HomeMy WebLinkAbout0072 GREENBRIER LANE - Health 7�2 -Greenb ier- Lane TT
Hyannis P =
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COMMO. ''EALTH OF ALASSACHtiSET'TS
01 E_ZECtiTI�'E OFFICE OF E-V\ZRO\ IE IN-T_zI _ F FAIRS
I a }': DEPARTMENT OF ENVIRONMENTAL PROTECTION
=� J
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TITTE 5
OFFICIAL INSPECTION FORA—NOT FOR VOLUNTARY ASSESSMENTS
SU BSURI'ACE SEWAGE DISPOSAL. SYSTEM F OWiI
PART A
l) CERTIFICATION �y
Property Address: 2p` 6-,reeve K///ei- L/1/ "l �
h 'nh�,s, ZV a(o // o/
Owner's Name: �,/ aklc-,v So,r. rOf -
Owner's Address: _JoZ G�ce., /ipY G4/
/- 01,6
Date of Inspection: // Q
.Name of Inspector:(please print)
Company Name:
Mailing Address: legO eax lot8?
Telephone\umber: O$ 7, 5!
CERTIFICATION STATE' TENT
I certify that I have personally inspected the sewage disposal system at this address and Lhat he info=ah0r-repo..ad s
below is true, accurate and complete as of the time of the inspection-1 he inspection:�-as;erFo^red bus d on m ��`
rrainirig and exaerience in the proper fiirciion and maintenance of on site sewage disposal st stem. i am, a rJLF-�
approved system inspector pursuant to Section 15.340 of Title 5(310 CIIR 15.000). i tae system:C:'
o _
P��aSSeS c,53 C�
Conditionally Passes
Needs F urther Evaluator by the Local Approving n `'
Autho_ _7>
Fails
ya
Inspector's Signature: Bate:
M
The system inspector shall submit a copy of this inspection repo^to the Approving_kuihori--+Board of ea =or
DEP)within 30 days of completing this inspection.If the system is a shared system or has a desgn e , o
gpd or greater, the inspector and the system owner shall submit the report to the anproprate regional o _Pce o
DEP. The original should be sent to the system ow-,er and copies sent to the hover; if an�1_icable. and the a,n o
authority. v
Notes and Comments
`***This report only describes conditions at the time of inspection and under the conditions of use at that
tine.This inspection does not address how the system will perform in the future under the same or different
conditions of use.
Tide ; Inspecnon Form 6,'1 5�/2000 pase ?
Pase 2 of 1 I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMT TS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
YAKT A
CERT/IrICATIO\(continued;
Property Address:
`7 a nvl�l. ad 6611
Owner: SI-111fo �
Date of Inspection: // / 01
Inspection Summary: Check A.B,C,D or E I ALWAYS complete all of Section D
A. Svstem Passes:
l/ 1 have not found anv information which indica-tes that anv of the fa- ure criteria Cescrbea r C\`R
15303, or'in 10 CNIR 15.3304 exist.Any failure criteria r•ot evaluated are indicated
Comments:
B,. S---stem Conditionally Passes:
/v One or more system components as described in the`Conditional Pass"section need-o^e-e-.laces'or
repaired. The system. upon completion of the replacement or repair; as approved by the Board of l egal . ,vi'1-ass.
Answer Les_no or not determined(Y,\',"N'D)in the for the following statements. If"Lot .ete= ea lease
explain.
The septic tank is metal and over 20 vears old,or the septic tank(n-he`th er metal or rot) is snicrurall_:
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. Svster~:v 11•,-ss ns o
existing tank is replaced with a complying septic tank as approved by the Board of Heal.
"A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Cerrif.ca-e of Co-r' a-ce
indicating that the tank is less than 20 years old is available.
\-D. explain:
Observation of sewage backup or breakout or high static water level in the List=bu-io bo::d etc broer.
obstructed pipe(s) or due to a broken,settled or uneven distribution box. System v ii pass inspeC C_
approval of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
'D explain:
The system required pumping more than 4 tunes a v_ear dui to broken or obs=tee
pass inspection if(with approval of the Board of Health):
broken pipes)are replaced
obstruction is removed
ti'D explain:
rage of 11
OFFICIAL, INSPECTION FORl1-NOT FOR VOLU T_ARY ASSESS'IENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEl1 INSPECTION FORM
PART A
/' CERTCERTIFICATION(continued)
Property-Address: / � t7—/'e2V7 6.1te e, z—
!S NIDS hANN/S ,
Ozyner: IQ
Date of Inspection: / Q
C..� Further Evaluation is Required by the Board of Health:
/V Conditions exist wEch require further evaluation by the Board of Health in or&r o
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(l)(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 w ater
Cesspool or privy is within 50 feet of a bordering yecetated wetland or a salr marsh
Z. 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 s✓stern has a septic tank and soil absorption system(SAS) and The SAS is « Thin 100 -ee cf 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 ! of a public w-arer spy_
The system has a septic tank and SAS and the SAS is w-ithin 50 feet of a privare w-aTer supph: e?i.
The system has a septic tank and SAS and the SAS is less than 100 fee:but 5C fe-r or mo- =crr,.
prig-ate water supply well".Method used to de-,- ne distance
"This system passes if the well water analysis,performed at a DEP cen Fred laborato-�-, for :ol_?c, in
bacteria and volatile organic compounds indicates that The well is free from polluTio-from t-.ar fac i'_U a-_-
the presence of ammonia nitrogen and nitrate ni«ogen is equal to or less uhan 5_p-pnit;aT no o?
failure criteria are triggered.A copy of the analysis must be attached To this for~ri.
3. Other:
T;tlo � �.�
PaQe 4 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESS�fEN T S
SUBSURFACE SENYAGE DISPOSAL SYSTEM INSPECTION FORA:
PAnT A
CERTIFICATIO'\(continued)
Property Address:
Ommer: ,- -5 ,, o S
Date of Inspection:
A System Failure Criteria applicable to all systems:
You must indicate"yes" or"no"to each of the following for all inspections:
Yes \'o
3aclmp of sewage into facility or system conmoner_t due to overloaded or clogged S_�S or:ess^co<
_ ischarge or pondina of effluent to the surface of the---ourd or surface , aters du2 r•: an Or
logged SAS or cesspool
✓ Static liquid level in the distribution box above outlet invert due to an overloaded o-clog_ S_=.5 c-
cesspool
uid depth in cesspool is less than 6"below invert or available-ol-u,ne is less t`a_� :%_-'a�
� =_o.
