HomeMy WebLinkAbout0005 KEEL WAY - Health 5 KEEL WAY
HYANNIS
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COMMONWEALTH OF 1VIASSACHUSETTS
EXECUTIVE OFFICE OF ENWIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
TITLE 5
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PARTA
CERTIFICATION
Property Address: 5 Keel Way
W Hyannisport
Owner's Name: David Reed
Owner's Address:
Date of Inspection:
Name of Inspector: (please print) William E_ . Robi_nson Sr.
Company Name: William E. Robinson Septic Service
Mailing Address: P O Box 1089
Centerville, MA
Telephone Number: (508) 775-8776
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 Secti 15.340 of Title 5(310 CMR 15.000). The system:
asses
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: Date:
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Healthvr
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 6/152000 page 1
Page 2 of I 1 r
1.
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OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ;
PART A
CERTIFICATION(continued) '
Property Address:5 Keel Way ,
W Hyannisport'
Owner: Reed
'Date of Inspection:
Inspection S mary: Check A,B,C,D or E I ALWAYS complete all of Section D
• A. Sys Passes: '
I have not found any information which indicates that any of the failure criteria described in 310 CMR
15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. ,
i
Comments: r t
4JE.7�o
B. System Conditionally Passes: �I
One or more system components as described in the"Conditional Pass"section need to be replaced or .
repa ed.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass.
- it
Answe yes,no or not determined(Y,N,ND)in the for the following statements.If"not determined"please }
explain.
e 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 x
existing is replaced with a complying septic tank as approved b`y the Board of Health. '`
•A meta septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance y.
indicati that the tank is less than 20 years old is available.
F
ND exp in:
bservation of sewage backup or break out or high static water level in-the distribution box due to-broken or '
obstru ed pipe(s)or due to a broken,settled or uneven distribution box.System will pass inspection if(with 's
appr al of Board of Health):•,
brokeui pipe(s)ate replaced
obstruction is removed
distribution box is leveled or replaced
r
explain: +.
The system required pumping more than 4 tines a yea due to broken or obstructed pipe(s).The system will ;
pas inspection if(with approval of the Board of Health):. '3
broken pipe(s)are replaced
obstruction is removed
ND explain: {
1F •
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Page 3 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 5 Keel Way
W Hvannisj2or
Owner• Ree
Date of Inspection:
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 iling to protect public health,safety or the environment.
I. 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. yytem will fail unless the Board of Health(and Public Water Supplier,if any)determines that the
syst m 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 froni a
private water supply well". Method used to determine distance
"This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
failure criteria are triggered. A copy of the analysis must be attached to this form.
3. Other:
F
3
Page 4 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS• y
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION,FORM"
PART A _
r
CERTIFICATION(continued) ]E
• t
Property Address: 5 Keel Way a!
W Hyannisport 0!
Owner: Reed
Date of Inspection:
System Failure Criteria applicable to`all systems:. c
Y must indicate`-yes"or"no"to each'ofth.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 L L
y _ Liquid depth in cesspool is less than 6"below invert or available volume is less than day flow
_ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number
of times pumped
Any portion of the SAS,cesspool or privy is below high ground water elevation.,
•y portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface -
water supply. r
y portion of a cesspool or privy is within a Zone 1 of a public well. -
_ y 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,
't performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds
i 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.] f
(Yes/No)The system fails. I have.!determined that one or more of the above failure criteria exist as f
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. La ge Systems: -
To be nsidered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 4
gpd• ,
a
You m st indicate either"yes"or"no"to each of the following:
(The f lowing criteria apply to large systems in addition to the criteria above) +
yes o f
the system is within 400 feet of a surface drinking water supply F
the system is within 200 feet of a tributary to a surface drinking water supply
the system'is located in a nitroger sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped
Zone II of a public water supply well
y r
_ A
If yo have answered"yes"to any question in Sestina E the system is considered a significant threat,or answered `
"yes'in Section D above the large system liras famed.The owner or operator of any large system considered a
sign ficant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR ` {
15. 04.The system owner should contact the appropriate regional office of the Department.
Y Page 5 of I I
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 5 Keel 'Way
Hyannisport
Owner: Reed
Date of Inspection: /_0
Check if the following have been done You must indicate"yes"or"no"as to each of the following:
Yes y0pumping
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?
— L/ Have large volumes of water been introduced to the system recently or as part of this inspection?
aG 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?.
V— Were all system components,excluding the SAS,located on site
I./ _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for
e b the condition
of thafffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum?
_ ✓ Was the facility owner(and occupants if different from owner)provided with information on the proper
maintenance of subsurface sewage disposal systems?
The size and location of,the Soil Absorption System(SAS)on the site has been determined based on:
Yes no
_ Existing information.For example,a plan at the Board of Health.
Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance
is unacceptable)[310 CMR 15.302(3)(b)]
5.
Page 6ofII
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS S
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
v PART C
SYSTEM INFORMATION
Property Address: 5 Keel Way -
W Hyannisport
Owner: Reed
Date of Inspection:
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): 3 , Number of bedrooms(actual):
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 4
Number of current residents:—A'� - {
Does residence have a garbage grinder(yes or no):A,�
Is laundry on a separate sewage system(yes or no):iU O [if yes separate inspection required]
Laundry,system inspected(yes or no): A. 10
Seasonal use: (yes or no): � 4ti. 1
Water meter readings,if available(last 2 years usage(gpd)):9 0 n n-01 '7_0500 gal. `
Sump pump(yes or no): A,o E 1 9 9 9-0 0 75,750 gal.
Last date of occupancy: .
!HER
ERCIAL/INDUSTRIAL '
establishment:
ow(based on 310 CMR 15.203):. gpd
design flow(seats/persons/sgft,etc.): `
rap present(yes or no):
l waste holding tank present(yes or no):
itary waste discharged to the Title 5 system (yes or no):_
eter readings,if available:
e of occupancy/use: r
:. (describe):
GENERAL INFORMATION " i
Pumping Records
Source of information:
Was system pumped as part of 6e inspection(yes or no):X O
If yes,volume pumped:_gallons--How was quantity pumped determined?
