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HomeMy WebLinkAbout0478 OLD TOWN ROAD - Health 478 Old Town Road Hyannis P A = 248 156 � o } ° t ti 1 a r ° � COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION h f I 1� 9•w s� TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A RECEIVED CERTIFICATION Property Address: —T 2Y, )/ d L-V J U N 1 .2 2002 N� 1-0141/f 'Z v/ TOWN OF BARNSTABLE Owner's Name: HEALTH DEPT. Owner's Address: d o Date of Inspection: Name of Inspector: (please print) /G1�"h� Company Name: &/1111 � c Mailing Address: /ot.' Telephone Numbev.,�y ) 29 i -- /2 2cc/f CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section.15.340 of Title 5(310 CMR 15.000). The system: Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: G�7 /- 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. s S Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: /J / O /� c Owner• ( r Date of Inspection: o Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A./ Sys�te Passes: I have not found an information which indicates that an f y y o the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not 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. 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 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: Page 3 of 11 OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: T�? t%'�� di w✓I c/ Owner: Date of Inspection• C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if 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 a manner which will protect public health,safety and the environment: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. 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 other failure criteria are triggered.A copy of the analysis must be attached to this form. Other: Page 4 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address- / `D ad Owner: G Date of Inspection: - 3 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No/ Z/ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool _,ZDischarge 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%2 day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped ,Any portion of the 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. _iZ Any portion of a cesspool or privy is within a Zone 1 of a public well. !� hy portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] Lam-(Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve 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. r Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: T c?12 FD f-tl �� C, Owner: 1 Date of Inspection: Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes No Pumping information was provided by the owner,occupant,or Board of Health Were any of the system components pumped out in the previous two weeks Has the system received normal flows in the previous two week period I- 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 available note as N/A) Y — Was the facility or dwelling inspected for signs of sewage back up Was the site inspected for signs of break out Were all system components,excluding the SAS,located on site !/ _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of&b es or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum v — Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no Existing information.For example,a plan at the Board of Health. _ Determined in the field if of the failure criteria related to Part C is at issue approximation f — ( any � o distance is unacceptable) (310_CMR 15.302(3)(b)] Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C L,( SYSTEM INFORMATION Property Address: / �F ©�� 'llkl Owner: /G Date of Inspection: o OW CONDITIONS RESIDENTIAL Number of bedrooms(design):3 Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): Number of current residents:_ Does residence have a garbage grinder(yes or no): Is