Required pumping more than 4 tines in the last year NOT due to clogged or obsa lc-ed p pe(s).
iaT times pumped
portion of the SAS,cesspool or prny s below high around Water eievailon.
Any portion of cesspool or privy is„thin 00 feet of a su face water supnl: or, m.butzr_:--o a : -a,c,
ater supply.
any portion of a cesspool or privy is within a Zone 1 of a public well.
_✓A v portion of a cesspool or privy is vrithin 50 feet of a private water su l we.'
Any portion of a cesspool or pricy is less than 100 feet but greater=nan 50 feet-t-ro-mapnivate Ater
supply well with no acceptable water qualit<-analysis. [This system passes if the well water anaivsis.
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 S ppm,prodded that no other failure criteria
are triggered.A coPy of the analysis must be attached to this form.]
" D (Yes/No) The system fails.1 have deternuned chat one or more of he above faihuie c-teT a e:iist:a
described in 310 CVIR 15.303.therefore the system fails. !-he system owner s not d on--ct-`_e pTT
Health to determine what will be necessary to correct the failure.
.E. Large Svstems:
To be considered a large system the system must serve a facility with a design tlmN,-of 10.000 -a d 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
Xth the system is within 400 feet of a surface drin;{ina water supply
the system is vvrithin 200 feet of a tributary to a surface drinking water summl_
e system is located in a nitrogen sensitive area(interim���eilhead
one II of a public water supply a-ell
if you have answered"ves"to any question in Section E the system is considered a
"yes"in Section D above the large system has failed.The owner or operator of an ;arse s°_ e� _
significant threat under Section E or failed under Section D sham ups ado the vote- v
15.304. The syste contact m accr_r� --
m owner should c the appropriate_ Qional office of the Denarnte-t,
Page 5 of 11
OFFICIAL: INSPECTION FORAI—NOT FOR VOL L1'T IRY"ASSESS-AIENTS
SUBSURFACE SEWAGE IDISPOSAL SYSTEM INSPECTION FORM
PART S
CHECKLIST
Property Address:
P%A 1
Owner: - gaolo
Date of Inspection:
Check if the following have been done. You must indicate"yes"or"no"as to each of the folio,-' zg:
Pumping information was provided by the owner;occupant, or Board of Heal,^:
any of the system components pumped out in the previous two weeks
r/ Has the system received normal flows in the previous two reek period?
Have large volumes of water been introduced to the system recently or as pa-of:Lis insnecr_on-
ere as built plans of the system obtained and examined'(If thev,�k ere not available note as\:'A)
Was the facility or dwelling inspected for sighs of se«-age 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 he tres P _0r
of the ba fies or tees, material of construction,dimensions; depth of liquid, depth of sludge and dep of�ZcuM
Was the r
facility owner(and occupants if different from owrer)provided-,Zan information or
maintenance of subsurface sewage disposal systems
The size and location of the Soil Absorption System(SAS)on the site has been base_o_ :
Y"Ps o
i*sting information. For example, a plan at the Board of Health.
Determined in the fieid(if any of the failure criteria related to Part C is at i zue a^nro:; ~=_ or _;;ta
is unacceptable) f310 CMR 15. 02(3)(b)
T;ti to cr�arr;r„� t=�,-.,.. 411[/-)nnn -
Page 6 of i 1
OFFICIAL INSPECTION FORA-'NOT FOR VOLL`NTIRY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTETM IoSPECTTO\ FORM
PART C
SYSTPEIM I ,`I=ORIMATIO
Property Address: Gf&Gill h!i e.— L-411"
nrl�
OR-ner•
Date of Inspection:
LO V CONDITIO'_!S
RESIDE\TIA,L
Number of bedrooms(design): Number of bedrooms(act<uai): _
DESIG'�tlow based on 310 C'vM 15.203 (for example: 110 gpd x_of bedrooms): 3:U
Number of current residents:_'
Does residence have a garbage grinder(yes or no): /v
Is laundry on a separate sewage system(yes or no":W if yes separate ir_�recr_on regn=red
Laundry system inspected(yeA or no):
Seasonal use: (yes or no):
Water meter readings, if available(last 2 years usage(pd)):
Sump pump(yes or no): �'�
Last date of occupancy:
COoD11ERCIA UE'DtiSTRIAL
I ype of establishment:
Design flow(based on 310 CMR 15203): 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):
GE1 ERaI.INFORMATIO\
Pumping Records
Source of information:
Was system pumped as part of the inspection(yes or no):
If ves; volume pumped: gallons--How was quantity pumped deterrrrined?
Reason for pu. ing:
TI OF'SYSTE. Z
Septic tank, distribution box; soil absorption system
_Single cesspool
_Overflow cesspool
_Privy
_Shared system(ves or no) (if yes, attach previous inspection records;if anv)
;nnovativ/Alternative technology.Attach a copy of the current opera ron and=
obtained from system owner)
Tight tank Attach a copy of the DEP approval
Other(describe):
Approximate age of all components, date}' talled(if 1moRn)ands rcz of info-n t on:
�/`C 1��✓1� L -- �O fY
Were se«-age odors detected when arriving at the site(yes or no):/4;�f
-
Page 7 of 11
OFFICIAL INSPECTION FOR.17—NOT FOR VOLUN i_--RY ASSESSMENTS
SUBSURFACE SEA;'AGE DISPOSAL SYSTEMn, SPECTIO\ FORM
PART C
SYSTE T IN OIZ�7ATION(.continued)
Property Address: pC G/22v► ri ems-
-��
Owner: c�C G1
Date of Inspection: // Q
BUILDING.SENVER(locate gn,site plan)
Depth below grade: O
Materials of construction:_cast iron r Kc_other(explain): _
Distance from private water supply well or suction line:
Comments (on condition of joints;venting,evidence of leakage;etc.):.