Reason for pumping: a''
TYP 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 r
obtained from system owner) I
Tight tank ,—Attach a copy of the DEP approval
Other(describe): 4 t
Approximate age of all components, date installed(if known)and source ohforma
ion:
/-C ! cs 14 o b•--es' ..
Were sewa a odors detected when arrivin at the site(Yes or no): 0
tr
f 3
6
Page 7 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 5 Keel Way
W Hyannisport'
Owner: Reed
Date of Inspection: a-/"0
Bi? DING SEWER(locate on site plan)
Dep below grade:
Mate ials of construction:_cast iron _40 PVC_other(explain):
Dis ce from private water supply well or suction line:
Co ents(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK:_(locate on site plan)
Depth below grade: ) �
Material of construction: Z✓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: ,
Sludge depth: a
Distance from top of sludge to bottom of outlet tee or baffle:
Scum thickness: 0
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:J
How were dimensions determined: A,C-LA-./
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels
as related�outlet invert,evide �of.11eakage,etc.):
,t L.
G ASE TRAP:_(locate on site plan)
Dep below grade:_
Mate 'al of construction:_concrete metal_fiberglass_polyethylene_other
(expl ' ):
Dime sions:
Scum hickness:
Dista a from top of scum to top of outlet tee or baffle:
Dista ce from bottom of scum to bottom of outlet tee or baffle:
Date f last pumping:
` Co ents(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity,liquid levels
as r lated to outlet invert,evidence of leakage,etc.):
i
Page 8 of I]
OFFICIAL INSPECTION FORM—NOTIOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM {
PART C ti
SYSTEM INFORMATION(continued)
Property Address: 5 Keel Way ,• '�
W HyannisE c�rfi
Owner: Reed ~'
Date of Inspection: �G•'�
TI T or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan)
Depth low grade:
Materia of construction: concrete metal fiberglass polyethylene -other(explain):
Dimen ions:
Capaci gallons ' f
D'sig Flow: gallons/day ,
Alarm present(yes or no):
Al level: - Alarm in working order(yes or no): r
Date f last pumping:
• Co ents(condition of alarm and float switches,etc.): -
c .
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 carryover,•any evidence of + ;
leakage into or out of box;etc.): ' • 1
' ,e Z4.." ,• i
71''
Y
PU P CHAMBER: (locate on site plan).-
. i
Pu ps in working order(yes or no): 3
Al s in working order(yes or no): {
C mments(note condition of pump chambar,condition of pumps and appurtenances,etc.):
a
4
. • iI
. 8 f
Page 9ofII
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART.C
SYSTEM INFORMATION(continued)
Property Address: 5 Keel Way _
W Hyannisport 4 `
Owner: Reed
Date of Inspection:/ —t7—/ + s '
SOIL ABSORPTION SYSTEM(SAS): f/ (locate on site plan,'excavation'not�required)
If SAS not located explain why:
• f 4
Type
aching pits,number:
leaching chambers,number:
leaching galleries,number: y
leaching trenches,number,length:
leaching fields,number,dimensions:
overflow cesspool,number:
innovative/alternative system Type/name of technology:' r�
Comments(note condition of soil,signs of hydr-auullic failure,level of ponding, damp soil,condition of vegetation,
etc.):
CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration: y
Depth—top of liquid to inlet�v�ert ty
Depth of solids layer: _• r
Depth of scum layer:
Dimensions of cesspool: J /
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.): f
PR (locate on site plan) '
Materi is of construction:
.Dimen ions: -
Depth f solids:
` Co ents(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
9. v h
t Page 10 of I l 1. k I
OFFICIAL INSPECTION FORM=NOT FOR'VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM. '
PART C I G
SYSTEM INFO_ RMATION(continued).'
continued). 3 t
Property Address•5 Keel Way
W Hyannisport
Owner:. Reed
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.
� � 6
, F• 1
oS A:ia 44
to
' adt
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Page 11 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 5 Keel Way
Hyannisport ` .
Owner: Reed
Date of Inspection: "d
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water .2—L�-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:6'—
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:
$. .j ay
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CONIMONWE.•\LTH OF NLkSSACHUSETTS
EXECUTr\E OFFICE OF EN
'VIROIvT4ENTAL AFFAIR,
DEPARTMENT OF ENvIRONMENTAL PROTECTION
r
ONE R'INTER STRrE`. BOSTON 1L-k 0210E (61i) 292•550u
TRUDYCO\i
Secre:arn
I •
I STP.•.:H'
ARGEO PAUL CELLUCCI � r•e:
Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM \�f
PART A
tA%%� CERT FlCATION � ®�
t� Name of owner 11tA1I��1— �'•'1 �_✓(/� '(O
I Property Address: S �C.0 ��- \t ►+
I Address of Owner: TO <0 r,e
1 NHS ok Qom_ 49
I Date of kupecti / y / t /� 9
Name of Inspector:(Please Print C it a c G f E�r^U `
I ant a DEP approved system inspector pursuant to Section 15•�340 of Trtie 5(310 CMR 15.000) 'qlF eta
// F k f� 'r« c. ....1� u F %
Company Name: At/ ri-r? /,�,H- O�(,�..`�
r MaMng Address: Z
I Telephone Number:
I
CERTIFICATION STATEMENT
certify that 1 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-
-,.Conditionally Passes Authority
_ Needs Further Evaluation By the Local Approving
_ Fai s
Date:
I {nspettor's Signature:-
1 Approving Authority(Board of Health or DEP)within thirty 1301 days o
The System Inspector shall submit a copy of this Inspection report to the
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
shad submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to ttre
system owner and copies sent to the buyer,If applicable, and the approving authority.
l
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NOTES AND COMMENTS
i -
lux—
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y,h,n, yN�\ow CsSSp�O � l'�`'L.1 u4.t� �\;'�''�t'4,.5 •.a(v� ��1�`2-�� < T��
o3 t kly",
5
revised 9/2/98 PY� iori►'.