laundry on a separate sewage system(yes or no):14 if yes separate inspection required] Laundry system inspected(yes or no)/eO Seasonal use: (yes or no): lvO Water meter readings,if available(last 2 years usage(gpd)): A000 —6/6avGZ p (•-j c��� Sump pump(yes or no):if/0 Last date of occupancy: c.a r-eeo f COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): �d Basis of design flow(seats/persons/sgf,etc.): Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no):_ Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Was system pumped as part of the inspection(yes or no): If yes,volume pumped: ffilons--How was quantity pumped determined? Reason for pumping: ,Y 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) _Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) _Tight tank _Attach a copy of the DEP approval _Other(describe): Approximate age of all components,date installed(if known)and source of informatio Were sewage odors detected when arriving at the site(yes or no): Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: / Y C/c / �vl� , .A/C Date of Inspection: BUILDING SEWER(locate on site plan) l/ 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 Z(locate on site plan) Depth below grade: Material of construction:_concrete_metal_fiberglass_polyethylene _other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions: six�l Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: J// n// Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bolt f f outlet tee or baffle: How were dimensions determined: r C� Comments(on pumping recommendations,inlet and alifflet tee or baffle condition,structural integrity,liquid levels as laced to outlet invert;evidence of 1 e,etc.): o� ; GREASE TRAP:0ocate 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.): Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C L//� SYSTEM INFORMATION(continued) Property Address: T/� O o6vo Owner: Date of Inspection: TIGHT or HOLDING TANK: C (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: Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage Tito or out of box,e1c.): tee/ 1410 5�0//cis PUMP CHAMBER G 1✓(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.): Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: �� ���� w H Owner. �,1 d 6 p/ Date of Inspection: o� O SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why: Type leachin its,number: leaching leaching chambers,number: leaching galleries,number: leaching trenches,number,length.- leaching fields,number,dimensions: overflow cesspool,number: innovativdalternative system TypeJname of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): tit Cw� of A° G2�A�t ti� G1 7� l���✓'S �lPct Gl N -0 R i 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 ce§spool: 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.): Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: �?f C�( �l I ot-,W Owner:,WC 'Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building. 6� Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: old w k Owner. "we C;. Date of Inspection: SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 33 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 yhin 150 feet of SAS) :j checked with local Board of Health-explain: A/JS Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must des c ho you established the high ground water elevation: k/ -/✓1 IC, / r 0 r+C 7Zo�v1e a� o A - (Pi l • rl i5 y S,cwNd�,a.�. l 7 331 Vol TOWN OF BARNSTABLE ` LOCATION - oI U(L SEWAGE # �-o VILLAGE :,42� ASSESSOR'S MAP & LOT,),V9- ISI INSTALLER'S NAME&PHONE NO. C- SEPTIC TANK CAPACITY :E-K,26�L tegV LEACHING FACILITY: (type) � '��1. I�� ul. (size) NO.OF BEDROOMS BUILDER OR OWNER PERMITDATE: I— 5-- 9 COMPLIANCE DATE: :1- — to i'� 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 s M M � o i f ./ M(`YV� No. �7 e Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: AZ Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 01pprication for Miopogal *pztem Cow6truction Permit Application for a Permit to Construct( )Repair(Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No.