Comments: (note condition of soil, signs o ydrauli i ure, level of ponding, condition of vegetation, etc.) PRIVY:_ (locate on site plan) Materials of constru n: Dimensions: Depth of solids: Comments: (n condition of soil, signs of hydraulic failure,.level of pondi condition of vegetation, etc.) (revised 6/15/95) 8 r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 1. A/, Owner: , Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' L 0 DEPTH TO GROUNDWATER Depth to groundwater:_LLLfeet method determination or approximation: �� (revised 8/15/95) 9