Y n led Ps r
• +.. , `• Panted or,�Y< p�
i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
' PART A
i CERTIFICATION (contirwed).
i
I 'ropefty.Address:SVA�f-k
i Jwner:
i Date of Inspection:
INSPECTION SUMMARY: Check A, 8, C, or D:
A. SYSTEM PASSES:
have not found any information which indicates that any of the failure conditions described in 310.CMR 15.303 exist. Any failure
+ criteria not evaluated are indic ted belo
COMMENTS: (� tA�k J,_& Qi t �t� o
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 ND). 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
1 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 f 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 pipelsl
or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of
Health).
r broken pipets) are replaced "
` obstruction is removed
{ distribution box Is levelled or replaced
_ The system required pumping more than four times a year due to broken or obstructed pipets). The system will pass
Inspection If(with approval of the Board of Health): t
broken pipe(s)are replaced
ti
obstruction-is removed
t ,
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r # j. r `
s¢e 2 of V
' ',fit h-..l tT �:1.7 Y•
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION Icon inued)
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 orde to determine if the system is failing to protect the
public health, safety and the environment.
NES IN
1) IS NOT FUNCTIONING UNLESS
A MANNER WHICH WILL PRO CIT THE PUBLIO HEALTH AND SAFETY AND THEIENVIRONMENTE SYSTEM
IS NOT
_ Cesspool or privy is within 50 feet of surface water
Cesspool or privy is within 50 feet of a bordering vegetated et land or a salt marsh.
J.
ER.IF
Z) SYSTEM WILL FAIL UNLESS THE BOARD OF HEAL PU IC PUB
WATER
AND SAFETY IAFID THEYENVI DETERMINES
THAT THE SYSTEM IS
FUNCTIONING IN A MANNER THAT PROTECTS THE
_ The system has a septic tank and soil absorp on 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 soil abso tion system and the SAS is within a Zone I of a public water supply well.
_ and toil abs rption system and the SAS Is within 50 feet of a private water supply well.
The system has a septic tank
_ am and the SAS Is less then 100 feet but 50 feet or more from a
The system has a septic tank and toll ab rption syste
private water supply well, unless a well ater analysis for eoliform bacteria and volatile organic compounds indicates that the
;
well is free from pollution from that fac'ity and the presence ofo
ammonia
oniation not valid).nitrate nitrogen is equal to or less
(apthan 5 ppm. Method used to determin distance
3) OTHER
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. 2, �' Page3olll .
revised- 9/ / ,
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
! CERTIFICATION (continued)
i
Property Address:
Owner:
Date of Inspection:
D. SYSTEM FAILS:
You must indicate either -Yes" or -No- to each of the following:
have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this
Is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure.
determination
Yes No
_ Backup of sewage into facility-or system component due to an overloaded or cogged SAS or cesspool.
Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS of
cesspool.
Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
volume is less than 1l2 day flow.
Liquid depth in cesspool is less than 6" below invert or available
{ _ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped_.
I , .
i privy is below the high groundwater elevation.
_ Any portion of the Soil Absorption System, cesspool or p, Y
I
feet of,a surface water supply or tributary to a surface water supply.
Any portion of a cesspool or privy is within 100
I i
i Any portion of a cesspool or privy is within a Zone 1 of a public well
water supply
Any portion of a cesspool or privy is within 50 feet.of a private y well.
i renter than 50 feet from a private water supply well with no
l or privy is less-than 100 feet but g
i — — acceptable water quality or lanic eof mthe wellpounds hnmmonia nitrogenas been-an6lyzed tandenivate nitrogen.ach copy of well water analysis for
Any portion of a cesspool.coliform bacteria, vole g
! E. LARGE SYSTEM FAILS:
You must Indicate either "Yes" or "No"
large each
of the in addition.to the criteria above:
The following criteria apply to gsystems ,.
!I The system serves a facility with a design)low of 10,000 gpd or greater(Large Systeml and the system is a significant threat to put
i health and safety and the environment because one or more of the following conditions exist:
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 mapped Zone II of a publi
the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPAI or a
y — water supply well)
lease consult the local regio
rode the system In accordance with 310 CMR 15.304(21. Pn
' The owner or operator of any such system shall upg _
" office of the Department for further Information. -
t, 9/2.:9 Yk Px�e 4 oClt.
8 �.
revised / ,...
I
I •
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
!f -
I property Address:
Owner:
Date of Inspection:
f Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following:
i�
I 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 normal flow
rates during that period. Large volumes of water have not been introduced into the system recently or as part of this
inspection.
A.
As built plans have been obtained and examined. Note if they are not available with MI
' — 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.
i
_ The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles
t or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum.
f 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, appr
oximation of distance is unacceptable)
115.302(3)(b))
1
1 The facility owner(and occupants,If different from owner) were provided with information on the propermnintPnanc_a-0f
f _ SubSurface Disposal Systems.
f
i
S
'T d� �{�. ems' � '•f �, ,, .K .
r4 kF i
revised- 9i/ ' 98 :�=.}.,paeecoctl
I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM.
I PART C
SYSTEM INFORMATION
'roperty Address: S VA, '
I Owner:
Date of Inspection:
t
FLOW CONDITIONS
RESIDENTIAL:
Design flow: g.p.d./bedroom.
Number of bedrooms(design):�'� Number of bedrooms (actual):,
i Total DESIGN flow_ r
Number of current residents: " `
j Garbage grinder(yes or no):
Laundry(separate system) ( es or n®�: 11 yes, separate inspection required
Laundry system inspected ye r no) "
Seasonal use (yes or no):
Water meter readings, if available (last two year's usage (gpd):1�%
i Sump Pump(yes or no):O
Last date of occupancy:
{ COMMERCIALANDUSTRIAL: ,
Type of establishment• '
' Design flow: qpd 1 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
's
PUMPING RECORDS and source of information:
___ �UInn,D•IIC� o�•Wt/l_��
I System pumped as part of inspection:(yes or no)tiA
If yes.volume pumped: gallons -
Reason for pumping:
TYP OF SYSTEM
Septic tank/distribution box/soil absorption system
Single cesspool
Overflow cesspool
t Privy
Shared system(yes or no) tit yes.attach previous Inspection records,It 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(if known) and source of Information:
6 r� b111
Sewage odors detected when arriving at the site:(yes or no)—L-Ir*�,
A
{ e' le, .. .,
�� `' ,`r i- 8.-; _ •i;;�e`J•:P��c6oltt :`.y �.'.�2 ,:1r''
'revi'sed .9�2�g
b
t 'S wq♦� r 1 ti -
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (contirmed)
'roperty Address: /
Owner:
pate of Inspection: /
BUILDING SEWER:
(Locate on site plan)
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 plan)
Depth below grade:
Material of construction:_concrete_metal _Fiberglass _Polyethylene they(explain
If tank Is metal,list age_ Is age confirmed by Certificate of Compliance (Yes/No)
Dimensions:
Sludge depth:__.
