HomeMy WebLinkAbout0263 CASTLEWOOD CIRCLE - Health 263 Castlewood Circle
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I )! ST A LLER'S NAME & ADDRESS
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DATE PERMIT ISSUED L/- �6
DATE CCMPLIANCZ ISSUED
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ASSESSORS MAP NO: �
No..- - " RCELNO.: D� �� F�s...,lr...........«.
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
_� .`l..............OF................................................ ............................................
Apphratiun for Dhopoii al Works Tomitrnr#iun ramit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
................................:a�...Y.. ._...._...._.................•........ ..........--........._...................... ....................... ..........._..
ion ddress or No. .. i
v Iry e l .eIle a 63 .i,ve��� �.e%v /�/ 4�h•
Wa O dd S "
.......................... �r�d' fi -
---•.............•---- ...... ----...........------.......------------.. . ........ g�n — ��
Installer Address
Type of Building Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms....... Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
a' Other fixtures -----•----------------•---•----- -
WDesign Flow............................................gallons per person per day. Total daily flow........:...................................gallons.
WSeptic Tank—Liquid capacity.Z ..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........................................
aTest Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................
(i Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
a' ....------•----
v� --------• .---•� ------�eG�---------------------------------•---------------......------ ------.._......_. ---•----•----••---
�70 Description of Soil............. ...................
W
U
w ----------• ----------------------------
x .� � �,I/ �fvw
U Nature of Repairs or Alterations—Answer when applicable...._..1.......................................................................................
......................-=..........................................................................................•------------•••-----•--•---••----••-••-•--•-•••••••••-•••---•---•......••-•-••----•.
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System.in accordance with
the provisions of TI'L U 5 of the State Sanitary Code The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has issue b the oard of health. Q
Signed. ..........................0
Date
ApplicationApproved By..................................................................................................
Date
Application Disapproved for the following reasons:..............................................................................................................
------------------------•---....------------••----•-----------•--•--------•-•---•-•--------•------------•.................----------------------•---------------•----•-•••••••;•--••-•---•-•••••••---•---
Date
PermitNo.......................................................- Issued.......................................................
Date
No................_....... Fss ...............
THE .COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
...----- .%: .✓$.,.I.............0F......f- r . ...>114ix�.....
Appliratinn for Ui4pnnttl Works Towitrurtion runfit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at: ✓� / r
.. ....... t{ �l,ots �"G�* Cri��1.d'
i-- Lm on- ddress of I•�t,No. ---
- = v /� atY!t°j1a+� el`t�t' '�f � f.//�e,a!i�o�-Ctrt/V1'........
----..-•-•--•-------- .. ...........................
.....-•--- --... ---- .....
Owner Address
sta;f,.._.._---•--------•-----•-••-•------------ ------•-•-----------------•--•--------......----•-----:..-----•--
Installer Address
� f Type of Building Size Lot___________________________S q. eet
U
Dwelling—No. of Bedrooms.........3.........:....................Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
Q1 Other fixtures .........................
w Design Flow............................................gallons per person per day. Total daily flow gallons.
WSeptic Tank—Liquid capacity..� `'�..gallons Length................ Width....._..___..... Diameter-_-_-___-____-_- Depth................Disposal
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 ( )
aPercolation Test Results Performed by.......................................................................... Date.........................................
Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................
GT, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
a -----------------=-----•---••------••----•••-•-----•-----.........---------••--•--•---••---•••-.............................................................
DDescription of Soil............. t. .................................................................................................................
x
w
UNature of Repairs or Alterations—Answer when applicable.__....j.'�__% `'_`.�...__� '-'''`" "'"�
•--------------------------•-------------------------------------------=-----------•---.......--------------------------------------------------------------------------------------------•••••......_.
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System.in accordance with
the provisions of TITLE:. 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.
Signed........ .:.._f=_........ ......-•----•-------•-------------------••----••-. ..........................
Date
ApplicationApproved By...................•---•----------------•-•---.....-•-•----•-•-----•------•....._._._............. ........................................
Date
Application Disapproved for the following reasons-----------------------•--------•------------------------------•------------•----------------------.......-•----
---•---•-••-----------------•-•-----•-------•---•-•------------------------•--•--------•-•-•---••------__.-•----•-•--------------•----------•----•••----------------------•-----•------------•-----------
Date
PermitNo......................................................... Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF...... ..............................................................