SEPTIC TANK:_(locateo�sire plan)
,Depth below grade:
Material of construction: concrete_metal_fiberglass_pol,ethy lene
other(explain)
Iftank is metal list age: _ Is age confirmed by a Certificate of Compliance(yes or noi:_;;a-ach a cc .,-o=
certificate) y r
Dimensions: ] X 7,
Sludge depth: —� a 9
Distance from top f sludge to bottom of outlet tee or baffle:
Scum thickness: eS
Distance from top of scum to top of outlet tee or baffle: !/
Distance from bottom of scum to bott�n of outlet tee or baffle:
How were dimensions deternuned: CJ�j
Comments(on pumping recommendations.inlet and ouIet tee or baffle condition. struc=ai inte l_cuid 1.
as r- ated to outlet invert. evidence of le ' a2ee.etc.): 1
✓`1 I✓1 h O 7L �/ l /�?-G G h/t/ G c
GREASE TRAP:l (locate on site plan)
Depth below grade:
Material Of COIlS TuCiiOn:_concrete_metal_fiberglass pC,yeta'lviene_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 pupping recommendations.inlet and outlet tee or baf Ie condition. strucP;r-a
as related to outlet invert, evidence of Ieakaoe, etc.):
}=aaE Q of 1 1
OFFICIAL INSPECTION FOR-NJ—NOT FOR VOLUNTARY ASSESSAIEN c
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PARS'C
SYSTEM I FOR_MATION(continued)
Property Address: /c� (TrP�"',6/t e,
I GN✓1t /!�/� OoZ6O/
ONs-ner: :::2 r�
Date of Inspection: // /� O b
TIGHT or HOLDING TANK:4 (tank must be pumped at time of inspection)(Iocate on site pla-:'
Depth below-grade:
Material of construction: concrete metal_fiberglass ethylene 07he-(e�:n1=
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 BOX: 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 ca._%,ove7, ant. e� de-c_ e .
leakage ±o or out of box. etc.):
PUNIP CHAMBER:/ (locate on site plan)
Punmps in working order(yes or no):
Ala_ms in Nvorking order(yes or no):
Comments (note condition of pump chamber;condition of pumps and appurtenances; etc.`:
Tirl� � to cr,orfi nr Fnrm (.I1;�;nnn
Page 9 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLLI-TARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION- FOR-M
Y_A RT C
/SYSTE�'I INFORINIA.TIOL 1'con�!nued)
Property Address: pC (7"�P�Ph✓rl�c/ /-"
Oa-6 19/
Date of Inspection: V/2r a�
SOIL ABSORPTION SY'STEIi(SAS): (locate on site plan,excavation not required)
If SAS not located explain why:
T pe_ x �/P— C. 5- 74'
leachmg pits,number:
leaching chambers-.number:
leachinn galleries; number: l J;Lp rzc
leaching trenches, number. length:
leaching fields; number, dimensions:
overflow cesspool. number:
innovative/alternative system Type/name of technology:
Comments(note condition ofsoil, signs of hydraulic failure:level ofponding, damp soil, condi-non of _e-no-.
) �
�D N c�/N5 pZ 6 G. 1 771L, S1_"i Gi
/SHf
CESSPOOLS: /y (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 scu,-n'laver:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater inflow(yes or no):
Comments (note condition of soil, signs of hydraulic failure;level ofpbndg. conditio- c= eCeta-eu.
PRIVY: (locate on site plan)
Materials of construction:
Dimensions:
Depth of solids:
Comments (note condition of soil, signs of hydraulic failure,level of ponding, cor_di
Page 10 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ,SSESSA rEoTS
SUBSURFACE SEWAGE DISPOSAL,SYSTEM I\SP ECTiON FOR-'NI
P 4RT C
SYSTEM I "FORnLAXIO (con-,i_ucd
Property Address:
Cariv��s D�6t/
Owner-z G �
Date of Inspection: Q�
SKETCH OF SEWAGE DISPOSAL SYSTEIN,I
Provide a sketch of the se,, aae disposal system including ties to at least t- o permanent reference lance:_ark_ or
benchmarks. Locate all \,,-ells within 100 feet. Locate where public water su-opl enters the 1 uild n?.
33
T;rlo G. r»c»nrtrn» V_,_ g/1:/onnn 10
t
Page 11 of I
OFFICIAI, INSPECTION FORM-\OT FOR VOLU T—RY _ASSESS'£ENTS
SI JBSURFACE SEWAGE DISPOSAL SYSTEM I'1 SPECTION FORM
YART C
SYSTEM INFORMATION(continued)
Property Address: 6_ree
('caner:
Date of Inspection: /0'&
SITE EXA.NI
Slope
Surface water
Check cellar
Shallow-wells j O
Estimated depth to ground water S feet GO.A
?lease indicate(check) all methods used to determine the high ground water elegy a=on:
Obtained from system design plans on record-If checked,date of design plan rep ie-.-ed:
O' rued site(abutting property observation hole within 1-0 feet of SAS)
Checked with local Board of Health-explain: _�G�S
Checked«:th local exca�-ators,installers-(attach documentai':on)
Accessed_SGS database-explain:
You mu des r e how you established tt��g'a h ground Hater ey vatd n:
i
COMMONWEALTH OF MASSACHUSETTS
Z F EXECUTIVE OFFICE OFNIIIaNIVIENAL AFFAIRS
d DEPARTMENT OF ENVIRONMENTAL P;a TSCTION
�� A 7(q� -
1ARCEL
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM F RWE C E IV E
PART A
CERTIFICATION S E p 14 2004
Property Address: 72 Greenbrier Lane TOWN OF BARNSTABLE
West Hyannisport,MA 02672 HEALTH DEPT.
Owner's Name: Bruce Kennedy
Owner's Address: same
Date of Inspection: September 1,2004
Name of Inspector:(please print) David D.Flah Jr.,R_S.