to bottom of outlet tee or baffle:
Distance from top of sludge
Scum thickness:
to top of outlet tee or baffle:
Distance from top of scum
Distance from bottom of scum to bottom of outlet tee or baffle:
How dimensions were determined:
rity.
.1omments:
ing, condition of inlet and outlet to s or baffles, depth of liquid level in relation to outlet invert, structural integ
(recommendation for pump
evidence of leakage,etc.)
GREASE TRAP'
(locate on site plan)
Depth below grade:
Material of construction:,_,concrete,_metal_Fiberglass _Polyethylene_other(ezpleinl
Dimensions:
I Scum thlckness:_
to top of outlet tee baffle:
Distance from top of scum
i Distance.from bottom of scum to bottom of o let tee or baffle:
Date of last pumping:
t
Comments:
(recommendation for pumping, condition Inlet and outlet tees or baffles,depth of liquid level In relation to outlet invert, structural integrity,
evidence of leakage,etc.(
I'rf;e 7 of 11
revised 9/2/98;
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continuedl
'roperty Address:'
6 Owner:
Date of Inspection:
TIGHT OR HOLDING TANK: (Tank must be pumped prior to, or at time of, inspection)
' (locate on site plan)
Depth below grade:_
j Material of construction: _concrete _metal_Fiberglass_Polyethylene _other(explain)
i Dimensions:
�I 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.)
j
I
j DISTRIBUTION BOX:_
(locate on site plan) '
I
Depth of liquid level above outlet invert:
I Comments:
(note if level and distribution is equal, evidence of solids carryover, evident of leakage into or out of box, etc.)
I '
i
PUMP CHAMBER:_
(locate on site plant
I1
1 Pumps in working order:(Yes or Not
Alarms In working order(Yes or No)
Comments: and app rtenances,etc.)
f (note condition of pump ehamber,•eondition of.pumpsI it
II
i
i
Y • 1,
r6dsed'
9 2 9 8 p.F�a.or I I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
1 SYSTEM INFORMATION (contirwed)
'roperty Address: r
Owner:
Date of Inspection:
SOIL ABSORPTION SYSTEM (SAS):%QA
t
(locate on site plan, if possible; excavation not required, location may be approximated by non-intrusive methods)
If not located, explain:
Type:
leaching pits, number:—A(rX S
leaching chambers, number:_
leaching galleries, number:_
leaching trenches, number, length:
leaching fields, number, dimensions:
overflow cesspool. number:
i Alternative system:
Name of Technology:
Comments:
( ote condition of soil, signs of hydraulic failure, level of ponding, damp soil, con 'tion If vegetation, etc.)) A�1 Ir
Q, lV t v -
e
CESSPOOLS:
(locate on site n)
Number and configuration: �V'v
Depth-top of liquid to inle;;nvert:
9epth of solids layer: �l
)epth of scum layer: C1'r
Dimensions of cesspool: ) l
Materials of construction: C6wc4g tt
Indication of groundwater: — v�
Inflow(cesspool must be pumped as part of inspection)
Comments:
(note condition of soil, signs of hydraulic failure,level of ponding, co dition veg tation, etc.) 4 `N
„ t
PRIVY:
(locate on site plan)
Dimensions:
Materials of construction:,
Depth of solids:
i Comments:
i
(note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.
if
l
page 9o111
revised, 9Y•2/98
i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
• PART C
SYSTEM INFORMATION )continued)
'roperty Address:S I AAA
)wner:
Date of Inspection:
fSKETCH OF SEWAGE DISPOSAL SYSTEM: "benchmarks
include ties to at least two permanent reference landmarks or
locate all wells within 100' (Locate where public water supply comes into house)
I ,
1 v
371
I
AO�
CL `i6�
t.
'r
1 �1r i • f ' ,
revised °9�2/.98 }. { Page toorIt
i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
I
SYSTEM INFORMATION (corrtinued)
roperty Address: S �
Owner:
Date of Inspection:
NRCS Report named
Soil Type_ — -------- -----
Typical depth to groundwater____._
J� USGS Date website visited
I Observation Wells checked
Groundwater depth: Shallow Moderate Deep ----___
SITE EXAM Slope NzZ)
Surface water rib
Check Cellar-]>
Shallow wells wo
Estimated Depth to Groundwater }_�Feet
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from Design Plans on record
1 Observed Site (Abutting property, observation hole. basement sump etc.)
I •
Determined from local conditions „
Checked with local Board of health
Checked FEMA Maps
Checked pumping records' K r
Checked local excavators. installers .-
,{ Used USGS Data
I Describe how you established the High Groundwater Elevation. (Must be completed)
SO
revised T:-9/2/9g ,, Page 11or11
COMMONWEALTH OF MASSACHUSETTS �®
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAI 4
p
DEPARTMENT OF ENVIRONMENTAL PROTE TIO n' ,rfCEQ
ONE WINTER STREET, BOSTON, MA 02108 617-292-5500 A(l� 1 1 1
997
totNVOFSARNST N
ef, HfALTHOfPTABLt
WILLIAM F.WELD TRUD �
Governor A
Z c tart'
ARGEO PAUL CELLUCCI E Lt.Governor STRUHS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM - Commissioner
PART A
11 CERTIFICATION
Property Address: 5 K wAy �F�clh/YV�S�T Address of Owner:. tr`QSo��ol�
Date of Inspection: "] (If different)
Name of Inspector: e✓ 1
am a DEP approved system inector pursuant to Section 15.340 of Title 511.1O-CMR 15.000)
Company Name: " t L
Mailing Address: r •�,�••a� S
Telephone Number: �—p(
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate
and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and .
maintenance of on-site sewage disposal systems. The system:
Passes
_ Conditionally Passes
_- Needs Further Evaluation By the Local Approving Authority
Fails
Inspector's Signature: Date: '7-9
The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(30) days of completing this
inspection. If the system is a shared system or has a design flow of 10.000 gpd or greater, the inspector and the system owner shall submit
the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
INSPECTION SUMMARY: Check A, B, C, or D:
A] SYSTEM PASSES:
V I have not found any information which indicates that the system violates any of the failure criteria a5 defined in 310 CMR 15.303.
