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HomeMy WebLinkAbout0057 SAINT JOHN STREET - Health 57 Saint John's Street Hyannis A= 291-027-002 = V TOWN OF BARNSTABLE LOCATION SEWAGE # -VILLAGE. A/YJ&2 ASSESSO 'S MAP & LOT&W 000 TNSPCR_'M,R.'S NAME&PHONE NO. ��(o SEPTIC TANK CAPACITY 1006) J LEACHING FACILITY:-(type) �„Q���� (size) UOO NO.OF BEDROOMS A- BUILDER OR WNER - PERMIT DATE: 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 ��. � � z-' �� � �,' -. �. - � s � �. V �� 6 _ C L TOWN OF BARNSTABLE .00ATION J J �J U�N �5 SEWAGE # nuAL IGE G ri d!i S ; ASSESSOR'S PhAP IA',r21 fir—� NSTALI-ER'S NAME&PHONE NO. ;EPnC TANK-C:APACTTY .EACH NG FACILITY- (tY�) __.�`.� l (size,) J' (0.OF'BEI R00 �l�l 13E11 OWNE'R.._ 'ERMIT'DATE:_ ,.,. COMPLIANCE DATE: reparation Distance Between the: 4axim►gym Adjusted Groundwater Table to the Bottom of Leaching Facility .«. eet bvatc dater Supply WeR and Leaching Facility l�u itu►y walls exist on site or within 200 feet of leaching facility) I idge of Wedand and Leaching Facility(If any wetlands st ' within 300 feet of *clung faci 'urnished by a�, n O o �Ij o T� 6 Commonwealth of Massachusetts VVV Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 57 St John's St Property Address Kenneth Morey Owner Owner's Name information is required for every Hyannis MA 02601 12-27-12 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. A. General Information - 1. Inspector: l� p - Shawn Mcelroy Name of Inspector Upper Cape Septic Services Company Name 29 Atwater Dr Company Address E. Falmouth MA 02536 City/Town State Zip Code 1-508-495-0905 S13971 Telephone Number License Number B. Certification 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 ❑ Fails ❑ Needs Further Evall. n by,the Local Approving Authority 12-27-12 T Inspector's Signature Date The system inspector shall submit a copy of this inspection report to thep roving Authoritoard of Health or DEP)within 30 days of completing this inspection. If the syste is a shard systtjyn or , has a design flow of 10,000 gpd or greater,the inspector and the system o ner shall submiP report to the appropriate regional office of the DEP. The original should be Pent to the'�syst owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the o*anditiilills 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. C ( o� t5ins•11/10 Title 5 Official Ins Form:Subsurface Sewage Disposal System-Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 57 St John's St Property Address Kenneth Morey Owner Owner's Name information is required for every Hyannis MA 02601 12-27-12 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary:'Check A,B,C'D or E I always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: System is in good working order with no sign of failure. 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. Check the box for"yes", "no"or"not determined" (Y, N, ND)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. r Y N El ND (Explain below): i t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 57 St John's St Property Address Kenneth Morey Owner Owner's Name information is required for every Hyannis_ MA 02601 12-27-12 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ 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 ' ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): , t 1 ❑ 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 ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 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 t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for.Voluntary Assessments ,M 57 St John's St Property Address Kenneth Morey Owner Owner's Name information is required for every Hyannis MA 02601 12-27-12 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 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 fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: , D) System Failure Criteria Applicable to All Systems: You must indicate "Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ®- Liquid depth in cesspool is less than 6" below invert or available volume is less than Y2 day flow t5ins-11/10 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 Commonwealth of Massachusetts _ Title 5 Official Inspection Form ` Subsurface Sewage Disposal System Form -Not for Vol untary.Assessments 57 St John's St Property Address Kenneth Morey Owner Owner's Name information is required for every Hyannis MA 02601 12-27-12 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) -Yes No ❑ ® 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. ❑- E 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 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 fecal coliform bacteria indicates absent 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 and chain of custody must be attached to this form.] El ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ® 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. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. 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. t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 57 St John's St Property Address Kenneth Morey Owner Owner's Name information is required for every Hyannis '"• MA 02601 12-27-12 page. City/Town State Zip Code Date of Inspection C. Checklist 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? Have large volumes of water been introduced to the system recently or as part of El ® this inspection? ` ❑ ® Were as built plans of the system obtained and examined? (If they were not available note as N/A) ®° ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? f ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid,'depth of sludge and depth of scum? E ❑ 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 F been determined based on: ❑ ® Existing information. For example, a'plan at the Board of Health. ® 0 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(5)] D. System Information , Residential Flow Conditions: Number of bedrooms(design): 2 Number of bedrooms(actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 1.10 gpd x#of bedrooms): 220 f t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 57 St John's St Property Address Kenneth Morey Owner Owner's Name information is required for every Hyannis MA 02601 12-27-12 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Date 2 Date Commercial/industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): _ Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 7 of 17 Commonwealth of Massachusetts " Title 5 Official .Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 57 St John's St Property Address Kenneth Morey Owner Owner's Name information is required for every Hyannis MA 02601 12-27-12 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: N/A Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: I 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 (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) and a copy of latest inspection of the I/A system by system operator,under contract ❑ Tight tank.Attach a copy of the DEP.approval. ❑ Other(describe): t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form. m Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 57 St John's St Property Address Kenneth Morey Owner Owner's Name information is required for every Hyannis MA 02601 12-27-12 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 1980's Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 30" Depth below grade: - feet Material of construction: ❑ cast iron ® 40 PVC ❑ other,(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): Good condition. Septic Tank(locate on site plan): Depth below grade: 24"feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 gal Sludge depth: 12" t5ins-11/10 - Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments p Y rY �M 57 St John's St Property Address Kenneth Morey Owner Owner's Name information is Hyannis MA 02601 12-27-12 required for every y ' page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 20" Scum thickness 1 Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 16" How were dimensions determined? Tape Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank is in good condition with baffles installed and no sign of leakage. Grease Trap (locate on site plan): Depth below grade: feet 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: Date t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments �M 57 St John's St Property Address Kenneth Morey Owner Owner's Name information is required for every Hyannis MA 02601 12-27-12 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 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 per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order. ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): "Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No t5ins•11/10. Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts ` Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 57 St John's St Property Address Kenneth Morey Owner Owner's Name information is required for every Hyannis MA 02601 12-27-12 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Good condition with water at working level and no sign of back-up from pit. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): t Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 f Commonwealth of Massachusetts f Title 5 Official Inspection , Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 57 St John's St Property Address Kenneth Morey Owner Owner's Name information is required for every Hyannis MA 02601 12-27-12 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1-1000 gal ❑ 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, etc.): Leach pit in good condition and empty at inspection with stain line at 18" below inlet invert. 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 ❑ No t5ins-11/10. Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -'Not for Voluntary Assessments w 57 St John's St Property Address Kenneth Morey Owner Owner's Name information is required for every Hyannis MA 02601 12-27-12 page. City/Town State . Zip Code Date of Inspection D. System Information (cont.) , 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.): t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 57 St John's St Property Address Kenneth Morey Owner Owner's Name information is required for every Hyannis MA 02601 12-27-12 page. Cdy/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view 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. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately 6 -,,F- 33 T t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 57 St John's St Property Address Kenneth Morey Owner Owner's Name information is required for every Hyannis MA 02601 12-27-12 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells _ Estimated depth to high ground water: 20 feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site(abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health-explain: ® Checked with local excavators, installers- (attach documentation) ® Accessed USGS database- explain: You must describe how you established the high ground water elevation: USGS and town maps show groundwater at greater than 20'. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-11/10 - Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 Co.Mrponwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 57 St John's St Property Address Kenneth Morey Owner Owner's Name information is required for every Hyannis MA 02601 12-27-12 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary:A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins-11/10 Title 5 Official inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 l COMMONWEALTH OF MASSACHUSETTS = ExECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTiRIT § 0-AFNNS f BLE 2005 saki 17 A M 9: 54 4 V� TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A ��^^ CERTIFICATION Property Address: TUfts �7 / AV 14 r 7 Owner's Name: re) Owner's Address: no Date of Inspection: /57 4 Name of Inspector• ple se p .nt) , i-,� Company Name: Gtr[L Mailing Address: fO ez'r 8 Telephone Number: 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: Date: 0 S The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner-and copies sent to the buyer, if applicable,and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 Page 2 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 37 ,54 Vb�HS SA r olfU Owner: it r rla c) Date of Inspection: Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: yI have-not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional s"section need to be replaced or repaired.The system,upon completion of the replacement or repair, pproved by the Board of Health,will pass. Answer yes;no or not determined(Y,N,ND)in the for following statements.If"not determined"please explain. The septic tank is metal and over 20 years of or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltr on or tank failure is imminent.System will pass inspection if the existing tank is replaced with a complying sep ' tank as approved by the Board of Health. *A metal septic tank will pass inspection if i s structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 year old is available. ND explain: Observation of sewage ba p or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a b en,settled or uneven distribution box.System will pass inspection if(with. approval of Board of Health): broken pipe(s)am xepLaced obstruction is removed distribution box is leveled or replaced ND explain: The system r quired pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if( 'th approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: 2 Page 3 of I I OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: So�kwg 5lian�5 Owner JCOC"ry Date of Inspection: V1 C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in ord 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 ith 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public alth,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 vege ed wetland or a salt marsh 2. System will fail unless the Board of Health nd Public Water Supplier,if any)determines that the system is functioning in a manner that protec the public health,safety and environment: _ The system has a septic tank and s absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a face water supply. _ The system has a septic tank d SAS and the SAS is within a Zone I of a public water supply. — The system has a septic t and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a Sept' 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 ' the well water analysis,performed at a DEP certified laboratory, for coliform bacteria and volatile rganic compounds indicates that the well is free from pollution from that facility and the presence of onia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are ggered.A copy of the analysis must be attached to this form. 3. Other: 7" 3 A Page 4 of 11 OFFICIAL INSPECTION FORM—NOT-'-FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DOSAL SYSTEM INSPECTION FORM PART.A, CERTIFICATION(continued) Property Address-_ J-01t1tv16 Owner: Date of Inspection: D D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No ( Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool A� Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool a( Liquid depth in cesspool is less than 6"below invert or available volume is less than'/z day flow _,k Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped A' Any portion of the SAS,cesspool or privy is below high ground water elevation. R 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 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis.IThis 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.) �d (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 followina- (The following criteria apply to large systems in.addition a criteria above) yes no _ — the system is within 400 feet of a s e drinking water supply — the system is within 200 feet o tributary to a surface drinking water supply _ the system is located in trogen sensitive area(Interim'Wellhead Protection Area—1WPA)or a mapped Zone II of a public w r supply well If you have answered"yes" o any question in Section E the system is considered a significant threat,or answered "yes"in Section D abov the large system has failed.The owner or operator of any large system considered a. significant threat un Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The syste owner should contact the appropriate regional office of the Department. Page 5 of l l OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: If 7 Owner: Date of Inspection: /S�0 Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes No i — 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? _ 4! 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) 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 the baffles 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 in enance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no Existing information.For example,a plan at the Board of Health. Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)] 5 Page 6 of I i OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address:_-1-7 6+JOA ns 15+' 9Gy1n(S Owner:rCC reio,('0 Date of Inspection: 'b"fo FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):_,3_ Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms)J330 Number of current residents: 0 Does residence have a garbage grinder(yes or no): Is laundry on a separate sewage system(yes or no): IJO (if yes separate inspection required) Laundry system inspected(yes or no):w0 Seasonal use:(yes or no):W Water meter readings,if available(last 2 years usage(gpd)): Sump pump(yes or no):A)1O/,,< Last date of occupancy: COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203):Z gpd Basis of desigXi ats/persons/sq cJ: Grease trap ps or no): Industrial wa tank pr ent(yes or no):Non-sanitary char to the Title 5 system(yes or no):Water meter f ailable:Last date of ose:OTHER(des GENERAL INFORMATION Pumping Records Source of information: Was system pumped as part of the inspection(yes or no):PO 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(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 information: 02o `fear.5 Were sewage odors detected when arriving at the site(yes or no):NO 6 Page 7 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM[ INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 7 S`� �`� St Ua phi-S owner: FeI r rw Date of Inspection: BUILDING SEWER(locate on site plan) Depth below grade: 3 Materials of construction:_cast iron _X_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: X (locate on site plan) Depth below grade:c2,S 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: Sludge depth: _ . 