Company Name: Flaherty Environmental Services
Mailing Address: P.Q.Box 363
Yarmouth Port,MA 02675
Telephone Number: (508)362-1657
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 fimction 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:
X Passes
Conditionally Passes
Needs Fuj1her Evaluation by the Local Approving Authority
Z r
Inspector's Signature: Date: / a
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.
Page 2 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 72 Greenbrier Lane
W.Hyanniggg MA 02672
Owner: Kennedv
Date of Inspection: September 1,2004
Inspection Summary: Check AAC,D or E/ALWAYS complete all of Section D
A. System Passes:
X 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' e"Conditional Pass"section need to be replaced or
repaired.The system,upon completion of the reply ent or repair,as approved by the Board of Health,will pass.
Answer yes,no or not determined(Y,N,ND the for the following statements, If"not determined"please
explain.
The septic tank is metal and r 20 years old*or the septic tank(whether metal or not)is structurally
unsound,exhibits substantial infll 'on or exfiltration or tank failure is imminent. System will pass inspection if the
existing tank is replaced with a lying septic tank as approved by the Board of Health.
*A metal septic tank will pass' 'on if it is structurally sound,not leaking and if a Certificate of Compliance
indicating that the tank is les 20 years old is available.
ND explain:
Observation of wage backup or break out or high static water level in the distribution box due to broken or
i obstructed pipe(s)or ue to a broken,settled or uneven distribution box. System will pass inspection if(with
approval of Board o Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
Th system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will
pass ins 'on if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
explain:
Page 3 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 72 Greenbrier Lane
W. isport,MA 02672
Owner: Kennedy_
Date of Inspection: September 1,2004
C. Further Evaluation is Required by the Board of Health:
Conditions exist which require further evaluation by the Bo 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 determi s in accordance with 310 CMR 15.303(1)(b)that the
system is not functioning in a manner which ' protect public health,safety and the environment:
Cesspool or privy is within 50 feet of a face water
_ Cesspool or privy is within 50 feet of bordering vegetated wetland or a salt marsh
2. System will fail unless the B rd of Health(and Public Water Supplier,if any)determines that the
system is functioning in a man er that protects the public health,safety and environment:
_ The system has a se tic tank and soil absorption system(SAS)and the SAS is within 100 feet of a
surface water supply o 'butary to a surface water supply.
_ The system h a septic tank and SAS and the SAS is within a Zone 1 of a public water supply.
The system as a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
The syst has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a
private at supply well".Method used to determine distance
"This sy tem passes if the well water analysis,performed at a DEP certified laboratory,for coliform
bacteria d volatile organic compounds indicates that the well is free from pollution from that facility and
the p ence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
failur criteria are triggered.A copy of the analysis must be attached to this form.
3. her:
Page 4 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 72 Greenbrier Lane
W.Hyanni sport,MA 02672
Owner: Kennedy
Date of Inspection: Sevtember 1.2004
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all inspections:
Yes No
X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
X_ Liquid depth in cesspool is less than 6"below invert or available volume is less than%day flow
X_ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped
X_ Any portion of the SAS,cesspool or privy is below high ground water elevation.
X_ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
X_ Any portion of a cesspool or privy is within a Zone 1 of a public well.
_ X_ Any portion of a cesspool or privy is within 50 feet of a private water supply well.
X_ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis. [This system passes if the well water analysis,
performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria
are triggered.A copy of the analysis must be attached to this form.]
No (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as
described in 310 CMR 15.303,therefore the`system fails.The system owner should contact the Board of
Health to determine what will be necessary to correct the failure.
E. Large Systems:
To be considered a large system the sy m must serve a facility with a design flow of 10,000 gpd to 15,000
gpd.
You must indicate either`yes"or" "to each of the following:
(The following criteria apply to ge systems in addition to the criteria above)
yes no
the system is 400 feet of a surface drinking water supply
the system' within 200 feet of a tributary to a surface drinking water supply
the syste is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped
Zone f a public water supply well
If you have eyed"yes"to any question in Section E the system is considered a significant threat,or answered
"yes"in Secti D above the large system has failed.The owner or operator of any large system considered a
significant at under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
15.304.Th system owner should contact the appropriate regional office of the Department.
Page 5 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 72 Greenbrier Lane
W.HvanniWA MA 02672
Owner: Kennedy
Date of Inspection: August 12,2004
Check if the following have been done.You must indicate`yes"or"no"as to each of the following:
Yes No
X _ Pumping information was provided by the owner,occupant,or Board of Health
X Were any of the system components pumped out in the previous two weeks?
X — Has the system received normal flows in the previous two week period?
X Have large volumes of water been introduced to the system recently or as part of this inspection?
X i Were as built plans of the system obtained and examined?(If they were not available note as N/A)
X _ Was the facility or dwelling inspected for signs of sewage back up?
X Was the site inspected for signs of break out?
X — Were all system components,excluding the SAS,located on site?
X Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the
conditio_n of the bales or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of
scum?
X _ 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
X _ Existing information.For example,a plan at the Board of Health.
X 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)]
Page 6 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE IDISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 72 Greenbrier Lane
W.HvannimgA MA 02672
Owner: Kennedy
Date of Inspection:Sptember 1,2004
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): 3 Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330
Number of current residents: 2
Does residence have a garbage grinder(yes-of no): NO
Is laundry on a separate sewage system(yes-or no): NO [if yes separate inspection required]
Laundry system inspected(yes ore): YES
Seasonal use:(yes-er no): NO
Water meter readings,if available(last 2 years usage(gpd)): '02: 111,452gal,3054.gpd; '03: 77,792 gal.213 go.
Sump pump(yes-of no): NO
Last date of occupancy:_PRESENT
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 03): gpd
Basis of design flow(seats/pe sgft,etc.):
Grease trap present(yes or
Industrial waste holding present(yes or no):
Non-sanitary waste to the Title 5 system(yes or no):
Water meter ,if available:
Last date of oc cy/use:
OTHER(d be):
GENERAL INFORMATION
Pumping Records
Source of information: owner
Was system pumped as part of the inspection(yes-of no): NO,pumped after inspection.
