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HomeMy WebLinkAbout0229 LINCOLN ROAD - Health 229 Lincoln.'Road Hyannis P A = 270 038 i I " COMMONWEALTH OF MASSACHUSETTS r EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION 1M See�% TITLE 5 OFFICIAL INSPECTION.FORM--NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM F ECEIVED PART A CERTIFICATION JUN 2 4 2002 Property Address: p o 4�� 14A TOWN OF BARNSTABLE HEALTH DEPT. Owner's Name:— TlA_. Owner's Address: Date of Inspection: PARCM Name of Inspect r• please.p�t!rint) IDS . { SIc —+�•�....:.�... Company Name. , LOT Mailing.Address: V U� s4 C0tle Telephone Number: --7`7/ --3 9q PARCEL ®' CERTIFICATION STATEMENT, LOT ; I certify that I have personally inspected the sewage disposal system at this address awn t3Tiat elation 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 ection 15.340 of Title 5(310 CMR 15.000). The system: Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Inspector's Signature: Date: The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP..The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. Notes.and Comments ****This report only describes conditions at..the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Title,5 Inspection Form 6/15/20.00 page 1 Page 2 of 11 A OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Li Owner Date of Inspection: lu i7 QhGoZ Inspectiori'Summary: Check A,B,C;D or E/ALWAYS complete all of Section D A. System Passes: Ahave 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: . . asp B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The•,s::stem iu on-=corn ]etion of the replacement or repair; as approved b the Board of Health will ass. P Y , °P' P P P � PP Y s , P " �S05iAS Answer yes,no;or.�rtot,determined(Y,N;ND)in the for the following statements: If"not determined"please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or.tank failure is imminent:Systern will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled'or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: 2 Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE.SEWAGE DISPOSAL SYSTEM'INSPECTION FORM PART A CERTIFICATION(continued) b Property Address: A Owner: Date of Inspection: % O C. .Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is.failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in manner which will protect.public health,safety and the environment: _ Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier, if any).determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a: surface water supply or tributary to.a surface water supply:. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. _ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system has-a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from.a., private water supply well".Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified:laboratory,for coliform bacteria and volatile organic compounds indicates that the well.is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no oily r failure criteria are triggered. A copy of the analysis must be attached to this form, 3. Other: 3 Page 4 of I 1 OFFICIAL.INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE'SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: Owner. Ta)?,,J�Ww', Date of Inspection: - a- D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool Static liquid level in the distribution box above outlet invert due to an overloaded;or clogged SAS or cesspool Liquid depth in cesspool is less than 6"below'invert or available volume is less than '/,day flow Required pumping more than 4 times in-the last year NOT due to clogged or obstructed pipe(s).Number J of times pumped L Any portion of the SAS,cesspool or privy is below high ground water elevation. Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface f water.supply. d/1 Any portion of a cesspool or privy is within-a Zone 1 ofa:publicwell. Any portion of a cesspool or privy is within 50 feet of A private water supply well. f/ 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 facilityand the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,.provided that no other failure criteria are triggered.A copy of;the analysis must be attached to this form.] (Yes/No)The'system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,thereforethe system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system musyserve a facility-with a design flow of 10;000 gpd to 15,000 gPd• You,must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no the system is within 400 feet of a.surface drinking water supply the system is within 200 feet of a tributary to.a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes" in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15:304. The system owner should contact the appropriate.regional office of the Department. 