(Entifiratr of Tompliatirr
THIS IS TO CE ; That t e Individual Sewage Disposal System constructed ( ) or Repaired ( `T
.�
b �.
y r ..........
In
�
has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code s described in the
application for Disposal Works Construction Permit No............. ---.:_1_n.<...... dated.......q. i.(_ : ....................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUA ANTEE THAT THE
SYSTEM WILL FUNCTIO. SATISFACTORY. �--�
DATE...................
. . -- ........................................ - Inspector..... ............---•------------------------••----------...............-•-------
j THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.......1..°..w.`............OF...._..1 r..f.....�..�`---------------------------------------
No......................... FEE... ±.............
%Voo ork Tonotrudion f rrmit
Permission is hereby granted........---- ...•'.' �� ................ ...�....
to Construct ) o Re�a}'r ( 1-1-an ndiv..ioual Sewage Dis sal System,
at No.:.._..._ 3...�as 17✓ Wmav`�:Q °'.. - e t
••-----------•----------------------------••-•-•-..........
Street
as shown on the application for Disposal Works Construction Permit No.........tJ.......... Dated......... .-J.......��...-.--
................................. '*---- ----.-•----
jj r)�! oardo h
f HealtDATE-----------------------4........_l......�-4.----......_...
FORM 1255 A. M. SULKIN. INC.. BOSTON
iy
1
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
�M
Inspection results must be submitted on this form or on the official Title 5 Inspection Form dated
6/15/2000. Inspection forms may not be altered in any way.
A. Certification
1. Property Information:
263 Castlewood Circle
Property Address
Muriel Brunelle
Owner's Name
same
Owner's Address
Hyannis MA 02601
CityfTown State Zip Code
Date of Inspection: 5/29/10
Date
2. Inspector:
Matthew L. Childs
Name of Inspector
same
Company Name
4 Orchid Ln.
Company Address
W. Yarmouth MA 02673
City/Town State Zip Code
508-989-1479
Telephone Number
Certification Statement: - ,
certify that I have personally inspected the sewage disposal system at this address and that the wa,
information reported below is true, accurate and complete as of the time of the inspection. Thy inspection
was performed based on my training and experience in the proper function and mai'ntenance9of on'site
sewage disposal systems. I am'a DEP approved system inspector pursuant to Section 1.5:340_*
Title 5 (310 CMR 15.000). The system: X7
® Passes ❑ Conditionally Passes ❑ Failsk+
t'
❑ Needs Further Evaluation by the Local Approving Authority co
5/29/10
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 applicable, and the approving authority.
****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.
Brunille.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 1 of 16
1
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
�M
A. Certification (cont.)
263 Castlewood Circle
Property Address
Hyannis MA 02601
City/Town State Zip Code
Muriel Brunelle 5/29/10
Owner's Name Date of Inspection
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® 1 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:
Passes, Recommend pumping of septic tank.
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:
N/A
Brunille.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 2 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
9
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
A. Certification (cont.)
263 Castlewood Circle
Property Address
Hyannis MA 02601
City/Town State Zip Code
Muriel Brunelle 5/29/10
Owner's Name Date of Inspection
B) System Conditionally Passes (cont.):
❑ 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:
N/A
The system required min more r stru obstructedpipe(s). The
❑ y q ed pumping g o e than 4 times a year due to o ob c
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced
❑ obstruction is removed
ND Explain:
N/A
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
Brunille.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 3 of 16
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
M
A. Certification (cont.)
263 Castlewood Circle
Property Address
Hyannis MA 02601
City/Town State Zip Code
Muriel Brunelle 5/29/10
Owner's Name Date of Inspection
C) Further Evaluation is Required by the Board of Health (cont.):
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: N/A
** 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:
N/A
Brunille.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 4 of 16
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
GSM
A. Certification (cont.)
263 Castlewood Circle
Property Address
Hyannis MA 02601
City/Town State ZipCode
Muriel Brunelle 5/29/10
Owner's Name Date of Inspection
D)System Failure Criteria Applicable to All Systems:
You must indicate"Yes" or"No"to each of the following for all inspections:
Yes. No
❑ ® 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.
❑ Z 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 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 e st a Y
xi s 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.
Brunille.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 5 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
^M Subsurface Sewage Disposal System Form
A. Certification (cont.)
263 Castlewood Circle
Property Address
Hyannis MA 02601
City/Town State Zip Code
Muriel Brunelle 5/29/10
Owner's Name Date of Inspection
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.