If yes,volume pumped:__,___gallons—How was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM
X Septic tank,distribution box,soil absorption system
_Single cesspool
Overflow cesspool
Privy
Shared system(yes or no)(if yes,attach previous inspection records,if any)
_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: 1999,Barnstable BOH
records.
Were sewage odors detected when arriving at the site(yes-er no): NO
Page 7 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 72 Greenbrier Lane
_W.HyanniMort,MA 02672
Owner: Kmngdv
Date of Inspection:_September 1.2004
BUILDING SEWER(locate on site plan)
Depth below grade: 12 inches
Materials of construction: X_cast iron _40 PVC other(explain):
Distance from private water supply well or suction line: >100 feet
Comments(on condition of joints,venting,evidence of leakage,etc.): ioints tight no evidence of leakage.
SEPTIC TANK:^(locate on site plan)
Depth below grade: 6 inches
Material of construction: X concrete metal—fiberglass polyethylene
_other(explain)
If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of
certificate)
Dimensions:., 1000 gallon
Sludge depth: 4 inches
Distance from top of sludge to bottom of outlet tee or baffle: 44 inches
Scum thickness: >1 inch
Distance from top of scum to top of outlet tee or baffle: 6 inches
Distance from bottom of scum to bottom of outlet tee or baffle: 14 inches
How were dimensions determined: tape measure,PVC"yardstick"
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.): pu_ping done at time of inspection,no evidence of leaka-ge,
inlet and outlet tees in good condition
GREASE TRAP:_,.,_(locate on site plan)
Depth below grade:
Material of construction: concret _metal_fiberglass_polyethylene_other
(explain):
Dimensions:
Scum thickness:
Distance from top of sc o top of outlet tee or baffle:
Distance from bottom o scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments(on pum g recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet vert,evidence of leakage,etc.):
' r
Page 8 of 11
u
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 72 Greenbrier Lane
W.Hyannisport,MA 02672
Owner: Kennedy
Date of Inspection•_September 1,2004
TIGHT or)MOLDING TANK: (tank must be pumped time of inspection locate on site plan)
Depth below grade:
Material of construction: concrete metal fiberglass_polyethylene other(explain):
Dimensions:
Capacity: _--gallons
Design Flow: gall day
Alarm present(yes or no):
Alarm level: Alarm in w ing order(yes or no):
Date of last pumping:
Comments(condition of al and float switches,etc.):
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.): D-box level,no evidence of 2MOLover or leak e.
PUMP CHAMBER: (locate site plan)
Pumps in working order(yes no):
Alarms in working order or no):
Comments(note coedit' ofpump 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: 72 Greenbrier Lane
W.fl angp sport,MA 02672
Owner:_Kennedy
Date of Inspection: September 1,2004
SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required)
If SAS not located explain why:
Type
X leaching pits,number:I
leaching chambers,number:_
leaching galleries,number:
leaching trenches,number,length:
leaching fields,number,dimensions:
overflow cesspool,number:
innovativelalternative system Typetname of technology:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,
etc.): no sign of hydraulic failure,no ponding,vegetation normal,water level 42 inches below invert
CESSPOOLS: (cesspool must be pumped as 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 inflo (yes or no):
Comments(note condition of oil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
PRIVY: . (l on site plan)
Materials of con ction:
Dimensions:
Depth of soli Xs:
Comments Ofiote 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: 72 Greenbrier Lane _
W.Hyannisport,MA 02672
Owner: Kennedy
Date of Inspection:, September 1,2004
G 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.
6 �
I� 3
Zs
-2 33
2- Z0i
Q 3 - 211 '
I
Page 11 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 72 Greenbrier Lane
W. sport,MA 02672
Owner: Kennedy_
Date of Inspection: September 1,2004
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water >20 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: 01/22/02
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)
X Accessed USGS database-explain:
You must describe how you established the high ground water elevation: re_p vious inspection using USGS data.
L�0'CAT10N,6 SEWAGE PERMIT NO.
VILLAGE
IV 7-
I N S T A L ER'S NAME i ADDRESS
f U I L D E 111 07
WN/ER
DATE PERMIT ISSUED
DATE COMPLIANCE ISSUED
`rl
O
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f\�
QJ
V''
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O ��x
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�+-
- _ r Com_M0 NNVEALTH OF MASSACHUSET_TS
Pz
EXECUTIVE OFFICE OF ENvIRONMENTAL AFFAIRS
:! DEPARTMENT OF ENVIRONMENTAL PRO OWN n ,
ONE WINTER STREET; BOSTOI %LA 02106 (617) 292--.
UDY CORE
Secretan
ARGEO PAUL CELLUCCI0�, t9 11719
D t.. B. STRUHS
Governor 9,
oinmissioner
Nob
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTIO M 4 ` �F
V` V PART A..
~
� CERTIFICATION
r ti
Lo — (3-7 QW`
Property Address: , �fUtt���j4A c R. Lk) Name of Owner )
`f W, Iddress of Owner: ��� �
Date of Inspection: L(Li,(l5°� , h
Name of Inspector:(Please P'rintl H ,�ct,1 lt:f JCC [G U p�•�`'��'�� a • Li\� t1
am a DEPapproved system inspector pursuant to Section 15.1340 of Title 5(310 CMR 15.000)
Company Name: LL1l A[ Fly Ht kc-_ L. ..s r AA �u F
Mailing Address:�?,r_-) A.,a 2 -3 U��N
Telephone Number: /�v� 4& 31 ;;Z. /Lr • 4=4=2_
CERTIFICATION STATEMENT
1 certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate
and complete as of the time of inspection. The,inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems. The system:
Passes
_4.1conditionally Passes
_ Needs Further Evalua 'on By t e Local Approving Authority
_ Fails
4
Inspector's Signature: l Date:
The System Inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEPlwithin thirty (30) days of
completing this Inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the Inspector and the system owner
shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the
system owner and copies sent to the buyer,if applicable, and the approving authority.
NOTES AND COMMENTS
revised 9/2/96 Pagel of11
Printed on Recycled Paper
it
( •1
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (contirwed)
'roperty Address:
Jwner:
Date of Inspection:
INSPECTION SUMMARY':'' Check A, B, C, or D:
A. SYSTEM PASSES:
4I have not found an:y,information which indicates that any of the failure conditions described in 310 CMR 15.303 exist. Any failure
—1 criteria not evaluated'are indicated below.