4 Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR.VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST,, Property Address: Owner- Date of Inspection: /7, 130 D Q_ Check if the following have been done. You must indicate`Yes"or"no"as to each of the following: Yes No --.� Pumpin-,.information was provided by the owner,occupant,or Board of Health Were,any of the system components pumped out in the previous two weeks? f— Has the system received normal flows.in the previous two week period? (/ Have large.volumes of water been introduced to the system recently or as part of this inspection? Were as built plans of the system obtained and examined?(If they were not availab]e note as N/A)' Was the facility or dwelling inspected for signs of sewage back up Ll _ Was the site inspected for signs of break out? Were all system components,excluding the.SAS, located on site Were the septic tank manholes uncovered,opened, and the interior of the tank inspected for the condition of:the baffles or.tees,material of construction, dimensions, depth.of liquid,depth.of sludge and depth of scum? _jZ _ 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 Jam— Existing information. For example,a plan.at the Board of Health. tl"�_ 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)J 5 Page 6 of l 1 OFFICIAL INSPECTION FORM-.NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM '.PART C SYSTEM INFORMATION Property Address: ` o� Owner: / Date of Inspection: ,/ mod© FLOW CONDITIONS RESIDENTIAL. Number of bedrooms(.design)-a. Number ofbedrooms(actual): DESIGN flow based`on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): Number of current residents: Does residence have a garbage grinder(yes or no . Is laundry on a separate sewage system(yes or no if yes separate inspection required] Laundry system inspected(yes or nQ-1A-1- Seasonal use: (yes or no): Water meter readings, if available(last 2 years usage(gpd)): Sump pump(yes or no/�& ..,, Last date of occupancy: ��C� / COMMERCIAL/INDUSTRIAL.L,/�' Type of establishment:` Design flow(based on 310 CMR.15203): gpd Basis of design flow(seats/persons/sgft;etc.): Grease trap.present(yes or no):— Indust.rial waste holding tank present(yes or no):— Non-sanitary waste discharged to the Title 5 system(yes or no):_ Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information:. 3 Was system pumped as part of the inspection(yes o)L'4yy4- If yes,volume pumped: gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM .�3eptic 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): ppr im ate'age of all components,date install (if known)and source of information- Were sewage.odors detected when arriving at the site(yes or no) 6 Page 7 of 1 l OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENT_ S SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM:INFORMATION(continued) Property Address: � oe4-aa�7. . Owner: Date of Inspection ��Q BUILDING SEWER(locate on site plan) - Depth below grade: Materials of construction:_cast iron _40 PVC other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage, etc.): SEPTIC TANK:0locate on site plan) Depth below grade: Material of construction:y/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: 5"` 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 were dimensions determined j,( 2( ,1i /;ems Comments(on pumping recommend ions, inlet and outlet tee or baffle condition,structural integrity,liquid.levels s related to outlet invert, evidence of leakage,etc.): -i �, 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(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage, etc.): 7 Page 8 of i] OFFICIAL IN FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner- Date of Inspection: a TIGHT or HOLDING TANK(tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass Polyetfiylene . other(explain): Dimensions:' Capacity: gallons Desi n Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX:Jz(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 aka�e into or out of b x, te.): , PUMP C HAM BER:AA�locate on site plan) Pumps in working order,(yes or no): Alarms in working order(yes or no)-'- Comments(note condition of pump chamber,condition of pumps and appurtenances,etc:): 8 Page 9 of 11 OFFICIAL INSPECTION FORM-,—.NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: _)J9 Owner / Date of Inspection: . SOIL ABSORPTION SYSTEM (SAS): locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number:_ leaching chambers,number: aching galleries,number: leaching trenches, number, length: leaching fields,number, dimensions: overflow cesspool,number: innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure, level of ponding, damp soil,condition of vegetatior4 etc : t� CESSPOOLS-{cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth'—top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool:- Materials of construction: Indication of.groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding, condition of vegetation,etc_): PRIVY:�(locate on site plan) Materials of construction:. Dimensions: Depth of solids: Comments (note condition of soil, signs of hydraulic failure; level of ponding,condition of vegetation;etc.): 9 Page 10 of 11 OFFICIAL INSPECTION FORM=NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C . SYSTEM INFORMATION(continued) Property Address: 0a9 g�a-� � Q Owner:— Date of Inspection: : 00 c� 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. 