Any failure criteria not evaluated are indicated below.
COMMENTS:
B] SYSTEM CONDITIONALLY PASSES:
One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon
completion of the replacement or repair, as approved by the Board of Health, will pass.
Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain why not.
The septic tank is metal, 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 conforming septic tank
as approved by the Board of Health.
(revised 04/25/97) Page I of 10
DEP on the World Wide Web: httpaMww.magnet.state.ma.us/dep
CJ Printed on Recycled Paper
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
t PART A
CERTIFICATION (continued)
I
Property Add'
Owner:
Date of Inspectio
B) SYSTEM CONDITIONALLY PASSES (continued)
Ly Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed
pipets) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the
Board of Health). Describe observations:
broken pipe(s) are ieplaced
obstruction is removed
distribution box is levelled or replaced
_ The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass
inspection if(with approval.of:the Board of Health):
broken pipe(s) are replaced .
obstruction is removed
C] FURTHER EVALUATION IS REQUIRED SY THE BOARD OF HEALTH:
Conditions exist which require further evaluation by the Board'of Health in order to determine if the system is failing to protect the
public health, safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING"IN A MANNER
WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
Cesspool or privy is within 50 feet of a surface water
Cesspool'or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT
THE SYSTEM IS FUNCTIONING IN A'MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet to a surface water supply or
tributary"to a surface water supply.
The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well.
The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well.
The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a
private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that
the welt'is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm. Method used to determine distance (approximation not valid).
3) OTHER
(revised 04/25/97) Pago 2 of' 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property ddr
Owner: %4p1k0,-.P
Date of Inspection: $_ -7
D) SYSTEM FAILS:
i You ust indicate ei;;,er "Yes" or"No" as to each of the following:
I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis
.for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct
j the failure.
Yes No ,
Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool.
Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or
cesspool
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 1/2 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 Soil Absorption System, cesspool or privy is below the high groundwater elevation.
Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
Any portion of a cesspool or privy is within a Zone I of a public well.
Any portion of a cesspool or privy is within 50 feet of a private water supply well.
Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no
acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for
coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
E) LARGE SYSTEM FAILS:
You must indicate either "Yes" or"No" as to each of the following:
The following criteria apply to large systems in addition to the criteria above:
The system serves a facility with a design flow of 10,000 gpd or greater (Large System) and the system is a significant threat to
public health and safety and the environment because one or more of the following conditions exist:
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)
The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program
requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.
(revised 04/25/97) Page 3 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 5 1 -e-�o,
Owner:.
Date of Inspection:
Check if the following have been done: You must indicate either"Yes" or"No" as to each of the following:
ZYe, 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 normal
flow 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.
The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of
baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum.
—The size and location of the Soil Absorption System on the site has been determined based on:
The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of
Sub-Surface Disposal System.
Existing information. Ex. 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))
i
(
(revised 04/25/97) Pago 4 of 10
i
I -
' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: S K-"'e-L Li.) �•�
i Owner:
Date of Inspects n:
FLOW CONDITIONS
{ RESIDENTIAL:
Design flow.. S" dJbedroom for S.A.S.
Number of bedrooms:3
Number of current residents:
Garbage grinder(yes or no):�
Laundry connected to syste (yes or no):
Seasonal use(yes or no):
Water meter readings, if available (last two (2) year usage (gpd):
Sump Pump(yes or no):�
Last date of occupancy: (eStier:''
i •
COMMERCIAL/I N D USTRIAL:
Type of establishment:
Design flow: gallons/dav
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:
System pumped as part of mspe on. (yes.or no)_
If yes, volume pumped: D�allons
i Reason for pumping:
TYPE OF SYSTEM
Septic tank/distribution box/soil absorption system
� *Single cesspool
i --je-Overflow cesspool
Privy
Shared system (yes or not (if yes, attach previous inspection records, if any)
VA Technology etc. Copy of up to date contract?'
j Other
APPROXIMATE AGE of all components, date installed (if known) and source of information:
Sewage odors detected when arriving at the site: (yes or no)
(revised 04/25/97)
Page S of 10
r "
SUBSURFACE SEWAGE-DISPOSAL SYSTEM IN FORM
PART C
tt SYSTEM INFORMATION (continued)
Property Address: \<-o'e .. 4�y
Owner: -�b0 �nJ
Date of Inspection:
BUILDING SEINER:
(Locate on site plan)
Depth below grade:
Material of construction: _cast iron _40 PVC rother (explain)
Distance from private water supply well or suction line
Diameter
Comments: (condition of joints, venting, evidence of leakage, etc.)
SEPTIC TANK:/ 1
(locate on site plan)
Depth below grade:
Material of construction: _concrete _metal _Fiberglass —polyethylene —other(explain)
If tank is metal, list age_ Is age confirmed by Certificate of Compliance _(Yes/No)
Dimensions:
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 bottom of outlet tee or baffle:
How dimensions were determined:
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.)
GREASE TRAP:
(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.)