COMMENTS`. % r'
. B. SYSTEM CONDITIONALLY PASSES:
One or.more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon
completion of the replacement or repair, as approved by the Board of Health, will pass. .
Indicate yes, no, or not determined (Y, N, or NO). Describe basis of determination in all instances. If "not determined", explain why not.
_ The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of
Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection; or
the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank
failure is imminent. The system will pass inspection if the existing septic tank is replaced with a complying septic tank as
approved by the Board of Health.
_ Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s)
or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of
Health).
broken pipe(s) are replaced
obstruction is removed
distribution box is levelled or replaced
_ The system required pumping more then four times a year due to broken or obstructed pipe(s). The system will pass
inspection if(with approval of the Board of Health):
broken,pipe(s) are replaced
obstruction is removed
revised 9/2/98 Page 2ofII
f
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:
Owner:
Date of Inspection:
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 t'he system is failing to protect the
public health, safety and the environment. /
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 0 CMR 15.303(1)(b)THAT THE SYSTEM
IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND AFETY AND THE ENVIRONMENT:
_ Cesspool or privy is within 50 feet of surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a sal marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC ATER SUPPLIER,IF ANY)DETERMINES THAT THE SYSTEM IS
FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEAL AND SAFETY AND THE ENVIRONMENT:
_ The system has a septic tank and soil absorption syste (SAS)and the SAS is within 100 feet of a surface water supply or
tributary to a surface water supply.
_ The system has a septic tank and soil absorption sy em and the SAS is within a Zone I of a public water supply well.
_ The system has a septic tank and soil absorption s stem and the SAS is within 50 feet of a private water supply well.
_ The system has a septic tank and soil absorption ystem and the SAS is less than 100 feet but 50 feet or more from a
private water supply well, unless a well water a alysis for coliform bacteria and volatile organic compounds indicates that the
well is free from pollution from that facility an the presence of ammonia nitrogen and nitrate nitrogen is equal to or less
than 5 ppm. Method used to determine dist ce (approximation not valid).
3) OTHER
revised 9/2/9 Page 3of11
4.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
property Address:
Owner:
Date of Inspection:
D. SYSTEM FAILS:
You must indicate either "Yes" or "No" to each of the following:
I have determined that one or more of the following failure conditions exist as described in 310 CMR 1 .303. The basis for this
determination is identified below. The Board of Health should be contacted to determine what will b ecessary to correct the failure.
Yes No
_ Backup of sewage into facility or system component due to an overloaded or clogged AS or cesspool.
_ Discharge or ponding of effluent to the surface of the ground or surface waters d to an overloaded or clogged SAS or
cesspool.
Static liquid level in the distribution box above outlet invert due to an overlo ed or clogged SAS or cesspool.
Liquid depth in cesspool is less than 6" below invert or available volume ' less than 1/2 day flow.
_ Required pumping more than 4 times in the last year NOT due to clo ged or obstructed pipe(s).
Number of times pumped_.
_ Any portion of the Soil Absorption System, cesspool or privy is elow the high groundwater elevation.
Any portion of a cesspool or privy is within 100 feet of a s face water supply or tributary to a surface water supply.
Any portion of a cesspool or privy is within a Zone I of public well.
_ Any portion of a cesspool or privy is within 50 feet a private water supply well.
Any portion of a cesspool or privy is less-than 1 feet but greater than 50 feet from a private water supply well with no
acceptable water quality analysis. If the well s been analyzed to be acceptable, attach copy of well water analysis for
,coliform.bacteria, volatile organic compound , ammonia nitrogen and nitrate nitrogen.
E. LARGE SYSTEM FAILS:
You must indicate either "Yes" or "No" to each of the f lowing:
The following criteria apply to large systems' addition to the criteria above:
The system serves a facility with a desig ow of 10,000 gpd or greater(Large System) and the system is a significant threat to public
health and safety and the environment cause one or more of the following conditions exist:
Yes No
the system is within 40 feet of a surface drinking water supply
the system is within 00 feet of a tributary to a surface drinking water supply
the system is loc ad in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA) or a mapped Zone II of a public
water supply w 1)
The owner or operator of any s h system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional
office of the Department for f her information.
revised 9/2/98 Page 4ofII
I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: -72 Owner:
Date (�
Date of Inspection: t
Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following:
Yes No
Pumping information was provided by the owner, occupant, or Board of Health.
)( _ None of the system components have been pumped for at least two weeks and the system has been receiving rwrmal flow
4\_ rates during that period. Large volumes of water have not been introduced into the system recently or as part of this
inspection.
As built plans have been obtained and examined. Note if they are not available with N/A.
The facility or dwelling was inspected for signs of sewage back-up.
The system does not receive non-sanitary or industrial waste flow.
_ The site was inspected for signs of breakout.
All system components, excluding the Soil Absorption System, have been located on the site.
Y _ The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles
tC or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum.
The size and location of the Soil Absorption System on the site has been determined based on:
Existing information. For example, Plan at B.O.H.
Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable)
�[ (15.302(3)(b)]
- _ The facility owner(and occupants,if different from owner) were provided with information on the proper maintenaace.of
Subsurface Disposal Systems.
4
revised 9/2/98 Page 5of11
� a
i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
'roperty Address: 7L 6)fAwt--b�''---
Owner:
Date of Inspection:
1 FLOW CONDITIONS
RESIDENTIAL:
Design flow:. 30 g.p•d./bedroom.