4 2� h 10 I Page l I of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Date.of Inspection: e 7, G� SITE EXAM Slope Surface water Check cellar Shallow wells . Estimated depth to ground water ✓57 feet Please indicate(check).all methods used to determine the high ground water elevation: Obtained from system design plans.on record-If checked, date of design plan reviewed:. Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with.local excavators, installers-(attach Jdocumentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: ll Permit Number: Date: Completed by:. H"GH GROUND-VVATE"R LEVEL COMPUTATION Site Location: Lot No.. O.wner:_ 1,tj. Address- Contractor:- Address: �e�/ " Notes:. SFF-R. 1 . Measure depth to"water table. to nearest.1./lo-it_....:_...................... 00 month/day%year• - STEP 2 Using:Water-Level.Range Zone and lndex We11..,ap locate site an determine: O4ppro.Priate.index welL.............._.. ,. //d1 Water-level range zone;,._.............. Using-month ly.nepar_t,."Current Water R.esources"Conditions" determine current-depth-to // = water level for index well .............._... ®s'I®Z °Y✓ month/year STEP. 4. Using,Table.o.f:uUater,l.exal Adjustments i for index Well (STEP 2,N),.current depth I� to water level for.index welj (•STEP 3} I t and-water-level zone (STEP•26) determine water-level:adjustment ..................- _ ........ STEP: 5 =stimate depth to:high water by subtracting the vvater ' level adjustment-(STEP 4`) from measu.red%depth to.water level-at site.(STEP"1) ........................................................_............. P,Z Figure- !J:"Reprv-:7uvible-COMr7 a._i•.D t.._. Cll:dilEli� IvtLil: �1 b y TOWN OF BARNSTABLE LOCATION S;CC43`r-- PJ A SEWAGE # ��6 VILLAGE X&i .S ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. � -0 h'�-��c.�•�t ���'� � SEPTIC TANK CAPACITY LEACHING FACILITY: (type)L( Ili() (size) NO.OF BEDROOMS BUILDER OR OWNER ( Olp e14 ReG.A PERMITDATE: 2COMPLIANCE DATE: Separation Distance Between the: Ge-o j, ��(, ,( (����,,,� 0� Maximum Adjusted Groundwater Table and Bottom of Leaching Facility SV',%A--Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) (1.1\ - Feet Furnished by Sew C'1 -nr.•��/.e � x rb ppop, r c' ASSESSORSMAP No. G�'""��Z FARCEL N0: Q3 19 Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION —TOWN OF BARNSTABLE., MASSACHUSETTS 0(ppYtcattou for �Digotal *pttem Cow6tructtou Permit Application is hereby made for a Permit to Construct( )or Repair(Vj"an On-site Sewage Disposal System at: j Location Address or Lot No. 02�� 6 Owner's Name,Address and Tel.No. Installer's Name,Address,and Tel.No.� /�s�y 1�G� Designer's Name,Address and Tel.No. J V 1 II Type of Building: ,,��// Dwelling No.of Bedrooms Garbage Grinder 4/0 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 Revision Date Title Description of Soil Nature of Repairs or Alterations(Answer when applicable)— Al y/ r3 C G 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 issued by this Board of - Signed Date 6 Application Approved by Application Disapproved for the following reasons Permit No. r L G Date Issued h 03 No. Fee ' THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLES MASSACHUSETTS F Application for Mtgponl *pgtem Cou5tructton Permit Application is hereby made for a Permit to Construct( )or Repair(�an On-site Sewage Disposal System at: ,2 �v - Location Address or Lot No. 63K Owner's Name,Address and Tel.No. Installer's Name,Address,and Tel.No. ) /—�C U� Designer's Name,Address and Tel.No. Type of Building: ,//� i q. Dwelling No.of Bedrooms Garbage Grinder.(/(/ Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures 7 Design Flow gallons per day.Calculated daily flow gallons. Plan Date Number of sheets Revision'Date t Title Description of Soil s i I `t Nature of Repairs or Alterations(Answer when applicable C-� �-k�{ CG�.SS O��S �rfitl Gen k cx' �LrJkur2 to C G i Date last inspected: t Agreement: 1 ?