For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the
questions in Section D.
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 II 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.
Brunille.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 6 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
M
B. Checklist
263 Castlewood Circle
Property Address
Hyannis MA 02601
City/Town State Zip Code
Muriel Brunelle 5/29/10
Owner's Name Date of Inspection
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 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?
® El 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:
® ❑ 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)]
Brunille.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 7 of 16
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
C. System Information
263 Castlewood Circle
Property Address
Hyannis MA 02601
City/Town State Zip Code
Muriel Brunelle 5/29/10
Owner's Name Date of Inspection
Residential Flow Conditions:
Number of bedrooms (design): 3 Number of bedrooms (actual): 2
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 gpd.
Number of current residents:
1
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No
Laundry system inspected? ❑ Yes ® No
Seasonaluse? ❑ Yes ® No
Water meter readings, if available last 2 ears usage d N/A
9 ( Y 9 (gpd)):
Sump pump? ❑ Yes ® No
Last date of occupancy: currentDate
Commercial/Industrial Flow Conditions:
Type of Establishment: N/A
Design flow(based on 310 CMR 15.203): N/AGallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.): N/A
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available: N/A
Last date of occupancy/use: N/A
Date
Other(describe): N/A
Brunille.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 8 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
�M
C. System Information (cont.)
263 Castlewood Circle
Property Address
Hyannis MA 02601
City/Town State Zip Code
Muriel Brunelle 5/29/10
Owner's Name Date of Inspection
General Information
Pumping Records:
Source of information: owner
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: N/A
gallons
How was quantity pumped determined? N/A
Reason for pumping: N/A
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:
Upgraded 20+ years ago. Added pit.
Were sewage odors detected when arriving at the site? ❑ Yes ❑ No
Brunille.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 9 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
M
C. System Information (cont.)
263 Castlewood Circle
Property Address
Hyannis MA 02601
City/Town State Zip Code
Muriel Brunelle 5/29/10
Owner's Name Date of Inspection
Building Sewer(locate on site plan):
Depth below grade: feet
Material of construction:
❑ cast iron ® 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: N/A
feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
All in good working order at time of inspection.
Septic Tank (locate on site plan):
.5'
Depth below grade: feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of ❑ Yes ❑ No
certificate)
Dimensions: 8'x5'x5' outside 1000 gal.
Sludge depth:
.4'
Distance from top of sludge to bottom of outlet tee or baffle 2.8'
Scum thickness
.5'
Distance from top of scum to top of outlet tee or baffle
.3'
Distance from bottom of scum to bottom of outlet tee or baffle
.7'
How were dimensions determined? sludge judge
Brunille.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 10 of 16
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
/GSM
C. System Information (cont.)
263 Castlewood Circle
Property Address
Hyannis MA 02601
City/Town State Zip Code
Muriel Brunelle 5/29/10
Owner's Name Date of Inspection
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tank shows no signs of leakage and is recommended to have it pumped as maintainance at time of
inspection.
Grease Trap (locate on site plan):
Depth below grade: N/Afeet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
N/A
Dimensions:
N/A
Scum thickness N/A
Distance from top of scum to top of outlet tee or baffle N/A
Distance from bottom of scum to bottom of outlet tee or baffle N/A
Date of last pumping: N/A
Date
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
N/A
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
N/A
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
N/A
Brunille.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 11 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
M
C. System Information (cont.)
263 Castlewood Circle
Property Address
Hyannis MA 02601
City/Town State Zip Code
Muriel Brunelle 5/29/10
Owner's Name Date of Inspection
Tight or Holding Tank(cont.)
Dimensions: N/A
Capacity: N/A
gallons
Design Flow: N/A
gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: N/A Alarm in working order: ❑ Yes❑ No
Date of last pumping: N/A
Date
Comments (condition of alarm and float switches, etc.):
N/A
Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert N/A
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.):
No d-box.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
I Alarms in working order: ❑ Yes ❑ No
i
Brunille.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 12 of 16
r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
a Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
C. System Information (cont.)
263 Castlewood Circle
Property Address
Hyannis MA 02601
City/Town State Zip Code
Muriel Brunelle 5/29/10
Owner's Name Date of Inspection
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
N/A
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
Type:
® leaching pits number:
2
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
i
❑ 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.):
2 6'x6' precast pits one with 1'of water and the other dry at time of inspection. Original pit had stain
lines at 4'and the upgraded pit with stain lines at 1'.