3�' 0 Distance from top of sludge to bottom of outlet tee or baffle: 0zq Scum thickness: c2 4/0 Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: �?K How were dimensions determined: M 2u6u r' Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related t outlet invert,evidence of leakage etc.): GREASE TRAP:_(locate on site plan) Depth below grade:_ Material of construction:_concrete_metal_fib glass_polyethylene other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outl tee or baffle: Distance from bottom of scum to bott of outlet tee or baffle: Date of last pumping: Comments(on pumping reco ndations,inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evi nce of leakage,etc.): 7 Page 8 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 57 is <6 Owner: r n04-0 Date of Inspection: TIGHT or HOLDING TANK: (tank must be pumpe t time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete me fiberglass_polyethylene other(explain): Dimensions: Capacity: gall s Design Flow: ons/day Alarm present(yes or no): Alarm level: Al working order(yes or no): Date of last pumping: Comments(condition alarm and float switches,etc.): DISTRIBUTION BOX:4(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Q✓� Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of pox,etc.): `6 'e oK woS /,ad G 4rCf 4.1 Ila S �� rn c c CG��1/�itr 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 ch er,condition of pumps and appurtenances,etc.): 8 Page 9 of 11 OFFICIAL. INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: S7 cS cAvl Owner: )Grr..D _ Date of Inspection:_ IV 10-16S SOIL ABSORPTION SYSTEM(SAS): f< (locate on site plan,excavation not required) If SAS not located explain why: Ty e leaching pits,number:L 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, etc.): � � CcX�s no - CESSPOOLS: (cesspool must be pumpe 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 groundw er inflow(yes or no): Comments(note co ttion 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 cond'�bnofil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): 9 Page 10 of l I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ' PART C SYSTEM INFORMATION(continued) Property Address:-C-7f 5_6-_ S� tiu nrn� Owner• r Date of Inspection: !S o 5r 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. / f �b ov P Re a"r •Page 11 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 3 T Owner: rorAAM Date of Inspection: SITE EXAM Slope P Q Surface water fJ 0 Check cellar V10 Shallow wells 00 Estimated depth to groundwater Q0 feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-if checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water�elevation: _r U SGS _I� oW C,V, L'lCWA.4cot� c cueA jo:g,ec� It �� tA"'l-L • o?�7 12 • o���. tea�. UO 1~ 41 r Vic' �� 90RTOLOTI'I CONSTRUCTION, INC. 765 W ACEBY ROAD,M ARSTON MILLS, 02648 o�sy `T9Z , - 508-771-9399 508-428-8926 FAX: 5 08428-9399 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION F g PART A CERTIFICATION Property Address: - Date of Inspection: ' /Co ' Inspector's Name: Owner's Name and Address: CERTIFICATION STATEMENT: 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 stems. The System: Passes Conditionally Passes Needs Further Eval on By t L 1 Aproving Authority Fails > . Inspector's Signature: ` Date: '" �?/J��F 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: y I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. B)SYSTEM CONDITIONALLY PASSES; 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 NU). 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 itbroken,settled or uneven distribution box. The system will pass inspection if(with approval of The Board of Health): - 1 - w .. =SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) a Broken pipc(s)«replaced e 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 Feel 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 ppm: - D)SYSTEM FAILS: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to 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 eIluent 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- edSA r`•cesspool. A Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow. ., Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped e -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 coliform 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: y The system is within 400 Feet of a surface drinking water supply The system is within 200-Feet of a tributary to a urface drinking water supply The system is located in a nitrogen sensitive area Interim Wellhead,Prot'ection Area (IWPA)or a mapped Zone Il of a public water,supply well The owner or operator of any such system shall bring the system and facilityjnto full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and G.00. •Please consult the local regional office of the Department for further information. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CIIECKLIST Check if the following have been cone: ✓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. 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 ��uk/,All 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- �,`f ,spected for condition of baffles or tees,material of construction,dimensions,depth of liquid, depth of sludge,depth of scum. t �he size and location of the Soil Absorption'System on the site Gas been determined based on existing information or approximated by non-intrusive methods. -3- 17 SUBSURFACE SEWAGE DISPOSAL'SYSTEM INSPECTION FORM PART B CHECKLIST(continued) 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 fNFORTi9ATlON.:. �:.,.