� 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- cateof Compliance has been issued by this Board of Signed Date G O 6 Application Approved by _ Application Disapproved for the following reasons ' Permit No. Date Issued ---v——-------------_--_ ��— THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISIONS BARNSTABLE, MASSACHUSETTS-4,11 Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System installed( )or repaired/repl ced(�on by a r��.- for Q.Z4a r✓N CZ-2.c.V_ aV L' Cs_ has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. O dated Use of this system is conditioned on compliance with the provisions set f�b17 elow: / _ r -- -- �-�� --- ---------------------- No. leo� Z Fee t,.1 r F THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS Migoal *p!6tem Con!5truction Permit Permission is hereby granted to SC<A r,\ •-r .L� to construct( )repair(V)an On-site Sewage System located at sQ{�� L l`^ t r>1 n RJ 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. ` All construction must be completed within two years of the date below. / Approved b Date: pP Ya ---_ r CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT(WITHOUT DESIGNED PLANS) I, �o� ��u�- , hereby certify that the application for disposal works construction permit signed by me dated le-1 w , concerning the property located at elb 9 cv�C\- l ri, meets all of the following criteria: •cam 1 LL Here are no wetlands within 300 feet of the proposed septic system •�re are no private wells within 150 feet of the proposed septic system •—'41;eobserved groundwater table is 14 feet or greater below the bottom of the leaching facility --�ere is no increase in flow and/or change in use proposed • ere are no variances requested or needed. t SIGNED:— DATE: . 5 LICENSED SEPTIC+SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER [Attach a sketch plan of the proposed system. Also if the licensed installer posesses a certified plot plan, this plan should be submitted]. r �. O�I .. ,� J ASSESSORS MAP TROY WILLIAMS PMCMN� --- � - -�g4> ` SEPTIC INSPECTIONS 'T Certified by MA Department of Environmental Protection ly1 -(508) 760-1819 40 Old Bass River Road = 1 '996 South Dennis, A s, 02660 Commonweafth of Massachusetts nopy Executive Office of Environmental Aftairs Department of Environmental Protection William F.Weld Trudy Coxe Governor Y Aigeo Paul Celluccl s.a.tary LL t3ossrrwr Davld B.Struhs Corranwelonsr SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: -?d y L;h c o h /2"( Address of Owner. O 6114 e_u 1 Date of Inspection: y/y�y, (If different) Name of Inspector.��yy w, ((�u M Y PQ. 130 X, y 9 l�/ Company Name,Address add Telephone Number. / .,N. S� 1141, o G 0 1 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 _ eeds Further Evaluation By the Local Approving Authority Fails Inspector's 9ignatttre �la_t L Date- sA/1 G The System Inspector shall submit a c6py 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: /N/X I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below B) SYSTEM CONDITIONALLY PASSES:N/A One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair, passes inspection. Indicate yes, no, or not determined (Y, N, or ND) Describe basis of determination in all instances If"not determined-. explain why not) The septic tank is metal, cracked, structurally unsound, shows substantial infiltration or enfiltration, or tank failure is imminent The system --d] pass Inspection if the existing septic tank is replaced with a ponfornung septic tank as approved by the Board of Health (revjseC 11/03/95) ) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 2 2 y L.h(v/,, Owner. R L� Date of Inspection: B)SYSTEM CONDITIONALLY PASSES(continued) Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(g) 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(@)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 pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed Cl FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect 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 PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system and 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 is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and 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 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. 3) OTHER (revised 11/03/95) 2 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: Owner. ,Qc4 Date of Inspection: D] SYSTEM FAILS: 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 failure. determine what will be necessary to correct the ^� Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. LL/ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. Z4 Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Y- 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 N Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. 