+ (raviaad 04/25/97)' • Page 6 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
• PART C
SYSTEM INFORMATION (continued)
Property Address:5 (J-�y { y
Owner:�ko&'Vow
Date ofinspection:
S`7''Q7
SOIL ABSORPTION SYSTEM (SAS):_
' (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods)
If not determined to be present, explain:
Type.
leaching pits, number: I
leaching chambers, number:_
leaching galleries, number:
leaching trenches, number,length:
leaching fields, number, dimensions:
overflow cesspool, number:
Alternative system:
Name of Technology:
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, C.
l 'c-M
elf
` CESSPOOLS: 1
(locate on site plan)
Number and configuration- �r tVVV4t,
Depth-top of liquid to inlet invert:
Depth of solids layer:_ 6"
Depth of scum layer. r
Dimensions of cesspool: f.-
Materials of construction: OL
Indication of groundwater:
inflow (cesspool must be pumped as part of inspection) S /VO
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
ND
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.)
(rwipd 04/15/97) Page 8 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C-
-SYSTEM INFORMATION (continued)
Property Address: vve — Woof
Owner. l�o��oti
Date of Inspection-
7'97
I _
TIGHT OR HOLDING TANK: (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 level: Alarm in working order_Yes; No
Date of previous pumping:
Comments:
(condition of inlet tee, condition of alarm-and float switches, etc.) '
-
DISTRIBUTION BOX: /
(locate on site plan)
Depth of liquid level above outlet invert:
Comments:
(note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, 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.)
(revised 04/25/97),; Page 7 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
'/
SYSTEM INFORMATION (continued)
Property Addr s: 5 Kew- w��� 4tly,
Owner: Oro;�o j
Date of Inspection:
7-47
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100' (Locate where public water supply comes into house)
r
0
(revised 04/25/97) Page 9 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
Owner: NA0PLQ0Vj
Date of Inspecti n:
Depth to Groundwater Feet
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from Design Plans on record
Observation of Site (Abutting property, observation hole, basement sump etc.)
Determine it from local conditions
Check with local Board of health
Check FEMA Maps
Check pumping records
Check local excavators, installers
Use USGS Data
Describe in your own words how you established the High Groundwater Elevation. Must be completed)
I
(rovisad 04/25/97) Page 10 of 10
1
y f TOWINT OF BARNSTABLE
LOCATION /� ' GAL- GV� SEWAGE # LI/
VfLLAGE G(/ ASSESSOR'S MAP.& LOTS Z^' l��
INSTALLER'S NAME&PHONE NO. /'
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) fo (size) 13�
NO. OF BEDROOMS 3
BUILDER OR OWNER
PERMITDATE: $`1�'+8 COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Lea ng Facility (If any wells exist
on site or within 200-feet of 1 hing facility) Feet
Edge of Wetland and Leachin acility (If any wetlands exist
within 300 feet of leac ' g facility)% Feet
Furnished by �� `�����f/�✓�`4Al
r
tl , r=
C
i
No. Fee $5 0
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS
Zipplication for Mi000al *pmem Comaruction 3pCrmit
Application for a Permit to Construct( )Repair(X)Upgrade( )Abandon( ) El Complete System O Individual Components
Location Address or Lot No. Owner's Name,Address and Tel.No.
5e�e1l Way, W Hyannisport David and Kate Reed
Assessor's ap P arce Z _/((�®�--/
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
Wm. E. Robinson Septic Service Earl Lantery Jr.
P O Box 1089, Centerville ct E Sandwich
s'. Type of Building:
Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Grinder( )
' Other Type of Building No.of Persons Showers( ) Cafeteria( )
i Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
` Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
i .
Nature of Repairs or Alterations(Answer when applicable) Title-5�e�ie systemms-aeeording
to th plans of Earl Lantery Jr, datar� g_4_01
3 Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to'place the system in operation until a Certifi-
cate of Compliance has been issue y
`ed b thi o of Health
p Signed a,fLL Date
Application Approved by Date
Application Disapproved for the following reasons
Permit No. Date Issued
No. �—( ..--"+-n t. +, :�.r � ' Fee$5 0
THE COMMONWEALTH OF MASSACHUSETTS M Entered in computer: / F
,+ —=PUBLIC HEALTH�DIVISION - TOWN OF BARNSTABLE s MASSACHUSETTSS es
Application for ;Di!5po9;a1 *p.5tem Cow5truction i3ermit
Application for a Permit to Construct( )Repair(X)'Upgrade( )Abandon( ) El Complete System ❑Individual Components
M1 T Location Address or Lot No. Owner's Name,Address and Tel.No.
'4 k Assessor`s Map P6l Way, W Hyan/nisport David and Kate Reed
_Z
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
Wm. -E. Robinson Septic Service Earl Lantery Jr.
P 0 Box 1089, Centerville qa E Sandwich
Type of Building:
Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Grinder( )
Other. Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets r Revision Date
Title
Size of Septic Tank Ty
p oft..S.�
Description of Soil
Nature of Repairs or/Alterations(Answer when applicable) Title-5 septic System a
etearding
tpoT4tl plans` off' Earl Lantery Jr, Gated 8-4-01
Date last'inspected:-
Agreement•11
The.,tindersigned agrees to ensure the construction and maintenance of the afore described;on-site sewage disposal system'.
in a -dance with:the provisions of Title 5 of the Environmental Code and not to place the system in opeiatiori until a Certifi-
. ^,,•;.Cate,of Compliance has been issu/ed by th opd of HealthJ/f
-_--Signed,i �`L� 7i -l / d Date
i
Application Approved by ' " Date
Application Disapproved for the following reasons
Permit No. /s o `-` Date Issued 'f "' ZOO/
THE COMMONWEALTH OF MASSACHUSETTS
--- - BARNSTABLE, MASSACHUSETTS
Reed w
Certificate of Com �Ytance;
THIS IS TO CERTIFY, that the On-site Sewage Disposal System Coiistru'cted ( )Repaired( X)Upgraded( )
Abandoned( )by Wm. E. Robinsonr' Septic Service,
at 5 Keel Way, W Hyanni Gnrt t �,..y. , has been constructed in accordanjce
with the provisions of Title 5 and the for Disposal System Co nsttructiori Permit No. ,06l-- dated -^ ✓`-
..:r Installer Will. E. Robinson Sr- � DesignerEarl Lantery Jr.
The issuance of this permit hall'tnof be construed as a guarantee that the syst ill function as designed.