%4-?8 ®/ T02 WA/ Owner's Name,Address and Tel.No. Assessor's Map/Parcel 1 2 Inst er's Name,Address,and Tel.No. 1 J Designer's Name,Address and Tel.No. ✓ tea+-r�1 . 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 --530 gallons per day. Calculated daily flow 7> gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank !E?et S( �J Type of S.A.S. il Cr `dam i` s'kTt'� Description of Soil 12 1) s� Nature of Repairs or Alterations(Answer when applicable) �yi TW �/ �Vt�/rts��t �Cr�Xi7 M,- L-T(-47V*1 L& Y" SEOV le-©G+/ �- etU S'r�"a— ,n 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 this Signed Date D�-S`�� Application Approved by / e Date 2d"' Application Disapproved for the following reasons Permit No.__ 97^ff Date Issued 9� y-No. �r a Fee � Entered in computer: THE COMMONWEALTH OF MASSACHUSETTS Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE. MASSACHUSETTS ZippYication for Mioom 6peum Construction Permit Application for a Permit to Construct( )Repair(t/)Up rade( '�)Abandon,( ' ) ElComplete System ElIndividual Components Location Address or Lot No. 4 78 �� TOw� Owner's Name,Address and Tel.No. �aN�c-/S�r% Assessor's Map/Parcel ���` jr �J5 51 I/ r" (�G ie Installer's Name,Address,and Tel.No. '� Designer's Name,Address and Tel.No. �rRv�u Type of Building: DwellingNo.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow. 30 ` gallons per day. Calculated daily flow 3 gallons. Plan Date Number of sheets Revision Date Title f Size of Septic Tank !E—jr 57r 0 hJ Type of S.A.S.. 1Ckj,C c,4C r K-f4,L ✓u70 f Description of Soil c` Nature of Re airs or Alterations(Answer when applicable) 5'rP+ vl� d.(, CG /, l T LI STov� nGv 57 s -/y// opt,", e,-t 6 r� �r�r ET 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 this Signed + _t�r,�.t."' Date 09--5 W Application Approved by Date 'Z-6o-2er- Application Disapproved for the following reasons Permit No. 9�—Ft` Date Issued —�—f ------------------------------ — 1 -7 -- THE COMMONWEALTH OF MASSACHUSETTS ,. BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY, that t On-site Sew�ag s osal System Constructed( )Repaired( )Upgraded(►/) Abandoned( )by at �! i()`CC� Y�� - br'[� has been constructed in accordance with the provisions of Title 5 and the for Disposal System=Construction Permit No. - Edated Installer Designer The issuance of this permit shall not be construed as a guarantee that the system will function as designed. Date 1 tAo - Inspector Jr --------------------------------------- No. /q 7 6 Y Fee �r THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BA°RNSTABLE, MASSACHUSETTS r 'igogal &pgtem ongtruction Permit Permission is hereby granted to Construct( )Repair( ))Upgrade(Abandon( ) - System located at W 7 90 6 0 TC " r �I 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. a Provided:Construction must be completed within three years of the date of this permit. Date: Approved by e i 1019/97 r NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. i CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT ENGINEERED PLANS) I, hereby certify that the application for disposal works r , construction permit signed by me dated o•�_ L�It concerning the. ; _ • property located at Z-c7wtu (22 arl meets all of the t following criteria: i • There are no wetlands located within 100 feet of the proposed leaching facility ! "• There are no private wells within 150 feet of the proposed septic system 9 'There is no increase in flow and/or change in use proposed i , There are no variances requested or needed. if the proposed leaching facility will be located within 250 feet of any wetlands,the bottom of the proposed