1/ Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. -A/ Any portion of a cesspool or privy is within a Zone I of a public well. .L1 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. El LARGE SYSTEM FAILS: A1117 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: — 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 11/03/95) 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: a a Owner. iQz_"a. Date of Inspeotlon: y/q Check if the following have been done: ✓Pumping information was requested of the owner,occupant, and 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. NL As built plans have been obtained and examined. Note if they are not available with N/A. ZThe 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. /VA 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. f/The size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods. ZThe facility owner(and occupants, if different from owner) were provided with information on the proper maintenance of Sub- surface Disposal System. (revised 11/03/95) 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: d Z 5 L;h o h Owner. R�q Date of Inspection: RESIDENTIAL: FLOW CONDITIONS Design lba: 3�Ilons Number of bedrooms: Number of current residents: Garbage Finder(yes or no):_A//o Laundry connected to system(yes or no): YES Seasonal use(yes or no): ND Water meter readings, if available: Last date of occupancy: Q C L u/O i NA. COMMERC - IAL/INDUSTRW.: Type of establishment: Design flow:�PlIons/day Grease trap present: (yes or no)_ Industrial Waste Holding Tank present: (yea 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 inspection: (yes or no)N0 If yea, 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) Other (explain) APPROXIMATE AGE of all components, date installed (if known) and source of information: Qf% y; ., 1 {a r10 C �✓ �� CA l�,�orux , S`yr3 BOA . Sewage odors detected when arriving at the site (yes or no) (revised 11/03/95) 6 i SU BSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM s PART C SYSTEM INFORMATION(continued) Property Address: I L i h Lo I Owner. f�L� Date of Inspeotiom SEPTIC TANK: (locate on site plan) Depth below grade: Material of construction:_concrete_metal_FRP—other(explain) ` 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: 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.//4 (locate on site plan) Depth below grade: Material of construction: _concrete_metal_FRP —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: 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 11/03/95) 6 i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Adaresw Owner. Date of Inspection: TIGHT OR HOLDING TANK: /V,/,9 (locate on site plan) Depth below grade: Material of constntction:_concrete_metal_FRP--other(explain) Dimensions: Capacity: ¢allOns Design flow: gallons/day Alarm level: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX:Y,//l (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.'A11A (locate on site plan) Pumps in working order:(yes or no) Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) (revised 11/03/95) 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(oontinued) Property Address: ,2 a 9 L;h L o 1 h R a. °.ones ae�of - Date Of Inspeotbn: SOIL ABSORPTION SYSTEM(SAS).,I (locate on site plan,if possible;excavation not required,but may be � y a PPronmated by non-intnuive methods) If not determined to he present,explain: Type: leeching Pits, number:_ wing chambers,number._ leaching galleries, number: leaching trenches, number,length: leaching fields, number, dimensions: overflow cesspool, number:_ c o✓c✓ v / Ge S r`o o a Co nts: (note condition of soil, signs of hydraulic failure level of ponding, condition of vegetation,etc.) �i000 W r-, i �•- f o�C�i ot.. CESSPOOLS: (locate on site plan) Number and configuration: Uh C. ji-i w', G LS Gio�o / Depth-top of liquid to inlet invert:_ Depth of solids layer._ y f' Depth of scum layer: /Vo/V Dimensions of cesspool:_,�aQ Materials of construction: Indication of groundwater:_�/�/a . inflow(cesspool must be pumped as part of in ion) Gc S r�uo W S ho 4✓r,��t� Q�tV . /.>rt C.L., d C omm en ts: (note condition of soil, signs of hydraulic failure, level of ponding, ,ccon tion of vegetation, etc.) u W ti f�J d /tom. .i .i - ✓ L -f"G J✓`. C. T -47 K L.Gt.•t Ui PRIVY: (locate on site plan) Materials of construction: Depth of solider Dimensions: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) (revised tl/o3/95) 8 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Addresu o?2 f' 1..i k o 12 6( , Owners i2 4"� Date of Inspection: 4 /9 SKETCH OF SEWAGE DISPOSAL SYSTEM: indude ties to at least two permanent references landmarks or benchmarks locate all wells within 100' rZ. Si CA a � M.L, h Ud�il�J DEPTH TO GROUNDWATER Depth to groundwater: feet adjusted high groundwater level method of determination or approximation: U5 &1-1 9