Date c� ' / F,` Inspectors _ --�
Fee $5 0
lw
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS
Reed lwiopool Gip temp Construction Permit
Permission is hereby granted to Construct( )Repair( )Q Upgrade( )Abandon( )
System located at 5 Keel Ways W Hyannj Spot
and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to
comply with Title 5 and the following local provisions or special conditions.
Provided:Construction must be completed within three years of the date of this it.-
Date: ��r D Approved by l
5/25/01
NOTICE: This Form Is To Be Used For the Repair Of Failed
Septic Systems Only.
PERCOLATION.TEST AND SOIL EVALUATION EXEMPTION
FORM
I, EARL LA N TCRX P o-hereby certify that the engineered plan signed by me
dated , concerning the property located at
5 Kr--EL WAY meets all of the
following criteria:
�• This failed system is connected to a resid'en.tial dwelling only. There are no
commercial or business uses associated.-with the•dwelling.
The soil is classified as CLASS I and the percolation rate is less than or equal to 5-
minutes per inch. The applicant may use historical data to conclude this fact or may
conduct preliminary tests at the site without.a health agent present.
V There is no increase in flow and/or change in use proposed
• There are no variances requested or needed. ,
• The bottom of the proposed'leaching facility will not be located less than fourteen
(14) feet above the maximum adjusted groundwater table elevation. [Adjust the
groundwater table using the Frimptor method when applicable]
Please complete the following:
A) Top of Ground Surface Elevation (using GIS information 4•
W. Elevation ustment for high G.W.2 .7 = 8.
µ MASi1q OF gS�9cy
CE
EARL m ER , y
-�
LANTERY, 1R. X
,o -1� No.26575 p chi
�0 `�� J DATE:
FSS/ONALG� 0
0V NOTICE
Based upon the above information, a repair permit will be issued for 3 bedrooms
maximum. No additional bedrooms are authorized in the future without engineered
septic system plans.
q:health folder:percexmp
t a y£ ti 5 b i ti i a� asY!! %��I� � i�1k�i! lJ P lj�. r all d�. 7 a 1a3�ar k.
i z t
t
/ TOWN OF BARNSTABLE
LOCATION `- �` ' G L' riV.� SEWAGE #
VILLAGE 1,U a 11 1 ASSESSOR'S MAP A LOcTgX'-Y)� .f4�_ '-
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY
_
LEAC. IN ..EA F.o�� Z�
G CILITY:
(type ;�" {si.
NO.' OF BEDROOMS 3 -
BUILDER OR OWNER
PERMITDATE: ..�`1�✓6 I. COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching-Facility. Feet
Private Watcr.Su 1 Well.and.Lea . n Facili an wells exist'
P_ .. PY. g .. tY � .Y
on site or.within 200-feet.of 1 hing facility Feet
Edge of Wetland and Leaden acility(If any wetlands exist
within 300.feet of leac ' g facility)) Feet `"
j Furnished by �� `7 fL -,f/ 14Al
i
_....
��' .o ,�
TOWN OF BARtiSTA.3LE 7
LOCATION SEWAGE # 9�—��/
i
VILLAGE �V4 ��`�I RP -� ASSESSOR'S MAP & LOT -t 7 l
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY 71 0huul Qswoo
LEACHING FACILITY: (type)' (size) (,)( S
f NO.OF BEDROOMS
BUILDER OR OWNER W --
?EIt4ff-DATE: COMPLIANCE DATE:
Sepgation Distance Between the:
Maximum AdJ justed Groundwater Table 40 d 1,B
Private Water Supply well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) F`
Edge of Wetland and Leaching Facility(If any wetlands exist
1 within 300 feet of leaching facility) N 84• F
Furnished by as
I
A.
TOWN OF BA R:tiSTP.BLE
LOCATION SEWAGE # 17
V'fLLAGE VVc ��NI , V�-� ASSESSOR'S MAP & LOT �,
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY T ON WiJJ (QS,SQ0 O
LEACHING FACILITY: (type) (size) s
NO.OF BEDROOMS 3
BUILDER OR OWNER
DATE: ( COMPLIANCE DATE:
Separation Distance Between the: 2-0
Maximum Adjusted Groundwater Table F
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) I rt F
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) N 1+q• F;= '
Furnished by As f u2)
w � F
' s
577 c a
F.
TOWN OF BARNSTABLE
LC;ICATION ��-Gse` t k.A414 SEWAGE #
VILLAGE ASSESSOR'S MAP & LOT
INSTALLER'S NAME & PHONE NO. (fiStaL
SEPTIC TANK CAPACITYG�S50cmC—
LEACHING FACILITY:(type) Fg4—,f -CA6( pl T (size) c3
NO. OF BEDROOMS PRIVATE WELL OR C WR
BUILDER OR OWNER fMr . {- 0L40,.Q�
DATE PERMIT ISSUED: , - Ll
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No
1
I t
r
t'
I Q '
�.
Y IT r
65 /X
No......................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH as %APPR
TOWN OF BARNSTABLE
Appliratiun for DispuuFai Workii Tonutrurt k
_�Application is hereby made for a Permit to Construct ( ) or Repair ( LKaan Individual Sewage Drgsal
System at:
................_. --------------.................---•------•
� J�pcation�dd ess � or Lot No.
Owner Add e s
a �--!�'`P=e-�- -�Y `!rc- :D,-�� UG C .......................
per........_..
Installer Address
d Type of Building Size Lot............................Sq. feet
V Dwelling—No. of Bedrooms.--.._.�......................................Expansion Attic ( ) Garbage Grinder ( )
Other—Type T e of Building No. of persons............................ Showers
� YP g --------•----•-•--••------•• P ( ) — Cafeteria ( )
Otherfixtures ------------------------------------•-----------------••------------•----•-•-•-•-••---•--•---------•--•--•--------------.....-•---•------...---------
W Design Flow........ ...................gallons per person per day. Total daily flow........... ..._......_..._..___._..gallons.
WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter--.----------.-. Depth................
x Disposal Trench—No. .................... Width �........--..... Total Length.................. Total leaching area....................sq. ft.