leaching facility, will no be located less than fourteen(14)feet above the maximum adjusted groundwater table elevation. . i Please complete the following: A)Top of Ground Elevation(according to the Engineering Division G.I.S.map) C 0 B)Observed Groundwater Table Elevation(according to Health Division well map) J-7` —r 67, D SIGNED: DATE: l LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER i a ' [Attach a sketch plan of the proposed'systein.Also If the licensed Installer posesses a certified plot plan, r _ ,this plan should be submitted). tr ' °y q:health folder:Bert l VJ G Q • c, TOWN OF BARNSTABLE LOCATION �j UI�.,�K�d SEWAGE# �� VILLAGE ,2;_ ASSESSOR'S MAP & LOT;X 9-./S6 INSTALLER'S NAME&.PHONE NO. M��',1(��� �ta L SEPTIC TANK CAPACITYL�"�S4 /dUi� L;)✓ACHING FACII.ITY: (type)t- l SAA Lk N_j U �_(size) 3lTf NOc:OF BEDROOMS . P.MDER OR OWNER \ PERMITDATE: 2- J - $ COMPLIANCE.DATE:_ X = !o Separation Distance Between the: 1 Bottom of L.eachin Facility Feet Table and Maxunum Adjusted Groundwaterg ty • Private.Water Supply Well and Leaching Facility (If any wells exist On site or within 200 feet of leaching facility) Feet ".0f;Wetland and Leaching Facility(If any wetlands exist i thin 300.feet of leaching facility) Feet I Furnished by ... ....... �r a • 3 � , o ' 3 I f 3 � ._ I o 3 : . r NEW LIFE S�ptiE SCUM ICC (508) 563-7433 (508) 548-3355 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Address of property owner's name k Date of Inspection PART A CHECKLIST -- Che if the following. have been done: Pumping information was requested of. the owner, occupant, and Board of Health._Z None of the system components have been pumped for at least two weeks Y P P P. 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. IV As built plans have been obtained and examined. Note if they are not available with N/A. L The facility or dwelling was inspected for signs of sewage back-up. VThe site was inspected for .signs of breakout. All system components, ..excluding the SAS, have been located on the site. The septic 'tank manholes were uncovered, opened, and the interior of the septic tank' was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. The size and location of the SAS on the site has been determined based on existing information or approximated by non-intrusive methods. The facility owner (and occupants, if different from owner) were provided with information on the proper .maintenance of SSDS. 1 :.-w,xe.re+av,ZrW�s'+3 wy-`'f< ,�.yfr,:,d� #•,w ,.._f.. ,... yv+_trm :.:, g r. ...�.- ._., . � n'4t�k f cyst3• �is+:Ty RE,..f `�.++. RrA, `3, ' ._ 9 ..'s a+ c.�.:e i ,.,.:.�:CW"r z€ 41r _ <.. .� .a .k _ .w.. ._.s... _..,..,-.-.... .� MV•.tas:� � F.r.4.t:k �;T.,.x a:s. :a;( t - -'�.r rtfi..• yrrca � n a �v:ry.w ;La1 s fna tea w,`p i Li2ww�++ �.»� T' h. :r h '�y,F T< zw-cam t maS 3.xr- YY `4"5c r5'94M1 .- {, r,4+'.w k .; ! 1 n'a .w`"s ;,r,. ..t +w-• h r a w Fir SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM -INFORMATION _ — FLOW CONDITIONS If residential � -number -of' bedrooms number of current residents garbage grinder, yes or no _Alb laundry connected to system, yes or no seasonal use, yes or no If nonresidential, calculated flow: Water meter readings, if available: Last date of occupancy GENERAL INFORMATION Pumping records and source of information: No �� r'l d !.A System pumped as part of inspection, yes or no if yes, volume pumped Reason for pumping: = TYPPiof 'system 410 15-�R�r V Septic tank/ soil absorption system Single cesspool Y em 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. Source- of information: �� �etifS ow tti k•en ovse v . bU:14 Ao Sewage odors detected when arriving at the site, yes or no k . 