I
Brunille.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 13 of 16
� I
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
GSM
C. System Information (cont.)
263 Castlewood Circle
Property Address
Hyannis MA 02601
City/Town State Zip Code
Muriel Brunelle 5/29/10
Owner's Name Date of Inspection
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration N/A
Depth—top of liquid to inlet invert N/A
Depth of solids layer N/A
Depth of scum layer N/A
Dimensions of cesspool N/A
Materials of construction N/A
Indication of groundwater inflow ❑ Yes ❑ No
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
N/A
Privy (locate on site plan):
Materials of construction:
N/A
Dimensions N/A
Depth of solids N/A
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
N/A
Brunille.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 14 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
a Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
'M
C. System Information (cont.)
263 Castlewood Circle
Property Address
Hyannis MA 02601
City/Town State Zip Code
Muriel Brunelle 5/29/10
Owner's Name Date of Inspection
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.
Castlewood Cir.
/S
263
2
O B-1-30' G1-21'
O B-2-33' G2-24
A-3-28' B-3-14'
WIT B4-23'
Brunille.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-
Page 15 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
a Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
M
C. System Information (cont.)
263 Castlewood Circle
Property Address
Hyannis MA 02601
City/Town State Zip Code
Muriel Brunelle 5/29/10
Owner's Name Date of Inspection
Site Exam:
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water:
Please indicate all methods used to determine the high ground water elevation:
® Obtained from system design plans on record
If checked, date of design plan reviewed: Date
® Observed site (abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health -explain:
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database -explain:
You must describe how you established the high ground water elevation:
Hand auger 10' in bottom of dry pit and did not encounter groundwater.
I
Brunille.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 16 of 16
��`' �''
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9a �, � �'
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J � !�
, �
YOU WISH TO OPEN A BUSINESS?
For Your Information: Business certificates (cost$30.00 for years). A business certificate ONLY REGISTERS YOIJFB.NAME in town (Which
you must do by M.G.L.-it does not give you permission to operate.) Business Certificates are available at the Town Clerk'.s Office, 1"FL., 367
Main Street, Hyannis, MA 02601 (Town Hall)
DATE: Fill in.please:
AG
APPLICANT'S YOUR NAM :/S.
BUSINESS YOUR HOME ADDRESS: 02 F 3 `(L W00� G-t%
- -
}� }{�{�RNNis M
- fl 0-26DI
TELEPHONE # Home Telephone Number
t R
NAME OF CORPORATION:
NAME OF NEW BUSINESS TYPE OF BUSINESS -Ti i I�G� i(3 N t 1 h16
IS THIS A HOME OCCUPATION? NO �� k
ADDRESS OF BUSINESS 9-G 3 og-5 r -S W Do]� G 12C.1 i'tY +�N i S MAP/PARCEL NUMBER [Assessing)
When starting a new business there are several things you must do in order to be in compliance with the rules and regulations of the Town of
Barnstable. This form is intended to assist you in obtaining the information you may need. You MUST GO TO 2®0 Main St (corner of Yarmouth
Rd. & Main Street) to make sure.you have the appropriate permits and licenses required to legally operate your"bosiness'in this town.
1. BUILDING COMMISSIONER'S OFFICE
l This individual has been informed of any permit requirements that pertain to this type of.business.
4 Authorized Signature*
-----COMMENTS:
2. BOARD OF HEALTH
This individual has b n infor e oft permit requirements that pertain to this type of business.
Auth zed Signature*
COMMENTS:
3. CONSUMER AFFAIRS (LICENSING AUTHORITY)
- This individual has been informed of the licensing requirements that pertain to this type of business:
Authorized Signature
COMMENTS: G rr ii (11
Date:
TOWN OF BARNSTABLE
TOXIC AND HAZARDOUS MATERIALS ON-SITE INVENTORY
NAME OF BUSINESS: FRIR (fiS P AIRT NTti2'rF�i�t�ENT
BUSINESS LOCATION: 263 C46TLE WOOD 4R• "ffNN iS- 1rA- 02661 INVENTORY
MAILINGADDRESS: 5WG h, AoVF1 TOTAL AMOUNT:
TELEPHONE NUMBER: (508)�1-1 A 6 G o-7
CONTACT PERSON: SVLI ftN A R. pftwws
EMERGENCY CONTACT TELEPHONE NUMBER: &S)Ao8a:_�-8 ?1U FWA-S MSDS ON SITE?