Number of bedrooms (design):O� Number of bedrooms (actual):-
Total DESIGN flow_
Number of current residents: O
Garbage grinder(yes or no):�
Laundry(separate system) (yes or no): 1J; if yes, separate inspection required
Laundry system inspected (yes or.no)
Seasonal use (yes or no):�1
Water meter readings, if available (last two year's usage (gpd): (`
Sump Pump (yes or no): N
Last date of occupancy: Cy� t,.a cwOS
COMMERCIAL/INDUSTRIAL:
Type of establishment:
Design flow: 92d ( Based on 15.203)
!Basis of design flow
Grease trap present: (yes or no)_
Industrial Waste Holding Tank present: (yes or no)_
Non-sanitary waste discharged to the Title 5 system: (yes or no)_
Water meter readings, if available:
Last date of occupancy:
OTHER:(Describe)
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
Ivu
System pumped as part of inspection: (yes or no)_
If yes, volume pumped: gallons
Reason for pumping:
TYPE OF SYSTEM
Septic tank/distribution box/soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system(yes or no) (if yes, attach previous inspection records,if any)
I/A Technology etc. Attach copy of up to date operation and maintenance contract
Tight Tank Copy of DEP Approval
Other
APPROXIMATE AGE of all components, date installed lif known)and source of information:
Sewage odors detected when arriving at the site: (yes or no) NV
revised 9/2/96 Page 6ofII
I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
'roperty Address: .1
Owner: 0),' 3i'kX V
Date of Inspection: l C-Lli�1dk
BUILDING SEWER: ��/��
(Locate on site plan) U b
Depth below grade:_
Material of construction:_cast iron_40 PVC other (explain)
Distance from private water supply well or suction line
Diameter
Comments: (condition of joints, venting, evidence of leakage, etc.)
SEPTIC TANK:
(locate on site p an)
w
Depth below grade:`
Material of construction: concrete_metal _Fiberglass _Polyethylene_other(explain)
If tank is metal, list age_ Is age confirmed by Certificate of Compliance_ (Yes/No)
Dimensions: 1000ci
Sludge depth: 3 V
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: teil
Distance from bottom of scum to bottom of outlet tee or baffle:
How dimensions were determined:
'ornments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, d`ppt�hCof liquid level in relation to outlet i ert, truQct Jr\inttegrity,
evidence of leakage, etc.)
GREASE TRAP: NO
(locate on site plan)
Depth below grade:_
Material of construction:_concrete_metal_Fiberglass _Polyethylene_other(explain)
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert, structural integrity,
evidence of leakage, etc.)
revised 9/2/98 Page 7of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
(� SYSTEM INFORMATION (continued)
Iroperty Address:
Owner: Vo vk-
Date of Inspection.
TIGHT OR HOLDING TANK: WC-) (Tank must be pumped prior to, or at time of, inspection)
(locate on site plan)
Depth below grade:_
Material of construction: _concrete_metal _Fiberglass_Polyethylene—other(explain)
Dimensions:
Capacity: gallons
Design flow: gallons/day
Alarm present
Alarm level: Alarm in working order: Yes _ No
Date of previous pumping:
Comments:
(condition of inlet tee, condition of alarm and float switches, etc.)
61
DISTRIBUTION BOX: f,W)
(locate on site plan) �T �-� , (1 l.�
Depth of liquid level above outlet invert:luC�,_0 oaW-i� `r'""`
Comments:
(note if level and distribution is equal, evidence of s ds carryover; evidence of leakage into or out of box, etc.)
�-P,ax d�sTnrl��Yi �s a.i�
PUMP CHAMBER: Wb
(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.)
F
revised 9/2/98 Page 8ofII
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
l , SYSTEM INFORMATION (conbrwed)
'roperty Address: 72 C1nUMV OVU �
Ovrnec: WL.��FA
Date of Inspection: � j
SOIL ABSORPTION SYSTEM(SAS):US
(locate on site plan, if possible; excaJation not required, location may be approximated by non-intrusive methods)
If not located, explain:
Type:
leaching pits, number:_
leaching chambers, number:_
leaching galleries, number:_
leaching trenches, number, length:
leaching fields, number, dimensions:
overflow cesspool, number:_
Alternative system:
Name of Technology:
Comments:
(rote condition of soil, signs of hydraulic failure level of po ding, p il, condition of veg tation, etc.)
c S
CESSPOOLS:
(locate on site Ian)
Number and configuration:
Depth-top of liquid to inlet invert:
Depth of solids layer:
)epth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater:
inflow (cesspool must be pumped as part of inspection)
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
PRIVY:
(locate on site plan)
Materials of construction: Dimensions:
Depth of solids:
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
revised 9/2/98 Page 9oftl
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
''rop"AAddress: (Z. UKQ WputgL-
lwner: k rec v,
Date of Inspection:
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent reference landmarks or benchmarks
locate all wells within 100' (Locate where public water supply comes into house)
L t '
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
roperty Address:`
Owner: Vj c.,A w.
Date of Inspection:
NRCS Report name V y —
Soil Type_ -- --
Typical depth to groundwater __ __
USGS Date website visited No
Observation Wells checked
Groundwater depth: Shallow Moderate Deep
SITE EXAM Slope ro
Surface waterNU
Check Cellar Ate)
Shallow wells N(A-
L
Estimated Depth to Groundwater�kld Feet
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from Design Plans on record
Observed Site(Abutting property, observation hole, basement sump etc.)
Determined from local conditions
Checked with local Board of health
Checked FEMA Maps
Checked pumping records
Checked local excavators, installers
Used USGS Data
Describe how you established the High Groundwater Elevation. (Must be completed)
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revised 9/2/98 Pageltof11
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TOWN OF BARNSTABLE
LOCATION tqQ \0C\t_tL. l--*,'.). SEWAGE#
VILO,GE W. `�u**363K �(L�— ASSESSOR'S MAP& LOTS
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK.CAPACrry k0Q !a
LEACHING FACEL=: (type) (size) l.brOO
NO.OF BEDROOMS
BUILDER OR OWNER V p
TERMLTDATE: \"\.a�__COMPLIANCE DATE: 2, /9
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Z 0 Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) I, Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) �, Feet
Furnished by D4atS�t
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op
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No. 7 S .... Fim..............................
Ltd.,
THE COMMONWEALTH OF MASSACHUSETTS
BOARD O HE
H
Applirntilan for Ui_q#una1 Works Tnnitrnrtinn rantit
Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal
Sys at: V -�,�i �-•Gj
.......
.. l.... . 1! .. / 1-_-._. �.--
'/J• �NJ
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Loc ion-Address.