9 SUBSURFACE SEWAGE. DISPOSAL SYSTEM. INSPECTION $ORM PART B / SYSTEM IN80RMATION continued 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 Tto top of outlet tee or baffle - __ r . _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, recommendations for repairs, etc. ) DISTRIBUTION BOX: (locate on site plan depth of liquid level above outlet invert Comments: (note if level and distribution is equal,. evidence of solids carryover, evidence of leakage into or out of box, recommendation for repairs, etc. ) _wJPUMP,JCHAMBER: (locate- on site lan) PUMPS in working order, yes or no A. Comments: . .. .,... n. s .. �(noteAcondition,-of�pump-chamber, -condition of pumps and appurtenances, recommendations for-maintenance-or­repairs,•etc.j=g ::.. icw.w i;;,, r«�•N+K.z• :-aF-t r -r T!n :. .,- „�. n.t-�e � :�� } ': ' .;yr p-`<-s,y�.�tr p .v .,.._... a kkd,ffiyv�+s�.` .� .�"�- � -��-..a:....�'n>,..v..,.a,.w-;� v+.,anx•�.w aama.,w v$5 roc.+ u,+.iMrr�• y s b -a .. " ! �. .,+�'Ft, '� $s; ,L:?e�'.(s •w�#`t �La' a.:ea^ssax.K.eaa-M a.c .m: ,.-.y.,r-.�.,..n.S+a."lr .,,>.vn§. rt+ewxwa,.ralr, ,•±n.�.»:;.,vcaY �,ya€e�,u.. ..rs,::�,. ... .. _.. _ x «.n '.a0.#`2`ir'ds: �"er��ib';`�did'iic,Aws�.,-. ._ ..Y'-,-v. , $�'� F. :.� "�"+"�it�a'=}, °'��4�4�re,"`".�w•r'`!`-M .'�-.;.M-•••w-za�ei"a-t,6• re:;nua,-:ems:,s..l....,4 7 3•ak t`,,,rts'a"} d { . ts+9}"tm , rse++"a:%x•-as-.,sew s �gv.µhw�.� .�rRHJ�,.T+i�`bR X#4*.�'PyL +Y Wr 'F�MfYY''�!k}' 's:'Fx'�9k'��+Yl,'a{'Nru�y�""2` ..+Al.:•VMvnr ,+,,, - .._. a^ F,a•� .- .3 '" , 'ga ' y �°3"`t•�r',;�rl�f`xt'�.�.�;,+r.� � �..e , -. � -��^#�+t f�,x 1 r; . SUBSURFACE -SEWAGE DISPOSAL SYSTEM INSPECTION FORM a PART B �k SYSTEM INFORMATION continued SOIL ABSORPTION SYSTEM- (SAS) : (locate on site plan, if possib e;.- excavation not re fired but ma approximated 9u , y be PP d b non-intrusi ve five methods . ) If not determined to be present, explain: Type leaching pits and number leaching chambers and number` leaching galleries and .number leaching trenches, number ,length leaching fields, number, -dimensions overflow cesspool, number Gee i Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, recommendations for maintenance or repairs,etc. ) CESSPOOLS (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-(cesspool must be pumped as part of inspection) 4 Comments: (note condition of soil, signs of hydraulic failure, level of ,ponding, condition of vegetation, recommendations for maintenance or repairs,etc. ) PRIVY: w, _ (locate on site -'Plan) materials of construction dimensions . ,. f depth of-wso'1 w , Comments m .T.�.,(note,,.condition�.of--,soil;Kwsi ns-•of-�:hydraulic failure, .level of ponding.,�µ_ .. �,condition of.vegetation;=�-recommendation's for'�painteriance or re airse etc. SUBSURFACE SEWAGE DISPOSAL BYSTEM INSPECTION FORM - - PART H , - - SYSTEM INFORMATION continued - SKETCH OF SEWAGE DISPOSAL SYSTEMS. include ties to at least two --perma-vent--references landmarks or benchmarks locate all wells within 100' � . o DEPTH TO GROUNDWATER �._ depth to groundwater method of determination or�approximation: " f P 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Pl1RT .C FAIL' -CRITERIA Indicate yes, no, or not determined (Y., ,N, or ND) . Describe basis of determination in all instances. If "not determined", e; plain why .not) Backup of sewage .into _facility_? -' 6 w Discharge or ponding of effluent to the surface of the *ground or surface -waters? Static liquid level in the distribution box above outlet invert? Liquid depth -in cesspool <6 below invert or available volume< 1/2 day flow? 1y Required pumping 4 times or more in the last -year? number of times -.pumped Septic tank ismetal? cracked? structural) unsound?y substantial infiltration? substantial exfiltration? tank failure imminent? n� Is any portion of the SAS, cesspool or privy: / v below the high groundwaterelevation? v I within 50 feet of a surface water? within 100 feet of a surface water supply or tributary. to a surface water supply? within a Zone I of a public .well? within 50 feet of 'a bordering vegetated wetland or salt marsh (cesspools and privies only, ILQt the SAS)?