TYPE OF BUSINESS: h`)OZA-L QA 1 1Q�f I N� /FRC;u- ?Pry 0?i'AU6 F o'P- VA'�&
INFORMATION/RECOMMENDATIONS: Fire District:
Waste Transportation: Last shipment of hazardous.waste:
Name of Haulers Destination:
Waste Product: Licensed? Yes No
NOTE: Under the provisions of Ch. 111, Section 31, of the General Laws of MA, hazardous materials use,
storage and disposal of 111 gallons or more a month requires a license from the Public Health Division.
LIST OF TOXIC AND HAZARDOUS MATERIALS
The Board of Health and the Public Health Division have determined that the following products exhibit toxic
or hazardous characteristics and must be registered regardless of volume.
Observed/Maximum Observed/Maximum
N Antifreeze (for gasoline or coolant systems) Misc. Corrosive
NEW USED Cesspool cleaners
Automatic transmission fluid Disinfectants
Engine and radiator flushes Road Salts (Halite)
Hydraulic fluid (including brake fluid) Refrigerants
Motor Oils Pesticides
NEW USED (insecticides, herbicides, rodenticides)
Gasoline, Jet fuel, Aviation gas Photochemicals (Fixers)
Diesel Fuel, kerosene, #2 heating oil NEW USED
Misc. petroleum products: grease, Photochemicals (Developer)
lubricants, gear oil NEW USED
Degreasers for engines and metal Printing ink
Degreasers for driveways & garages Wood preservatives (creosote)
Caulk/Grout Swimming pool chlorine
Battery acid (electrolyte)/Batteries Lye or caustic soda
Rustproofers Misc. Combustible
Car wash detergents Leather dyes
Car waxes and polishes Fertilizers
Asphalt & roofing tar PCB's
Paints, varnishes, stains, dyes Other chlorinated hydrocarbons,
Lacquer thinners (inc. carbon tetrachloride)
NEW USED Any other products with "poison" labels
Paint &varnish removers, deglossers (including chloroform, formaldehyde,
Misc. Flammables hydrochloric acid, other acids)
Floor &furniture strippers Other products not listed which you feel
Metal polishes may be toxic or hazardous (please list):
Laundry soil & stain removers NO 5 ORt P6 / Pfl'I o -r W�11...L P�,C-
(including bleach) TUR oTdi ,- 0 N Ly T( .� I`Vp-.o0 K)T
Spot removers & cleaning fluids G�55p1 ? l%p{Z -j'(�E :a7p�,
(dry cleaners)
Other cleaning solvents
Bug and tar removers
Windshield wash
WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS
1
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
J
DEPARTMENT OF ENVIRONMENTAL PROTECTION
RECEIVED
NOV 2 4 2004
TOWN OF BARNSTABLE
TITLE 5 HEALTH DEFT.
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION.
Property Address:
Owner's Name: , A �'ARLE1 ®4%
Owner's Address: /4 /. LOT
l� J -
Date of Inspection: l-,/I f
Name of Inspecto (please print j. J�V
Company Name.
i
Mailing Address:
Telephone Number:602-`7'7/- 101)
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 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
Fails
Inspector's Signature: Date: pl 16'y
T
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.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 I I
OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Addressio
62/4
Owner:
Date of Inspection:
Inspection Summary: Check A,B,C,D or E./ALWAYS complete all of Section D.
A. S stem Passes:
I have not found an informa
tion ton which indicates that any of the failure criteria described in 310 CMR
15.303 or in 310 CMR 15.304 exist.Any.faiiure criteria not evaluated are indicated below.
Comments:
& 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.
2
f
i
Page 3 of 1'1
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
'CERTIFICATION(continued)
Property Address: a /
Owner: ' '
Date of Inspection: // y-
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:
3
Page 4 of I I
OFFICIAL,INSPECTION.FORM—NOT FOR..VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property.Address: �.t,'�
Owner: loha:0 V-�Wqlzia,46;
Date of Inspection: �/� 00ocl
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all inspections:
Yes No/
s/ 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
1✓ 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 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.
,�l are triggered. A copy of the.analysis must be attached to this form.]
J P (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 IL 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 1 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION'FORM
FART B
CHECKLIST
Property Address:
Owner:
Date of Inspection:
Check if the following have been done. You must indicate"yes"or"no"as to each of the following: _
Yes No
I�— 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?
Z — Has the system received normal flows in the previous two week period ?
i
_LZ
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 breakout?
