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HomeMy WebLinkAbout0020 OAK HILL ROAD - Health 20 ®akhi ll Rd o ; 0 -\ O LMOi�,T%i�EAI:TH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS. , E'PAF�TNSEi*tT OF ENVIRONMENTAL:;PROTECTION TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE. SEWAGE DISPOSAL SYSTEM-FORM' PART A CERTIFICATION , Property Address: 06,: U Owner's Name Owner's Address: 4J ca-A, Date of Inspection: i ~' ---�• 1 Name of Inspecto I lease print) ,r ,lO _ _ Company Name: o �'l Ln Mailing Address: 1_ t Telephone Number: CERTIFICATION STATEMENT inspected the sewae disposal-system at this address and that the inf rmation reported 1:certify that I have personaily msp g� p Y ; below;is trae,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,..1 am.a DEP -approved system inspector pursuant to Section 15 340 of Title 5(310 CMR 1SA00) ,The system:. Passes. Conditionally Passes_ Needs Further Evaluation by the Local Approving Authority as Inspector's_Signature. Date: 4. The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or. DEP)within'DO days of completing this.inspection.If.the system is.a.shared system or has.a design flow of 107000 gpd Cyr greater,the inspector and the system owner shall submit,the report to:the appropriate regional office of the DEPJThe original should be sent to the system'owner and copies sent to:ahe: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`hoyvthe system will perform in the futur.6under the same or different conditions of use: Title-5 Inspection Form 6/1572Q00 page 1 Page 2 of 11 OFFIC IAL INSPECTION FORM-NOT:FOR VI)LUN'T'ARY ASSESSMENTS SUBSURFACE SEWAGE',DISPOSAL SYSTEM INSPECTION FORM .. PART A CERTIFICATION (continued) Property Address: Al. Owner:. Date of Inspectiob. ns G . Inspection Summary:,Check'A,B',C,D or E/ALWAYS complete.all of Section D A. /System Passes: V I have not found any information which indicates that any of the failure criteria described s abed in 310:CMR 15.303 or in 310.CMR 15'3Q4 exist.Any failure criteria.not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the`'Conditional Pass"sectionneedto be replaced or repaired.The system, upon completion of the.replacement or repair;:as approved by the Board of Health;will pass. Answer yes,no.or not determined(Y,—N, in the for the following statements "not determined".please explain. The septic tank is metal and over 20 years olds or the septic tank(whether metal or not)°is structurally unsound,exhibits substantial infiltration or exfiltraiion o'r.tank'failure is imminent:System will pass inspection if the existing tank is replaced with a complying septic tank.as approved by the-Board of Health. *A metal septic tank will pass.inspection if it is structurally.sound,not leaking.and if a Certificate of Compliance indicating.that the tank is less than 20:years old is available: . ND explain: Observation of sewagebackup 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: Pne of 11 OFFICIAL INSPECTION FORM-:NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE.DISPO:SAL SYSTEMINSPECTIONFORM PART"A CERTIFICATION(continued) Property Address: P 2 4 f)d� aey 1 Owner: Date oflnspectio .• C. Further.Evaluation is Required by the'Board of Health: Conditions exist which require further evaluation by the.Board of Health in orderto determine.ifthe.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(i)(b)that the system is not functioning in a manner which will protect..public health,.sa'fetyand'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)deter mines that the . system is functioning in a manner that protects the public health,safety.and:environment: -, _ The system has a:septic tank and soil absorptiomsystem(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 I of.a public;-water supply. The.system has aseptic 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:150 feet or.more from a private water supply well**..Method% to determine,distance 1. **This system passes if the well water analysis,performed,at a DEP certified 1 oratory, for coliform bacteria and volatile orzanic compounds.indicates that the well is.free from pollution from that facility and the presehce.of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided.thatno other failure criteria are triggered. A copy.of the analysis must be attached to this.form. 3. Other: 3 . Page 4 of.I 1 OFFICIAL-1NSPECTION FORia1 . NOT OR VOLU1 dTARY ASSESSiVIENTS SUBSURFACE•SEWAGE DISPOSAAL.SYSTEM INSPECTION FORT PART A CERTIFICATION(continued). Property.Address-.. G Owner Date of Inspection., f Dt. 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 sew!age;into.facility orsystern component due to overloaded:or clogged SAS or..cesspool Discharge or ponding of effluent to the surfaced the ground.or surface waters due to an overloaded or clogged SAS or cesspool. _ Static liquid level'An the distribution;box above.outlet.invert due to an.overloaded or clogged SAS or cesspool _ Liquid_depth 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 _ c� Any portion,of the..SAS,cesspool..or privy is..below high ground water elevation. _ + Any.portion of cesspool.or privy is within 100 feet of a surface water supply or tributary to.a.surface water supply Any portion of a cesspool or privy is within a Zone 1 of a.public well. Any portion of a cesspool:or privy-is within 50 feet of a.private-water.supply,well, Any portion of a cesspool or privy is,less.:than.1.60 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 ai..a:DEP'certified laboratory,for colifor.m bacteria andvolatile organic compounds , indicates.thatthe.well is free from.pollution from that:facility and the presence.of ammonia nitrogen and nitrate nitrogen.is equal:to or less than 5 ppm,.provided>that no other failure criteria are triggered'...A copy of the analysis.must be attached to this form.] (Yes/No)The system fails.I have determinedthat one or more of:the above;failure:criteria exist as described in 310.CiMR 15.303,thereforethe system fails.The..system-owner should contact the Board of Health to determine what will be necessaryto correct'.the failure: E. Large:Systems: To be considered,a largesystem the system must serve a facility with.adesign flow of.10,000 gpd to 1.5,000 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.2K feet:of a tributary to a surface drinking water supply the system is located ina nitrogen.sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone lI of a public water supply well If you have answered"yes"to any question in Section.E the systertr 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 3.10 CMR 15.304.The system owner:should contact.the appropriate regional office of the Department. i 4 Pag-e 5 of I OFFICIAL INSPECTION.FORM=NOT FOR VOLUNTARY ASSESSMENTS SUiSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM TART-B . . : CHECKLIST Property Address: V (� . Q _ Owner: 41— Date of Inspection: I i Check if the following-have.been done-You must indicate`yes"or `no"-as to each.of the: £otlowm�: _r . Pumping-.information was.provided by the owner;occupant,.or Board of Health i�Were any of the system components pumped out in the previous-two wee' s �— Has the system received normal flows in the previous two week period:? Have larze volumes of water been introduced to the system recentlyor as. art of this ins pi ection.? Were as built plans of the system obtained and examined? (If they were not,available;note as`N/A) 1H — 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 Were the septic tank manholes uncovered,opened, and the interior of the tank inspected for the condition of the b es 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 Sol]Absorption System (SAS)on the site has been:deterinmed 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)]. 4 Palle 6 of 11, OFFICIAL INSPECTION FORM;4N TARY ASSESSMENTS SUBSURFACE SEWAGE`DISPOSAL SYSTEM INSPECTION FORM PART.C SYSTEM INF.ORMATION Property Addres'. ' Owner: Date,of Inspection: . FLOW.CONDITIONS RESIDENTIAL I/ Number.of bedrooms(design) Number of bedrooms(actual)- DESIGN-flow based'on 3IG CMR 15.203(for example: 11.0 gpd x h of bedrooms): Number of current residents:. _ Does residence have a garbage grinder(.yes or no): Is laundry on.al separate sewage system(y or no):/t�(_).[if ves_separate inspection required] Laundry system'inspected(yes or no): Seasonal use:(yes or no): (j Water meter reading a s. if ava'lab e" I (last 2 years usa�e.(�pd)):, Sump pump(yes or no)--.. Last date of occupancy aJ v COMMERCIALANDUSTRIAL A/C Type of.establishment_.. Design.flow(based on a 10 CMR 15.203): gpd Basis ofdesisn flow(seats/persons/sq ft,etc):. Grease trap present(yes;or-no),: Industrial.waste loldin 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` Recordsy P — Source of information: ^(, Was system pumped as part of the inspection(yes or o): AlG If yes,volume pumped:' gallons —How was quantity.pumped determined? Reason for pumping: TYPE OF SYSTEM ,/Septic tank,_distribution box,soil absorption system. Single cesspool _Overflow.cesspool Privy Shared system(yesor 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): .` roximate ale of all components, date installed 'f known)and source of information: Were sewa-e odo Q rs detected wh en arrivt a b n t the site es or no :. U 6 Page 7 of l 7 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL`SYSTEM INSPECTTON'-FOR M PART—C.. ., SYSTEM.INFORMATION(continued) O Properly Address: � key 4 zA_44 Owner: . Date of Inspection-Ci BUILDING SEWER(locate on site plan)`" Depth below grade: Materials of construction: cast iron _40 PVC_other(explain): Distance from private water-supplywell or:suction line:- Comments(on conditionbfjoints,venting, evidence of leakage, etc.): SEPTIC TANK: (locate on site plan) Depth below grade: Material of construction:. ✓concrete_metal fiberglass olyethylene.. - _other(explain) If tank is metal list age: Is age:confirmed by a Certificate of Compliance(yes'or no):;_(attach.a copy of certificate) _ i • Dimensions: l�. �D Sludge depth: Distance from top of sludge to bottom.of outlet tee or baffle: Scum thickness: - It Distance from top of scum,to top.of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee r baffle: How were dimensions.deter mined: �j( � ��A Comments(on.pumping recommeikatiionsTmlet and outlet tee or baffle condition, structural integrity,.liquid levels as elated to outlet invert,evidence of leakage,etc.): ,? i all- /r GREASE TRAP: locate on site..plan) : Depth below grade:_ Material.of construction:_concrete metal_fiberglass: Polyethylene_other I (expIain): 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.): I . Page 8 of 1.1 OFFICIAL INSPECTION FORM=NOT"FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL:SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued).: Property Address:4XItXz �fc�TC Owner Date of Inspection: �. 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 Polyethylene other(explain); Dimensions: Capacity: -gallons Design Flow: gallons/day' Alarm- present.(yes or no)' Alarm level:. Alarm in working.order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION.BOX (if present must.be opened)(locate on site.plan) Depth'of liquid level above outlet invert. G� �,f/l Comments(note;if box i8level.and distribution to outl equal,:any evidence of solids carryover;any evidence of age,into or out of box,etc. r PUMP CHAMBER:. : (locate on site plan).. Pumps in working.or.-der(yes or no): Alarms in working.order(yes or no): Comments(note condition of.pum-:chamber, condition of pumps and appurtenances;.etc.); i 3 Page 9 of 11 OFFICIAL INSPECTION FORM.-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE-SEi�AOE DISPO.SAL;SYSTEM INSPECTION FORM- PART G SYSTEM INFORMATION.(continued) Property Address: Q v �i - q A f Owner Date oflnspectio SOIL ABSORPTION SYSTEM (SAS):Jlocate o�{ n site plan,excavation not required) If SAS not located explain why: T Type _.. leaching pits,number: leaching chambers,number �leaching.galleries, number: leaching trenches,number, length: leaching fields,.-number,dimensions: overflow cesspool,number: innovative/alternative system. Type/name of technology: Comments(note condition of soil, signs of hydraulic.failure,level of ponding,damp soil, condition of vegetation, 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 faiLu�re,:level o f pondin&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 1.1: OFF'ICIAL I�+iSPECTIONI- ORIVI NOT FOR,,VOLLNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM .....PART-C. SYSTEM.;INFORMATION(continued) Property Address: , i Owner: ' Date of Inspection:. ( SKETCH OF SE AGE 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. I r 1 � l5 . Jb , 0. 9 t c- 10 Paae l 1 of 11 OFFICIAL INSPECTION FORA—NOT FOR'VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM.INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner- bate of Inspections .�iZ� 6 SITE EXAM �. Slope Surface water Check cellar Shallow wells Estimated depth to ground water / feet Please.indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abuttinc property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with.local excavators,installers=(attach documentation) _7Accessed USGS database-explain: You must describe how you established the high ground water elevation: AA ® © u�� 11 r Permit.Number: Date: Completed by: HIGH GROUND-WATER LEVEL.COMPUTATION j Site Location: ^/ - Lot No.. Owner: Address: Contractor: e'� C Address: 475~ •p�' ' Notes: STEP 1 Measure depth to water table to nearest 1/10 ft. ........................................:.:.::..:.......................:..... .Date morith%day/year STEP 2 Using Water-Level Range Zone.;• .. and Index Well Map locate, site and determine.:,,,..: OA .Appropriate index well .......................... OB Water level range zone_ ............................................ STEP 3 Using. Y re 9 Port..Current`.: . Water.ReSources;Conditions determine�current`depth to �y D/ / O water level fonndexwell !/ Y/ b month/year STEP 4 Using Table of Water levehAdjustments for index:well--(STEP-.-.:2A),-current-depth to water.-level.-for index--well (STEP 3), and water level zone (ST.EP 213) determine'-water-..I vel.adiustment ..............................................................................:........... STEP 5 Estimate depth to high water by subtracting the water level adjustment.(STEP 4) from measured depth to water 1 levelat site(STEP 1) ......:......................................................................................... ............ ✓I 5 I Figure 13.-.Reproducible computation form. 15 1 TOWN OF BARNSTABLE q . .:: LOCATION � of �"� SEWAGE # `.VILLAGE CT'. ,/ S ASSESSOR'S MAP & LOT Z��— Z ' INSTALLER'S NAME&PHONE NO. /CDd���DII�I �X67 7?/-�369 `�. SEPTIC TANK CAPACITYG//4 L 1w/'/��ii fa-S �yJ size. /v � LEACHING FACILITY: (type) (size) 'NO.OF BEDROOMS 3 i :.::::BUILDER OR�I PERMITDATE: GlI`2 �7 COMPLIANCE DATE:. "Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Sf Feet Private Water Supply Well and Leaching Facility (If any wells exist on.site or within 200 feet:of leaching facility) a Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by a ,et l TOWN OF BARNSTABLE q LOCATION Zo o tI1111 SEWAGE # ! 7- 31�" VILLAGE Cf' rl/ ASSESSOR'S MAP & LOT YR—d�EZ INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY Imo//� LEACHING FACILITY: (type) _Ly `1./,I (size) iU X ?c X-2 NO. OF BEDROOMS 3 BUILDER 0 , PERMIT DATE: kl`Z 4P 7 COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Sf Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by �� ti � _ ,. �,+. • s: . r '; _ � � � a `� �� � �E\ �. No. Fee �� THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes ` PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS Z[ppliration for Migool *pgtem Construction Permit i Application for a Permit to Construct( )Repair( )Upgrade(/Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. Owner's Njmte,,Addrq s and Tel.No. Me Assessor's Map/Parcel Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. &/W&//) c010y; 77/—�' Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( Q 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 01 Size of Septic Tank Type of S.A.S. lz?z Description of Soil Nature of Repairs or Alterations(Answer when applicable) ! Gl lGYe 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 is y th' realth. Signed Date Application Approved by Date 7 Application Disapproved for the following reasons Permit No. kf 7> Date Issued p No. Fee _ THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: _ Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS 1 Application for �Digoml *potent Construction Permit ' Application for a Pen-nit to Construct( )Repair( )Upgrade( /Abandon( ) ❑Complete System ❑Individual Components r Location Address or Lot No. a74i��r Owner's N e, ddres and Tel.No. yAssessor's Map/Parcel ��,Jr Installer's N�hm`e,Address,and Tel.No: Designer's Name,Address and Tel.No. F Type of Building: i Dwelling No.of Bedrooms n Lot Size sq.ft. Garbage Grinder( } Other Type of Building ke5lGae',*?-e No. of Persons Showers( ) Cafeteria Other Fixtures i. Design Flow gallons per day. Calculated daily flow - ' gallons. Plan Date Number of sheets Revision Date Title ' Size of Septic Tank /J�O/J Type of S.A S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) 7-1 7-le CV i tE - 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,,b th' d o ealt Signed -� Date Application Approved by ;` Date e-,'- _2 7 Application Disapproved for the following reasons E i Permit No. Date Issued ___________ ___. ——-- THE COMMONWEALTH OF MASSACHUSETTS Zyg�®gz BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CE TIFY, tha the On site Sewage Disposal System Constructed( )Repaired ( )Upgraded Abandoned( )by at zl/��?' has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. ? 3 dated Installer Designer The issuance of this ermit shall not be construed as a guarantee that the system will function as designed. Date W ' `y Inspector Q\ No. Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS lwigpogar otent Con.5truction Permit Permission is hereby granted to Construct( TRePair( )Upgrade( )Abandon System located at L��.. Ia c� 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 permit. Date: Approved by i I f e G:,*�tki u lk ��4- 0 a _ ;.tom•. ...... �'.� ...Y.. .. Y T -'. �'� fctiY^L.�.ay-.i t�� L•'t,•w - 5},1 F��i� t.. '��� ��.'S' ��u,�s .� �:'��.*..,'6Y=": .4�'-4•-.� .. � ::..• . .,;¢�n�'r �:..z's"•via„sr ., Ft' -.3 dj•33xx"5 na`A�'�aw���`�.,,�G _ . NOTIC7E:This Forms To Be Used For"tithe RepairOf Failed d Septic Systems Only. CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAT WORKS CONSTRUCTION PERMIT (WITHOiTT DESICIFD Pi ANSI J �,4' ekelNle&ereby certify that the application for disposal works construction permit signed by me dated concerning the property located at � � j�/7/,j meets ail or the foilowins criteria: ��—,e-eare ere are no wetlands within 300 feet orthe or000sedseptic system : no private wells within 150 eet or the proposed septic system F/ one observed_zoundwater table is i! =eel or_*eater below the bottom or:he �eacninZ_ _ iaciit, Y I � • ere s no increase n flow snd-or cnanse in use or000sed o SIGNED : DATE: LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTA13LE NUMBER [Attach a sketch plan of the proposed system.Also if the licensed installer posesses a certified plot plan, this plan shouldbe submitted]: ?k L� ., �L ' �2'P�'8ar�oj'"'x+FTC'rt"�,- - •'tom-.Y�_.._ vY,�? TOWN OF BARNSTABLE � 1-7 LOCATION . O ,�1' 9 SEWAGE # VII.LAGE, ASSESSO MAP&LOT��� PqCroRs'NAME&PHONE N SEPTIC TANK CAPACITY / LEACHING FACIIITY:°°--(type) (size) LD x_� NO.OF BEDROOMS 3 BUILDER O OWNER PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by �,_ � m` �_ � � APB c 1997 q OF P,PNSTABLE T:;"FPL BOR'I'OLO'1"I'I CONS'CRUC'I'ION,'INC. de 765 WAKEBY ROAD,MARSTONS MILLS, MA 02648 508-771-9399 508-428-8926 FAX: 508-428-9399 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: ' Date of Inspection: - - Inspector' Name: is Name and Address: i C_F.RTIFICATION TAT M NT• I certify that I have personally inspected the sewage disposal system at this address and that the informa- tion reported below is true,accurate and complete as of the time of inspection. The inspection was per- formed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The System: Passes Conditionally Passes I o 3 Needs FuriliZEv��Kation By e ocal Aproving Authority Fails G 06 a 3 Q —7 Inspector's Signature: Date: �97 / The System Inspector shall submit a copy of this inspection report to the Approving authority within thir- ty(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: A)SYSTEM PASSES: I have not found any information which indicates that the system violates any of the failure cracria as defiried hi 310 C-MR 15.303. Any failure criteria not evaluated are indicated below. B)SYSTEM CONDITIONALLY PASSES; One or more system components need to be replaced or repaired. The system,upon comple- tion of the replacement or repair,passes inspection. Indicate yes, nor,or not determined(Y,N,OR ND).Describe basis of determination in all instances. If not determined",explain why not. The septic tank is metal,cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing sep- tic tank is replaced with a conforming septic tank as approved by The Board of Health. Sewage backkup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of'I"lie Board of Health): - l - ✓'r � R 1 k SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPEC'i'ION FORM f � PART A CERTIFICATION (continued) Broken pipe(s) 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 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 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 FUNCTION- ING 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 with 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 the facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 PPin. D)X11have EM FAILS: determined that the system violates one or more of the following failure criteria as defined in 310 9AR 15.303. The basis for this determination is identified below. The Board of Health shoul contacted to determine what will be necessary to correct the failure. Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of efluent 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 clog- ged SAS or cesspool. Liquid depth in cesspool is less than G" 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 -2- SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) 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 coliforn►bacteria,volatile organic compounds,ammonia nitrogen and nitrate nitrogen. E)LARGE SYSTEM FAILS: The following criteria apply to a large system in addition to the criteria above: The design flow of a system is 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 11 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. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Check if the fallowing have been done: .Pumping information was requested of the owner, occupant, and Board of Health. _None of the system components have been pumped for atleast 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. __IZAs-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. __Zfhe site was inspected for signs of breakout. _ZAll system components,excluding the Soil Absorption System, have been located on site. _The septic tank manholes were uncovered,opened, and the interior of the septic tank was in- spected for condition of baffles or tees, material of construction,dimensions,depth of liquid, depth of sludge,depth of scum. e size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods. o SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PA RC B CHECKLIST(continued) r'' The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of Subsurface Disposal System SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM-.INFORMATION., FLOW CONDITIONS REST ENTIAL: " Design Flow: 0 gallons Number of Bcdrooms:_a Nun beery f Current Residents: Garbage Grinder: Laundry Connected To System: V Seasonal Use:/ — Water Meter Readi s, if ilable: Last Date of Occupancy: COMMERCIAL/INDUSTRIAL• (� Type of Establishment: Design Flow: gallons/day,, Grease Trap Present: (yes or no) Industrial Waste Holding Tank Present: Non-Sanitary Waste Discharged To The Title V System: Water Meter Readings, If Available: Last Date of Occupancy: OTHER: Describe) Last Date of Occupancy: GENERAL INFORMAT ON /l/ Ow PUMPING RECORDS and source of information: �9� System Pumped as part of inspection:_ If yes,volume plump d: Ilons Reason for pumping: TYPE OF SYSTEM: Septic Tank/Distribution Box/Soil Absorption System Single Cesspool Overflow Cesspool Privy Shared System(If es, ch previous inspection records, if any) ✓O r(exp in): P OXIMATE A E of all components,date installed(if known)and source of information: A Sewage odors det cted hen arriving at t ieMe: -4- SUBSURFACE SEWAGE DISPOSAL SYSTEM'INSPECTION FORM PART C GENERAL INFORMATION (continued) SEPTIC TANK: Depth below grade: Material of Construction: concrete metal FRP Other (explain) — Dimisions: Sludge Depth: Scum Thickness: Distance from top of sludge to bottom 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: 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: 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.) TIGHT OR HOLDING TANK: Depth Below Grade: Material of Construction:—concrete—metal_FRP—Other(explain) Dimensions: Ca acit i p y gallons Design Flow: gallons/day Alarm Level: Comments: (condition of inlet(ee,condition of alarm and Iloal switches, etc.) DISTRIBUTION BOX,,-,AO 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: (/ Pump is in working order. Comments: (note condition of pump.chamber,condition of pumps and appurtenances,etc.) -5= SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (conlinued) SOIL ABSORPTION SYSTEM(SAS): 6 (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: s;, Leaching chambers, number: Leaching galleries,number: Leaching trenches, number, length: Leaching fields, number, dimensions: Overflow cesspool, number: Comments: (note condition of soil, signs of hydraulic failure level of ponding condition of vegetation, etc.) - ---- CESSPOOLS: V Number and configuration: -r!o XS Depth-top of liquid to inlet invert: , Depth of solids layer: Depth of scum layer: Dimensions of Cesspool: o Materials of construction:(P"�Indication of groundwater: Inflow(cesspool must be pumped as part of inspection) Comments: (note condition of soilk, signs of hydraulic failure, le I of pondi condition of vegetation, etc.) - �� Ile PRIVY:A_)_0 Materials of construction: Dimensions: Depth of Solids: Comments: (note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation, etc.) -6 - SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (confirmed) SKETCH OF SEWAGE DISPOSAL SYSTEM: Include des to atleast two permanent references, landmarks or benchmarks. Locate all wells within 100 Feet. V \ LO 1104, l� 6��"' DEPTH TO GROUNDWATER: Depth to groundwater: l� Feet Methqd of Deternunadon or Ap roxim don: ® r r © " c11 ,- -7- _ b k t