_.y within ,50 feet of a_private water supply well? t94, ' ''s'i`Cu<�" 24 nµi.'-°' ,o ^. ', w,.r: .x '' .•..z,,.,..:F°' ... °�.: ,.. _...... �„{gem+ .. sue.:.M il4y ®r,wsn+•wm•*=s.na-.:. ....:tr..aaaa+,4+-Nd✓a'Y.w'.n'nnuµ,w i +1!M:i3u f�"s'A`+'4'.a 1 rau�a:sn#•eFtic,w eN+ca.wm•+wcr+,h•... M .. _..,,E.._ .._` aess,than-than' 0--feet-.but-greater;�tharn,450'4feet�="from a"'privatewater ,=.supply..well,-.with-,no->acceptabl-e-water "quality analysis?---' f the `wel`l` Chas "been-;analyzed-to. be acceptable:;attach copy�'of well:'water analy' for .co1'if6xi bacteriii j volatile organ ct�compounds; ammoh a nitrogen ,_ �.and�'nitrate .ritrocjen:' xti . �.•.aMwi .. !e +su+t+•fi»v.•,}hS a R sv�YvMWa m{n`ilr M1a! yx 14e+':-<' LY✓T,;u __ r*r+.••+=ta.«,w+��,.cn. r, aa.e..q� a�at w�.ns+gww• . ��• .. x++,�•.,w•2' i,,,§..-+;a�6. t,. a.'�'w3... ,�s?»� .am .,d w wr., ..._ '' ,r .Ya:y=.fi*•e.»si4'a.:+4takwv:..Fsr`h•-e�k�lbia*vk.aYa,-witr w,�h a«�wi rl.#at<'v.Fu?.•Y.:a. ��.�: ' p Y . h � , .. ,'SM°kW a GM�s,+rh4d!'Lvae trcw+�,.<a T!N. 4.a w:N-.ya.w*.r--}.•�.•wsw_cF w.t,a.n^..�w,..a:vr f+:a••,_. .,,...:,...._ l f F ,;'.tfi <, Y' _ ,s � ! a �*.n_• ,���- '.fit . r .. r _ a ,..4:d. >,aax:.§^b,v''^4 et-<"r .x_. .r•�. ,. ? .vt ;,.�; .. .. ?:• , a".�_�..T�s'�..f......�.�'Y�.:=.__— -'----..—.-.. ti# 13 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART D CERTIFICATION p;:,Name-of s-Inspector "/, _Company Name__ - NEW LIFE SEPTIC SERVICE P.O. Box2119 - Company Address Teaticket,MA 02536 (508)548-3355- Certification Statement I certify that I have personally inspected the sewage disposal system -at this address and_-that_the information reported is, true, accurate and complete as of the" time-of; inspection. The inspection was.performed and any recommendations ..regarding upgrade,:-:maintenance and repair are consistent with my training,-and-.experience in the proper function and manitenance of on-site sewage disposal systems. Ch k one: I have not found any information which indicates .that the system fails to adequately protect public health or the environment as defined in 310 CMR •15.303 . Any failure criteria ,not evaluated are as stated in the FAILURE CRITERIA section of this form. I have determined' that the system fails to protect public health and the environment as defined in 310 CMR 15.303 . The basis for this determination is provided i the FAILURE CRITERIA section of this form. Inspector's Signature Date Original to system owner Copies to: Buyer (if applicable) Approving authority Ya'�• ''+ y's£"'5'` �" L .-*. ,r.�.. ? c d.�°'�x 1::`+�Y�� X.� ..nr�s� -elf Y,.,,'• 'rl,•, ,..i tx + � , ,� P 7:" d r KEY NUMBER,<2699 - y NAME '<JOHNSONEDWIN ,TnA iL ' ' B—C 2 K R3 B C4 ZOC S'1�REET�.,44 8} OLDTOWN_ ROFiD �� y� � ��a;� �_•��� , _ ._ .CITY y <HYANIVI3 �k '.ST MA ZIP 0260 �3¢60 REF ' 1 REF 2 `-PHONE F REF 3 REF 4 ,hl _* METER NO. < 2509> DATE READING CONS -STREET <OLD TOWN RD NO478> 12/31/94 80 27 CITY. CEN L L79 ST LOC 06/30/94 53 __2.0 ._ PHONE- (508) 775-0152 12/31/93 33 43 ROUTE NUMBER .23 08/05/93 4377 10 SERVICE DATE 06/19/64 06/30/93 427 14 METER_. _ DATE 08/05/93-- --- _12•/31/92 - 413 20.. ... CAPACITY 7 Y � 06/30/92 393 11 STYLE T10 , SIZE " 1 RATE SCHEDULE KEYS PIT PLASTIC. . ,z NOTE-.,RR: RIGHT SIDE ADDITIONAL CONS 0 j _i ALTERNATE MIN 0 411 <I < 4i$._'t^r• .a.u_ f r x-.,•° -£ y�4_:. h $t-.�{ 7""l T...^ � *:: !6 F �9,d 4 s �� i ,4^7 F r.- zf�'.� �,z�_.a"'Y x f t..r•_ a`l � �r�`,c-n, ..u.. .a �k,.'� IN; ca a'3 ,a,F"` . h � � 7 '� `�dx � b� p y5-�'�'9a t,'E 5 'S- �'• '� F :«ti .. ..!} `C -,.7�` .7+'y r f t:.°G �4 �� t•a i 3i,s��4.. �r'��' a � � :� �,".�. � t.�F NX {;,n ,a-R k" 'r a+w�* c '.aai" , i' '.• I •r C �#�• ,.a - .. . '�.,S",'c e�$>,n..sdt'y;5+ ".`=awro-1�'"'Y'r`y�^,,. �,'d k'Al _