_ 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 thefiaffles 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
_ 1--l-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:t
Owner:
Date of Inspection: k.
( .
j FLOW CONDITIONS
RESIDENTIAL V
Number of bedrooms(design):' Number of bedrooms(actual):
DESIGN flow based on 3 I O.CI R 15.203 (for example: 11.0 gpd x#of bedrooms): ' (
Number of current residents:_�
Does residence have.a garbage
_grirder(yes or no):+th
Is laundry on a separate sewage system(yes or no);_ .cif yes separate inspection required]
Laundry system inspected(yes or no):/)()
�CSeasonal use: (yes or no) ) ...
Water meter readings, if available(last 2 years usage(gpd)): 03—241.2 T, ,
.gV-301
1,751
Sump pump(yes or no): 0
Last date of occupancy: ,
COMMERCIAL/INDUSTRIAL.,�j'('
Type of establishment:
Design flow(based on 310 CMR.15.203): gpd
Basis of design flow('seats/persons/sgft,efc.):
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:Was system.pumped as part of the nspection(yes or
If yes, volume pumped: gallons--How was Pantity.'prumped determined? - -
Reason Tor 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
Zther(describe): s%G Q_w
proximate age of all components,date ins ta led(if known)and source of information
Were sewage odors detected when arriving.at the site(yes or no�
6
Pace 7 of 1 1
` OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
t4
Owner:
Date of Insp ction: 1C0 7
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: ' /
Material of construction:� oncrete_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: (,a K
Sludge depth:
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:
Distance from bottom of scum to bottQjn of outlet tee or baffle:
How were dimensions determined:
Comments(on pumping recommen ations, • let and outlet tee or baffle condition, structural integrity, liquid levels
a elated to outlet invert, eviden a of leakage,etc. :
o
GREASE TRAPA/,,)(locate on site plan)
Depth below grade:
Material _
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 g -
OFFICIAL-INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address-
-
f�!
Owner: '
Date of Inspection: U62
TIGHT or HOLDING TANK/.1�GC/(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): y
Alarm level: Alarm in working order(yes or no):
Date of last pumping:
Comments(condition of alarm and float switches,,etc.):
DISTRIBUTION BOJy/ (if present must be opened)(locate on site plan)
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 (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.):
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:
I
Owner: �>
Date of Inspection: JJ, (,y
SOIL ABSORPTION SYSTEM (SAS): locate on site plan, excavation not required)
-If SAS not located explain why:
Type
:teaching pits,number:
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): °
L/ICo `k 7La,
L��97-P�GIIYt,. �c,,�° �2 C� �1C CO �• C��� G � ��12�t' ..-c� � �Qf���C�
CESSPOOLS:AA(cesspool must be pumped as part of inspection)(locate on site plan) 1 �J
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.):
PRIVl �(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 INFORMATION(continued)
Property Address: >
Owner: '
Date of Inspection: y9o"
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.
03
d3
V .
4Q
Le ock L
10
Page 11 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
.Property Address 7
Owner:
k/0 hL, 9"41 P A 0_1f�AP
Date of Inspection: /
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water ZO 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:
hecked with local excavators, installers-(attach documentation)
Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
11
S - o
3 "
9
p5
i
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1
j6
ag .
- K!
t
L `
=•7
991 $
S ,
C
2
1
J
Permit Number: Date:
Completed by:
HIGH GROUND-WATER LEVEL COMPUTATION
Site Location: /� Lot No.
Owner: /�/ � ^ �1�Address:
Contractor: ® ! i5/ Address: ���� �✓^ �
Notes: �5/
STEP 1 Measure depth to water table /`
pa
tonearest 1/10 ft. .............................................................................. .Date /!
month/day/Year
STEP 2 Using Water-Level Range Zone
and Index Well Map locate
site and determine: Z 7
OAppropriate index well................................�/.............
OWater-level range zone .....................................................
STEP 3 Using monthly report "Current
Water Resources Conditions"
determine current depth to
water level for index well ........................... month/year
.STEP 4 Using Table of Water-level Adjustments
for index well (STEP 2A), current depth
to water level for index well (STEP 3),
and water-level zone (STEP 2B) -7 7
determine water-level adjustment ..........................................................................................
STEP 5 Estimate depth to high water
by subtracting the water-
level adjustment (STEP 4)
from measured depth to water
level.at site (STEP 1) .............................................................................................................
Figure 11--Reproducible computation form.
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