Seepage Pit No....../------------ Diameter.................... Depth below inlet....49........... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
a Percolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. 1................minutes per inch Depth of Test Pit...........--....... Depth to ground water........................
( Test Pit No. 2................minutes per inch Depth of.Test Pit.................... Depth to ground water------..................
a •••-••••-••-----------------••-••••••-•••-••--•--•----•----•---•-••---------.......•--------•-•.............-----------••••--------••...----------•••-•.-----
O x Description of Soil........................................................................................................................................................................
UW ••-•-•---•--------------••-•-----•••--•---------•----------------------------------•-••-•-•------------•----......----.......-------- ¢ -
Nature of Repairs or Alterations—Answer when applicable....G.{.� �. ................. t.1...............
5 -: �,r-�-...... ------------------------------------------------------------
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Compliance has been issue the board of health.
------------
Sined ................ :::...... ............
Application Approved By ............ . .....:...................................... -- ..l'....... �..
Application Disapproved for the following reasons: ........................................................................................................................................
........................................................................................................................................................................................................... ....................................:...
Dare
PermitNo. ... ��......................-7....................... Issued ....................................................................
Date
Finc
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Appliration for Disposal Works C�ono rns#ions anti# �� ,y`9
Application is hereby made for a Permit to Construct ( ) or Repair ( (,)--an Individual Sewage Disposal
System a
p,f ( cationf�ddess or Lot No.
.................(.1.1..__....1tC&S:C.='`.G�!.................................. .............•....................................................................................
u Owner Add s
0, 60,7
............................ ...........• •. ..................._._
Installer
Address
Type of Building Size Lot............................Sq. feet
'Dwelling—No. of Bedrooms_•_...................................Expansion Attic ( ) Garbage Grinder ( )
Other—T e of Building
a Other—Type g ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
Q Other fixtures
W Design Flow.......�.. -...................gallons per person per day. Total daily flow........ . ...............gallons.
WSeptic Tank—Liquid'capacity............gallons Length................ Width................ Diameter................ Depth................
x Disposal Trench—No. .................... Width.................... Total Length................. Total leaching area....................sq. ft.
Seepage Pit No......I------------ Diameter.................... Depth below inlet.... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by............................................................................ Date...................................----
Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground'water..............:.........
.
44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth,to ground water........................ L=
Ix .................................•-.............---.............------.......------...........___._..........................................................
0 Description of Soil........................................................................................................................................................................
U ................•------..............--------•-----------...............-•----....------------------------•--•----------•--•-•-•-----------•---------•----•-----------------•--------•------.............
x ----------------------------••-------------•---------------•---------••------------...•-••---------------•----......---------- ------ ---------------
V Nature of Repairs or Alterations—Answer when applicable..__ 7 ``_ ....... _ ......
�.................
�P (... ST!-1'` , x� `o=S C�L••-•---•--••------------•--••••------------------------••--.
---- ------- r
Agreement:
The undersigned agrees 'to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Compliance has been issued the board'of health.
4 ..
Si ned .-------'-'-- - l - Z
Application A roved B`F L
PP PP Y ......:.. .... ....L.�: .............C1
Application Disapproved for the following reasons: ........................................................................................................................................
.........................................................................................................................................................:......................-.... .....-----------------......------------
rn Dare
PermitNo. ................�� f�� Issued.................................................... ----------------------- ......................................
Dare
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Ce>r#ifirate of Contylianre
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired
bC�. -.(- 1..n ll ...s? ��...�.Y.............................................................................................................................
Y ...
� Insraller
at ..................................... ............ �(. ,.�^-.w.d.....
has been installed in accordance with the provisions of TITLE 5 ;f The Stat nvironmental Code a�des1i'bed in
the application for Disposal Works Construction Permit No. ..... ...�-..`.. ....... dated .....�.. �...... ............
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE-----------------,�.... .........�..�....`...�.. ..................... Inspector ......... ... :s ...........................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF` BARNSTABLE
No..�2- TOWN 7 �l FEE....=��-(--�----_.
Diopoottl orko �ono#rion lerutit
Permission is hereby granted........C-�--�L�...........-5 / ----•--------•--------•-•••.........••--•-•---•.....................
to Construct ( or Repair (1-)-aIndivir3ua1 Sewage Disposal System
at No---------------- L'-e � . ............ ` ...
Street
as shown on the application for Disposal Works Construction Permit No Z _._.....7 Pated..... 2_... ...__._
---•....••••---•-•-c--` ---G---------------------•-•-•••------ •.....-•-•--
DATE------ 2 ............................................ Board of Health
------- ---•1-7-�---��-----Z
FORM 36508 HOBBS Q WARREN.INC..PUBLISHERS
sr Fi-O'D
FL. 46,0
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A,�D C F\LL 1 1 c 1�[ E_ nt�orlt� STATsT)N� W 01'
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ap I 3 ]SF_DROOM
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5 INGLE FAMILY 1?W E1l..!_lNG W13 BEDRDMS -5 E o 1 "" = '0- �
CS AR6 P►.E3L D 15 P O S N L_ i S EW r"\\'v`L.
1._ DAILW FLDW = 4l0 X 3 = 33U G. 1-3, 20 10 a 20 40
SEPTI C TAi�Y. CVvL. R�.Q' D,� -- F)^/1: to
ram,e �� ,, � M . t I�l. D 1��V I D (.:�. ';;L�
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15 00 �,� . r li �IY�C - o . Iot. LEGENu PE��. RATk
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U SE 6-3x (Yx )' WFIL1-AT6RS om1'or- STONE. �t 1'4 4-'�TONC ✓ �o.._ Ex►snn1� or�ioUR LOT 1 / /=\ 55. NIA', e 'f7 �L 165
L1 F ECT1`J E D1�V,1 H = Z. C) W I-1 YA N t\1 13FO _
2,x C I 0 8 t- M X 0.7 4 = l 7 mot- -- — - a�,� ��✓rah
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ui1 .
hPhCIT\Y = 3 74 bM 5 . a I -T• OT l�L- C --I 4 5►OR � CA L � � I •�.
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