1ee2 .... ..... --•---------•-------• -••-------------_---- ......_... ...
essOwne ACr
i /
Installer Address �y
Type of Building Size Lotf .1_ ___.....Sq. feet
U
Dwelling—No. of Bedrooms............................................Expansion Attic ( '- Garbage Grinder ( )
Other—T e of Building No. of persons............................ Showers — Cafeteria
Q' Other fixtures _______________________________ __
W Design Flow...........................................gallons per person per day. Total daily flow.........33�(O.._.._......._.___gallons.
WSeptic Tank—Liquid capaciallons Length Width................ Diameter._.... Depth
x Disposal Trench—No. ................... Width......`.._.._._..._ Total Length........... __... Total leaching area...... ____sq. ft.
Seepage Pit No.......-/---- -- Diameter..1.40......... Depth below inlet..6�_............. Total leaching area-.'=�sq. ft.
Z Other Distribution box� Dosing tank ( ) /
`" Percolation Test Results Performed by---------------------�j -Pam.. Date 6 ��
,aa Test Pit No. I......Z.r______-minutes per inch Depth of Test Pit--------,C ..... epth to ground wafer. ..
(i Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water------------____--_-_.-.
--------------- ..... ...................................................................
ODescription of Soil----••----------o-�Z t�G`„�'t.... . -•-----------------------------------------------------------------------------------•--•------
--•--•--•----------------------------------------------------- --------------------•--- -- ._...
W •-••-------•- -------------------------------------f_2/ -------- `Z,
VNature of Repairs or Alterations—Answer when applicable.-----------------------------------------------------------------------------------------------
...---•----•-•-----------------------•---•------•----•------•-•--•-•---•----•------.......-•----•------•---••-----------........------------------•------••---...-•----•----•......--------•--•---•---•
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of'TT L- 5 of the State Sanitary Code— he undersigned £ur :er agrees not to place the system in
operation until a Certificate of Compliance has been i u by t e and of 1 lth.
�S i gn
Date
Application Approved By.......... { v/ --------------- 1�
Application Disapproved for the following reasons:................................
--------------------•-----------Date----•---------
--••-------------•----------•---------------•---------------•----------------------------------------------•------•---•••-•-••--------••----•---•------------------------------------------------------
Date
PermitNo......................................................... Issued.......1. -a__. ------
Date
No........77's .... Fps.......`-.... ...........
THE COMMONWEALTH OF MASSACHUSETTS
BOARD 01= HE L
......OF........ .. ,C1 .. --- -------------------------
Appliration for Uiipuiial Works Tiamitrurtinn ramit
Application is hereby made for a Permit to Construct ,(�or Repair ( } an Individual Sewage Disposal
7,04
Loc/ion-Addres r Lot,N/o. pj
wne A ress
W /!
,-7 ............. rah ---- •• ,f f.r M'". ... ._..... r'R1'°L?'l ..........................
In f _.....
Instafr Address
dType of Building Size Loti1 ..---....Sq. feet
Dwelling—No. of Bedrooms___.. '..�....::.............•.•.....__..__Expansion Attic _ Garbage Grinder ( )
p-1 Other—Type of Building ............................ No. of persons-_-_. _-__-__-____________ Showers ( ) — Cafeteria ( )
al Other fixtures .
d •.....
W Design Flow.............................. ._.gallons per person per day. Total daily flow____.__ gallons.
04 Septic Tank—Liquid capac / allons 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._....___.._ '" •_
a - 4 � '"- ....`��ei
U*t.. Date.. .
Test Pit No. L_... __._minutes per inch Depth of Test Pit_______ ._._ th to round water_..__.___e
P P g
(z., Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground Water........................
---•---•----------•-•---------------------------------•-----------------------------------------------------------
D Description of Soil........ ...... _.
-------- `......... Z
U Nature of Repairs or Alterations—Answer when.applicable---------------------------------------------------------•--_-__-_-_-------______------•----__.
-••--•......-•--•-•.......................................
Agreement
The undersigned agrees to install the aforedescribed Individual Sewage Disposal-System in accordance with
the provisions of TITLE, 5 of the State Sanitary Code— he undersigned fur :er agrees not to place the system in
operation until a Certificate of Compliance has been > ue y t ard f h lth. r
Sag -��� "' - ------------------- --- ....-----=
+ f Wpm Date >
Application Approved By.••••• / t t..�--.. --- Date
Application Disapproved for the.f ollowing reasons:---------•-----•-------
............................................................. _......•---_.......y...................................................................................................................
Date
PermitNo..............................••-----------••----------- Issued.......................................................
`. Date
THE'COMMONWEALTH OF MASSACHUSETTS
'• 'BOARD O9 .�HEAD` _.._.
... 1 9........ ..OF..... .15,i.'. '" .�.....: ...............................
C LFW irtt# of Toutpliattrr
THIS IS ERTIFY, :)r
e Individual Sewage Disposal System constructed ( or Repaired ( )
�r ��,%,_-proyis
Installerypat--.--•--..-- Z�� '� A! jt's -__ ,�..W `d_d +`�` `'has been instal ed in accordance with ions o T •.'��`yyof The State Sanitary C de described in the
application for Disposal Works Construction Permit IN _ ._......'-��._...__.... da.ted_. `" l'`_ ... ..........
,tt .
THE ISSUANCE OF THIS CERT,FICATE SHALL'NOT BE CONS UE® AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTIONS IS TORY.
`_' 7
DATE.... ,............�• I pector.,..._.._
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF EALT
�`'� ✓
pI ...:...®F.......... '��'' -.,.-..,_ ............................. �•�...--
o......................... FE
Bispusal ; ks Cnonstrnr#i u ramit
Permission is hereby granted a'' ! '"fie r.f --•-•-------. :.............
` - ...
to Constructer Repair ( ) arg Individual ewage:Disp94 System
atNo............................ ------ f¢' 4 - ''= ------------------- •--------- ------...............
Street
as shown on the application for Disposal Works Construction P No.. .4oa
Dated-......................................
.... ... - u='t------
d- �q Health —...
DATE.... --------------• ---------------------•------------•--------
FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS '