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HomeMy WebLinkAbout0544 OLD STRAWBERRY HILL ROAD - Health 544 old Strawberry.Hill Road A 273—106 .. Hyannis i a N 1 a p d 6 xx1 o M 3 a N p 1 ' S, TOWN OF BARNSTABLE 'C * qq LOCATION OLb =9aAU-O(%.C-VArJ4Dt t_ !2 Jt, . SEWAGE# VELLAGE z ,.�� ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. /Y,lt r-�Ce4og e. S'P /C 6_ SEPTIC TANK CAPACITY l o o 0 LEACHING FACILITY: (type) /dc 2 ja�C'_-,(size) NO.OF BEDROOMS BUILDER OR OWNER PERMITDATE: COMPLIANCE DATE: 77 - Separation Distance Between the: / Maximum Adjusted Groundwater-Table to the 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 � � � � -�C to �,, _ 4 �v.� —r� � � ^ ' e T � � � N � � �Iw F ., � � �� �- v e�" r �♦ m L��. �.. _ 4 's .r . 'h �� s No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: le? PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS 0(ppritatton for Ztoogat *pgtem Conmruttton Permit Application for a Permit to Construct( )Repair( )Upgrade(V")Abandon( ) ❑Complete System .Individual Components Location Address or Lot No. 51�4 vv Owner's Name,Address and Tel.No. Assessor's Map/Parcel Installer's Name,Address,and Tel.No. �P Designer's Name,Address and Tel.No. 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 �_k,-ky gallons per day. Calculated daily flow , gallons. 'Plari Date Number of sheets Revision Date Title Size of Septic Tank c"- kOCQ L'4 Type of S.A.S. 't C" c� Description of Soil ozb0— �L!0 Nature of Repairs or Alterations(Answer when applicable) ;:;tv..��_t� 4,=� �_ 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 Issue �tis Signed Date —b Application Approved b Date Application Disapproved for the following reasons Permit No. `' Date Issued " �' No. 9�� x / Fee / THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 0[ppYication for �igponl *pztem Con!Aructim Permit Application for a Permit to Construct( )Repair( )Upgrade(V')Abandon( ) O Complete System ` .Individual Components Location Address or Lot No. `-f Q t D 15T f Owner's Name,Address and Tel.No. Assessor's Map/Parcel .-� •?3- !� + Nl Installer's Name,Address,and Tel.No. i— ✓ 1 Designer's Name,Address and Tel.No. K1'% D—C Ae-e-S-epc� t� �C;-A`-- Ste- ! — 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 7 gallons. Plan' Date Number of sheets Revision Date Title Size of Septic Tank `A�t�c,�>>��T L nCO k1AA Type of S.A.S. 0-k c Description of Soil 'Nature of Repairs or Alterations(Answer when applicable) �'1�.4� yl�� ��c'Cx �' - LX et\� C% f3r'�,(-Sd !c`T B� �r ►x tl 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_b" issue y Si en Date tfiis �. g 90 ` -<l Application Approved b Date Application Disapproved for the following reasons e xt i f Permit No. ` Date Issued / ----------------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS (Certificate of (Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired ( )Upgraded Abandoned( )by _ Q\<' _ at t7 27 1 �- has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. a dated :!!! f Installer Designer d, The issuance of this perfiyi�iR's ra�lll n/k bite cow strued as a guarantee that the syste•_'wi11y uunitioyn as;Resigned. Date 6 e f I � Inspector 0 No. � � --_------------------------------- Fee —Z THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE: MASSACHUSETTS 'igo$al bp$tem Cow6tructioin QrrrYit Permission is hereby granted to Construct( )Repair( )Upgrade( )Abandon( ) System located at `4�4 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 b clom'p?.11eeted within three years of the date of this e t. Date: �1 '' � �7 l' R'" Approved by/" �. ,r�� 1/6i99 NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WTMOUT DESIGNED PLANS) --�e✓ hereby certify that the applica tion for disposal works construction permit sided by me dated :2--6-ak�( concerning the property located at C�`�� i` S c 1.i meets all of the t following criteria: /1-1The failed system is connected to a residential dwelling only. There are no commercial or business uses associated with the dwelling. I • The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch. There are no wetlands within 100 feet of the proposed septic system G There are no private wells within 150 feet of the-proposed septic system / 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 five feet above the ma.-imum adjusted groundwater table elevation. [Adjust the groundwater table using the Frimptor method when applicable] ,,,44the S.A.S. will be located with 250 feet of any vegetated wetlands, the bottom of the proposed leaching facility will not tie located less than fourteen(14) feet above the maximum adjusted groundwater table elevation, Please complete the following: A) Top of Ground Surface Elevation(using GI information) t B) G.W. Elevation 2�'O-the AkX. High G.W. Adjustment . DIFFERENCE BETWEEN A and L p SIGNED : .. DATE: [Sketch proposed plan of system on back]. q:health folder.cen �t , , .��. V �.�,� �� TOWN OF BARNSTABLE LOCATION '`I'� aL� S��►c,�II�Gl1alNi�t SEWAGE # r VILLAGE ASSESSOR'S MAP& LOT ' INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) a/0 C' (size) // 3-2 NO.OF BEDROOMS BUILDER OR OWNER PERMTTDATE: ,'> —::::COMPLIANCE DATE: n ' � Separation Distance Between the: Maximum Adjusted Groundwater Table to the 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 7—e t i _ �j LOCATION SEWAGE PERMIT N.O. L-0 1 a// O/d S f f o co a-ee 24 !fir# Met V'I L-L AG E IN.STA LLER'S NAME & ADDRESS Roo i Guy G� B U I*L D E R OR OWNER Ca .,v- LJ I'd -e j re,( Cd DATE PERMIT ISSUED ; -77 DAT E COMPLIANCE ISSUED _ . � �— RN K �e CA ✓ems` ��_ r a ! TOWN OF BARNSTABLE LOCATIOM�Zf— I I ��7 � � K SEWAGE# VILLA GIs" ASSESSOR'S MAP&LOT o 73 06 INSTALLER'S NAME&PHONE NO. ®v SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) NO.OF BEDROOMS BUILDER OR OWNER OE PERMITDATE: ZO&Z 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 P—rfC/at rEa,w Pt Ax1 e)Aj f-'I LL lv- �. ��. ems.- . �, r '� � �I i r+ i o , � � N o � � � � - 2 � �� � ; O � s �. i st '� m a � Y I „'�� X ��%L � r i � - ,I t _ .. t. �. r _ -_- --_ - t ..R �a oo �. 1. � :� No....... F•...... r FEs.............................. THE COMMONWEALTH OF MASSACHUSETTS �{ BOARD OF HEALTH L� ( Town OF.........Barnstable ............................... .............................................. Appliratii'n for Dispog al Workii C omarnrtion ramit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: Old Strawberry Hill Road Lot 11 Land Court Plan 32849A ... ..........._........_....................•--_•••••--•----•--•--.._..----•-..........._..... ............................................... .......� .._.......-----•--•---• cation Addr ss or Lot 49 ....---•........- - ---------•-----•------ p Owner ..----•-____....•.......•.......Address _ _o.r l� Installer Address Type of Building 3 Size Lot../-�.Q 0®._..._..Sq. feet U Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) 1:14.-I Other—T e of Building No. of persons............................ Showers Cafeteria a' Other fixtures ...................................................... Design Flow.....-SS.................................gallons per person pper day. Total daily flow.._....330.__.._______._...............gallons. WSeptic Tank—Liquid capacity 1000-gallons Length...$'.-6... Width_4_'_.-10.'.�Diameter................ Depth___5�__-8" x Disposal Trench—l�o. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No.__--•--_'1_--_---_-- Diameter.................... Depth below inlet................... Total leaching area.......200...sq. ft. Z Other Distribution box"( X) Dosing tank ( ) `-' Percolation Test Results Performed by.Baxter &..Nye-A. Jones P, .E,_ Date___12l_.12/77................ aTest Pit No. 1......2.......minutes per inch Depth of Test Pit----- ......... Depth to ground water........................ Test Pit No. 2.......2......minutes per inch Depth of Test Pit.....12...._.... Depth to ground water........................ ------••--------------------------------------------------•--------------------•------------------------------•-••••-•-••.......----•--------------------... O Description of Soil..............2-21 Loam and subsoil 2 -121 clean--medium--sand•••-•--_--_--_-_----- x c, w ------------------------------------------------------------------------------------------------------------------------------------------•-------•---------------------------------------------------- U Nature of Repairs or Alterations—Answer when applicable................................................................................................ ---------------------------------------------------------------•-----------------------.............----.....--------- ......................................................-.......................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of MIZ 5 of the State Sanitary Cod The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been e the board of ealth. Gal e ',oevelc VneM"' C� ► Sign d_... z 7--... A lication Approved B . D to Date Application Disapproved for the following reasons:.----•---------•----•--••....-••----•-•-•-•--•---•••--••-------------•-•-------•--------•-•----•-----.........._ -------------------------------------•--...--------------------•••--•••--------•---....-•----------....-•---------------------------...------....�..-------------....................................... Permit No......................................................... Issued-.......� ---4L 4i-------_Date------ Date r` b No................----••. F&s.............................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH " Town Barnstable . ......................_.........-----.....OF.................--....-..---•---.....--................................................ Appliration for Disposal Wurks Tonstratrtinn ramit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: Old Strawberry' Hill Road Lot 11 Land Court Plan 32849A - --_ .. ..... -------------- --•------:-------- -------•--._..__........--- •-......-- •---•--------- ------•-------- ocation:-Add es q or Lo�r o. PIS D�--_......C3l�Ll_. R_1P__._....-•--------------- .... ...... -••--•----•_______________ Owner Address 0 a ............ 4,2x�r •--------------------------------------•-- Installer Address Type of Building Size Lot_L. .6®6.__..._..Sq. feet .., Dwelling—No. of Bedrooms____________________________________________Expansion Attic ( ) Garbage Grinder ( ) aOther—Type-of Building ---------------------------- No. of persons............................ Showers ( ) — Cafeteria ( ) Q' Other fixtures __________________________•.... -_. W Design Flow_____5S________________________________gallons per person !r d iy. Total dailyflow-__.._._a`�-30__.___..-___-__.__-_.____._.gallons. WSeptic Wank—Liquid capacity gallons Length_._8__"b__ Width_--'". ©._ Diameter................ Depth-__ x Disposal Trench—:�o_____________________ Width$__•............... Total Length_--________._�.__ Total leaching area_..____..`,.�___sq. ft. Seepage Pit No-------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box (X) Dosing tank ( ) Percolation Test Results Performed by I asct®r & .lone$ Pw B. 1�/19/77 ' --•-••• ---•-------- ----- ---- Date ............................. Test Pit No. 1......2-------minutes per inch Depth of Test Pit.....32 ......... Depth to ground water------------------------ (i Test Pit No. 2....... ......minutes per inch Depth of Test Pit..... .......... Depth to ground water........................ ---------------- __-•-- -----•---•------•-•-- O Description of Soil______________�"2�_..LOt-� 81ctd �ub5oi 2�••12� �I@aA_ mBd3ltmt S�ttid x V ------------------ W UNature of Repairs or Alterations—Answer when applicable............................................................................................... --•--•-•-----•••••••-----••-•----------•----••---•--•--•----..•----------------------------------------------- --=•------•------•------•_.___••----••----_-___•-_._....--__-_.______._.: Agreement The undersigned agrees to install the aforedescribed Individual :Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Code The undersiped further agrees not to place the system in operation until a Certificate of Compliance has been is U. d e board of health. c�F � SeveIoP"'eN-r Cav2i>. �Ign t.-a-.......... ---------•--••-- �L 20._Z7__._....-- • u 4r/. - • -yam e /�7••� !• Application Approved By. ...... ---- ............ r�................................ ........................................Date S Application Disapproved for the following reasons.6!........................................................... ....................•--------•-•---r•_.-_----------......__.._..___. / Date Permit No................. - - Issued. . [t.-- --- ' 'Date. THE COMMONWEALTH OF MASSACHUSETTS BOAi4D OF HEALTH ................... .OF....:...j 1. �1 :�. +1.. ..................................... a. Tq itiratr of Toutph anrr THI S CERTIFY ,That the, Individual Sewage Disposal System constructed (,,) r Repaired ( ) by........... .........-•--------------•-•--..........-----------•.................................................................................................... a Installer .....E)•i-•-•- e -S-T 2_x' ,e J ill:f':r ;l { �1 - �J!� '.--- �i N!��' t...../nA----::...--•-•••-••-•-••- has been installed in accordance with the provisions of TITLE 5 of The State Sanitary ��d.aijdgSQ* � in the Vr application for Disposal Works Construction Permit No......................................... dated................................................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. tt /- ,. DATE.• `�.'.'....��"` -••-----------------••-_------ Inspector._ __ L� ............. � --•-• :fir -.:_ .........._. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALT "'x.:,,'., No......................... FEE_. ......... ]RIspos hS T,antrnrtilan rrntit - Permission'is hereby gra --•-••--•-••---•----------•--•-•--------•-------------- to Construct ( der Repair ( ) an Individual Sewage Disposal System at No.. T)I tol �tf ...- -rraFY:I.+ // r- ,� �1 �i // � 1-���} �f �i.Q /�y ••- I ......J �`•- J.PM_ .sue]•,e_i?--p �. I V 7-v ! aI_ `"�•_•7_• �_�'J -l• •)f-+--+-I._( •_____• •_•-•__ Street as shown on the application for Disposal Works Construction e'r it N f ..h Dated._-._/_._....'--__-_.......-I.... ........ • k G4Y/• ��''"" ........ .....-_____________________________•____.-_._--.---- ---------------------------------- Board Board of Heal DATE....2_`.A�-_Zf............................................. FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS • I �Z=IJk-L CAM j �rl-1CC -T 4-1V- fSC 6.P.0 { 9 u,t:_- _t oc-)C> 6aL l�j .I- ,F•cr�,c,.L F-'IT - ��5E ►Ooo G,a.t.._ . .� �� � � It ✓� �� A�E.A = tSo 1 EPW--14-4. Exp -FC,7-,&L '�ES►GF.I6L iihlL`( �LL>kA/ = 3306.�. Vt1'T E : lf,l 2M1 IJ ore L�SSgj 'r W: s 1 Io' ^ P T u� ' Map► '-*, ` I � lJ Us. \J 1� 1 Aj vi 1 N' ! j 4� To'r P u o.o �-59 . uA M fjf>t' I Oo[:7 z. sv a 30 1 t_ Lj r�P� DFST. I AN. ('>o l. `Box. 9c.g Sc-QrIC I AN. ) T`A nl K F , fUOQ cis.B I GAL. 9G.0 1 LAN A PST p, w+rw H F-0 )M I'Ja�¢ ('/i S^M D WASHED L►T 2 T t T`--r am u ��t_c>.r ��t_ A," r10 W^% Erz tz/I9 /77 Ph,uCx,5E0 1 t_LI, r11=ter `rl-(�,-T- -I,I~ oveyQ�T1oN St-1c- c/►J 4�t_.tt,►�1 12i=1=C_t�i:�.it_% t 1t t;lrlrl.l C i..4li'l_�!a `l/ ITi� j'1-li_ ilt)G-- t_It 1E- i R to S'T 8 E , (} —2 4 J (mot ° I�l ��/.�'n — 1 c�LGl�s tt ,:i=ta 11�r�� ;U '_vr:Yvl Ll o-v t?,A t'Y� 01 .iTE�vtl_U" v AAA may, y" h YFai: i � t:/ ,�l:- 1..C'a"C" l_{ I�.I;.:.:� i ,I 4.• �1.� ic.t i�t=_11•_._� 116i99 NOTICE: This Form Is To Be Ifsed For the Repair Of Failed Septic Systems Only. CERTIFICATION OF SKETCH AiYD APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANS) I, o c—��•' hereby certify that the applic ation for disposal works construction permit signed by me dated -�—�1�( concernin- the property located at `�� 1S (}v meets all of the following criteria: The failed system is connected to a residential 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. There are no wetlands within 100 feet of the proposed septic system • There are no private wells within 150 feet of the proposed septic system • There is no ineiease to flow and/or change in use proposed There are no variances requested or needed. ". e bottom of the proposed leaching facility will not be located less than five feet above the ma.-dmum adjusted groundwater table elevation. (Adjust the groundwater table using the Frimptor method when applicable] ,,44the S.A.S. will be located with 250 feet of any vegetated wetlands, the bottom of the proposed leaching facility will not be located less than fourteen(14) feet above the mx-dmum adjusted groundwater table elevation, Please complete the following: A) Top of Ground Surface Elevation(using GIS information) r B) G.W. Elevation �Jl�+the ivtA.`C. High G.W. Adjustment . '�_ �r O DIFFERENCE BETWEEN A and p SIGNE�-. . (Sketch proposed plan of system on back]. q:health folder:cen S-. TO NI OF BARiVST.A.BLE OrAIION a-`��{ O�t SEWAGE # '' ULLAGE 4 ,,r .... �-1 L SSESSOR'S MAP &_ LOT DISTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY AGC)O!,*\ LEACHING FACILi IY, (type) (size) f2 LT NO.OF BEDROOMS 3 BUILDER OR OWNER -ILPS tar.�� PERMITDATE: 1,15 COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility ZQ Fce, Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) #J(14 Fee, Edge of Wetland and Leaching Facility(If any wetlands exist tAl.within 300 feet of leaching facility) f�: Fee_ Furnished by 1,q�cx,�Za � p.. V 1 1 � 1 C� �' �� � �� CA � {{� � cnr � 1 N 1/1 � � � — � ' � . � '4`— i � " �' .� �' W N i �. .. � �� 1 c _ ...: �i��. . - - COMMON\\E.�I TH OF I�L�SS.�CHt"SETTS h - ExFcUTI\'E OFFICE OF EN`VIROtiI`IENT.0 AFFAJI1 S Jr DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE CCI\TER STREET. BOS T ON 0210r (61 292 :5:r i TRUDY CO\F Secretar. ARGEO PALL CELLUCCI DAt'ID B STRL:HS Commiss:one: Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A �j �C1ERRTIF�ICATION 1 " Property Address: S � ��0.� � ` of Owner t-ko'% J'vYb. (ntijT1 ,3It ress of Owner: Date of Inspection:�l t����t �a / � ,� ,/U Name of Inspector:(Please Print)f� JEL GC 1 am a DEP approved system inspector pursuant to Section 15.[340 of Trtfe 5(310 CMR 15.000) Company Name: 8t+ r Alt L^,'Y'L,u kk" r in+C,& F Mailing Address: � �"' L-A g4- oZC 4"� Telephone Number: / SQ7�! L.6 9 - 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 Evaluatio the Local Approving Authority Fails ` inspector's Signature: Date: 4r t The System Inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)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. NOTES AND COMMENTS 8 9 i m q �0 rr 3199g A revised 9/2/98 Page IofII %J# Printed on Recycled Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) i 'roPef-tY Address: Jwnef: Date of Inspection: INSPECTION SUMMARY: C k A, B, C, or D: A. SYSTEM PASSES: 1 have not found any informa ion which indicates that any of the failure conditions described in 310 CMR 15.303 exist. Any failure criteria not evaluated are indic ted below. COMMENTS: B. SYSTEM CONDITIONALLY PASSES: One or more system components as de cribed in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, s approved by the Board of Health, will pass. Indicate yes, no, or not determined (Y, N, or ND). D scribe basis of determination in all instances. If "not determined", explain why not. _ The septic tank is metal, unless th owner or operator has provided the system inspector with a copy of a Certificate of Compliance (attached) indicating th the tank was installed within twenty (20) years prior to the date of the inspection; or the septic tank, whether or not meta is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will p ss 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 w ter level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribu 'on box. The system will pass inspection if(with approval of the Board of Health). broken pipe(s) are replaced r obstruction is removed distribution box is levelled or r laced _ The system required pumping more than four times 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 :o r V •, � d revised 9/2/98 Page 2of11 J SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Owner: Date of Inspection: C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of Health in order to det rmine if the system is failing to protect the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE TH 310 CMR 15.303(1)(b)THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH NO SAFETY AND THE ENVIRONMENT: _ Cesspool or privy is within 50 feet of surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or salt marsh. f 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC W SUPPLIER,IF ANY)DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH D SAFETY AND THE ENVIRONMENT: _ The system has a septic tank and soil absorption system(S S)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. _ The system has a septic tank and soil absorption system d the SAS is within a Zone I of a public water supply well. _ The system has a septic tank and soil absorption system nd the SAS is within 50 feet of a private.watertupply well. _ The system has a septic tank and soil absorption syste and the SAS is less than 100 feet but 50 feet or more from a . private water supply well, unless a well water analysis or coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the p esence 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 9/2/98 Page 3of11 r 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM \ PART A CERTIFICATION (continued) Pr Address: Owner: - Date of 1 on: D. SYSTEM AILS: You must indica either "Yes" or -No" to each of the following: I have d ermined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this determinat' n is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No _ Backu of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. _ Discharge r ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. Static liquid leve in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool _ Liquid depth in cessp of is less than 6" below invert or available volume is less than 1/2 day flow. Required pumping more t n 4 times in the last year NOT due to clogged or obstructed pipe(si. f Number of times pumped Any portion of the Soil Absorpti 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 wit in a Zone I of a public well. Any portion of a cesspool or privy is within feet of a private water supply well. _ Any portion of a cesspool or privy is less-than 1 0 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has een analyzed to be acceptable, attach copy of well water analysis for -coliform bacteria, volatile organic compounds, amm is nitrogen and nitrate nitrogen. E. LARGE SYSTEM FAILS: You must indicate either "Yes" or -No- to each of the following: The following criteria apply to large systems in addition to the criteria a ove: The system serves a facility with a design flow of 10,000 gpd or greater( rge System) and the system is a significant threat to public health and safety and the environment because one or more of the following onditions 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 suppl the system is located in a nitrogen sensitive area(Interim Wellhead Protection Ar -IWPAI or a mapped Zone 11 of a public water supply well) The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.30 ). Please consult the local regional office of the Department for further information. �1 revised 9/2/98 Page 4oru SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B / CHECKLIST -roperty Address: Owner: Date of Inspection: Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Yes No Pumping information was provided by the owner, occupant, or Board of Health. Y _ None of the system components have been pumped for at least two weeks and-the system has been receiving normnl 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. X _ 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: Existing information. For example..Plan at B.O.H. Determined in the field if any of the failure criteria related to Part C is at issue, approximation of distance it unacceptable) [15.302(3)(b)] The facility owner (and occupants,if different from owner) were provided with information on the propermaintanaoc".of SubSurface Disposal Systems. revised 9/2/98 PagcSof11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION 'roperty Address: � W Owner: Date of Inspection: FLOW CONDITIONS RESIDENTIAL: Design flow: g.p.d./bedroom. Number of bedrooms (design): Number of bedrooms (actual): Total DESIGN flow, 3n Number of current residents: 07 Garbage grinder(yes or no): /V l Laundry (separate system) (yes or no):(/�' ; If yes, separate inspection required Laundry system inspected b5 r no) Seasonal use (yes or no): Water meter readings, if available (last two year's usage (gpd): Sump Pump (yes or no):�J Last date of occupancy: -A COMMERCIALANDUSTRIAL: Type of establishment: Design flow: qpd ( 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 r � PUMPING RECORDS and source of inform@tyo� System pumped as part of inspection: (yes or no)_ If yes, volume pumped: gallons Reason for pumping: F SYSTEM Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system (yes or no) (if yes, attach previous inspection records, if any) I/A Technology etc. Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other Ar APPROXIMATE AGE of all components, date installed(if known) and source of information: tL A:. Sewage odors detected when arriving at the site: (yes or no) revised 9/2/98 Pagc6(if II SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) 'roperty Address: Owner: Date of Inspection: BUILDING SEINER: (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 pl nl� Depth below grade: u Material of construction: ,concrete_metal_Fiberglass _Polyethylene—other(explain) If tank is metal,list age_ Is age confirmed by Certificate of Compliance_(Yes/No) t Dimensions: Sludge depth: . Distance from top of sludge to bottom of outlet tee or baffle: r d� Scum thickness:_ A/ Distance from top of scum to top of outlet tee or baffle:_ I yr Distance from bottom of scum to bottom of outlet tee r baffle: How dimensions were determined: r � omments: (recommendation for pumping, con con of inlet and tlet tees or baffles, depth of liqu' eves in relation tyi out et Inver str tural irate ity. evide ce of leakage a c.) ------------- 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.) revised 9/2/98 Page 7oftt SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C �^�y���, SYSTEM INFORMATION (continued) propertyJ� Address: 5qq Ga It,► tvjut ' V ` Owner: Date of Inspection: TIGHT OR HOLDING TANK:1�-- (Tank must be pumped prior to, or at time of, inspection) (locate on site plan) Depth below grade:_ Material of construction: _concrete _metal_Fiberglass_Polyethylene_other explain) Dimensions: Capacity: gallons Design flow:, gallons/day Alarm present Alarm level: Alarm in working order: Yes _ No_ Date of previous pumping: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX: (locate on site plan) Depth of liquid level above outlet invert:f6J ` r Comments: _ (no a if level d distrib tion is eq I, evade ce of solids arry ver, evrd c f leakage ft 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 9/2/98 Page sorII f i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C p SYSTEM INFORMATION (continued) `roper::Address: Owner: Date of Inspection: (L� SOIL ABSORPTION SYSTEM(SAS): (locate on site plan, if possible: excavaEioYr�ot required, location may be approximated by non-intrusive methods) I� If not located, explain: Type: leaching pits, number:4 leaching chambers; number:_ leaching galleries, number:_ leaching trenches, number, length: leaching fields, number, dimensions: overflow cesspool,number:_ Alternative system: Name of Technology Comments: (not condition of soil, si ns of hydraulic failure, level of ponding, dam soil, c ndrtion of egat on, etc.) CESSPOOLS:_ (locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: r )epth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater: inflow (cesspool must be pumped as part of inspection) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY:_ (locate on site plan) Materials of construction-- Dimensions: Depth of solids: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of.vegetation, etc.) revised 9/2/95 Page 9of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) 'roperty Address: )wner: Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) ' t O / 7n revised 9/2/98 Page 10of11 i i 1 - SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C R SYSTEM INFORMATION (continued) roperty Address: Owner: Date of Inspection: NRCS Report name --- Soil Type_ ----- -"-- Typical depth to groundwater___--------- USGS Date website visit Observation Wells checked Groundwater depth: Shallow Moderate Deep SITE EXAM Slope Surface water�n Check Cellar DV'j Shallow wells Estimated Depth to Groundwater:�I "'Feet Please indicate all the methods used to determine High Groundwater Elevation: t Obtained from Design Plans on record Observed Site (Abutting property, observation hole. basement sump etc.) Determined from local conditions Checked with local Board of health Checked FEMA Maps r � Checked pumping records �) Checked local excavators, installers x Used USGS Data Describe how you established the High Groundwater Elevation. (Must be completed) revised 9/2/98 Page 11of11