�, FLOW CONDITIONS RF.si_nF.NTLAi - Design Flow: 70 allons Number of Bedrooms: Number of Current Residents: Garbage Grinder: ' Laundry Connected To System:117 Seasonal Use: ") Water Meter Readings,if available: Last Date o Occupancy: - f c — o2vl 0-fie. , kc/- c e Comm RCLAi JiND 19T IAL IJJ' v -Type of Establishment: Design Flow: gallons/day` Grease Trap Prescnt: (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 INFORMATION PUMPING RECORDS and source of information 1 V System Pum as art of inspection ` L) `" -If yc ;voluna pumpech `�r gallons y l p 1 / Reason for pumping: TYPE SYSTEM: Septic Tank/Distribution Box/Soil Absorption System Single Cesspool Overflow Cesspool Privy Shared System(If yes,attach previous inspection records, if any) Other_(explain): ROXMUTrE AGE of all components,date installed(if known)and sourcerof,;iriformation:' S ge odors detected when arriving at the site: UBSURFACE-SEWAGE DISPOSAL SYSTEM INSPECTION FORM S .: PART C GENERAL INFORMATION (continued) SEPTIC TANK: Depth below grade: Material of Construction: concrete metal FRP_Other (explain) �' Scum Thickness: Dimisions: e 5' X Sludge Depth: Distance from top of sludge to bottom of outlet tee or baffle: Distance from bottom of stun to bottom of outlet tee or baffle: Comments: (recornmendatiort for pumping;ycondition of inlet and outlet tees orb es,depth of liquid level in relation lation t outlet invert,structural integrity,evidence ofleak ge,etc.) !x� GREASE.TRAP: Depth.Below Grade: Material of Constructiou:_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,tevidence of leakage,etc.) TIGHT OR HOLDING TANK:, Depth Below Grade: Material of Construction:_concrete_metal_FRP_Other(explain) Dimensions: Capacity: gallons Design Flow: gallons/day Alarm Level: Comments: (condition of inlet tee,condition of alarm and float switches,etc.) DISTRIBUTION BOX: Depth of liquid level above outlet invert: - Comments: (note if el and distribution i e ual,evid nce of solids carryover,evide a 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- • r SUBSURFACE SEWAGE DISPOSAL-SYSTEM J,NSPECTION FORM PART C SYSTEM INFORMATION (conlinucd) SOIL ABSORPTION SYSTEM(SAS): ✓ (Locate on site plan,if possible;excavation not required,but may be approximated by non-intrusive methods) If not determined to be present,explain: Type: Leaching pits,number: l Leaching chambers, number: Leaching galleries,number: Leaching trenches,number, length: Leaching fields,number,dimensions: Overflow cesspool, number: Comments:(note condition of soil signs of hydr ulic fail re level of ponding,condition of vegetation, etc. ;D / U i 7G` ki ia.n tfOw'�jr� CESSPOOLS:/Jd 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) Comments: (note condition of soilk,signs of hydraulic failure, level of ponding,condition of vegetation, etc.) PRIVY:/yd Materials of construction: Dimensions: Depth of Solids:, Comments: (note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation, etc.) t -6 SUBSURFACE SEWAGE"DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMA"PION (continued) SKETCH OF SEWAGE DISPOSAL SYSTEM: Include ties to adeasl two permanent refcrcrims, landmarks or benchmarks. Locate all wells within 100 Feet. \' I/'' I DEPTH TO GROUNDWATER: Depth to groundwater: Z> Feet Method of Determination or Approximation: _—/ - 7- THE'COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Appl ration for DispasallUjOrks Toustrudion 1rrmit Application is hereby.made for a Permit to,Coristruct ( or Repair ( ) an Individual Sewage Disposal System at e • .... nn...a..._ ..... Location-Address. ....._ of Lot No. ............. .....Cs �:&z,,o.......Owner.................. ------------------------ ............................................Address........................ a ------------------------------ ...ko&l N ................................................................................................... Installer Address Type of Building Size Lot.... feet U ',Dwelling—No.Hof Bedrooms.................:...........................Expansion:Attic Garbage Grinder ( ) p� Other—Type of Building ............................ No.'of persons................:........... Showers ( ) — Cafeteria w d Other fixtures ..__.::.. :..__... : ..:...... ............... W Design Flow........ ...�—�......... ._...gallons per person per day. Total daily flow............................................gallons. WSeptic Tank Liquid capacityLo�OF�.gallons Length.£ t�___ Width'A--5L Diameter................ Depth$..1;;7Y=1= x Disposal Trench—No..................:... Width........................ Total Length.....................Total leaching area....................sq. ft. ` 3 Seepage Pit Diameter..?4..cF .."Depth below ....Total leaching areaz __..sq. ft. Z Other Distribution box (Se) Dosing tank ( ) t 0-.4 -12 A 3,o. c sic- Percolation Test Results Performed by...........:......:....... ,......._..___.... .:._......:;.... Date.__......................._ ,aa Test' Pit No. 1._ Z...minutes per inch Depth of Test Pit.... ___.:_:_. Depth•to ground water..J��R... GL, Test Pit No. 2................minutes per,inch , Depth,of Test Pit......:............. Depth to ground,water..................:..:: oc� .. Z4 L ................. ..... O Description of Soil.. z 4 coo'"�o,�s._..Ar....�. -- __ = _;o�GLs C,u =- r-tZ" G�ra.rz '`:`1Z..-:� �....c �S T� v :.............. s 3:... WC„ ?ut� ... ---_.....iq>`1 -�...1 4?._:. 1.Z /V ,o ?.!_ mac ...:.................... UNatured Repairs or Alterations—Answer when apPlicable................................_..____.................._..:.................................. Agreement The. undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TIITLZ 5 of the'State Sanitary Code— The undersigned further agrees n gtgcehe s ystem in operation until a Certificate of Compliance has-been issued by the board of health.' Signed...... .t ....= © ......------•--•--...--•--- -- •• .........._.... ` • � L� Date ApplicationApproved By..:_... .............. ............................................ .............. y - . Date Application Disapproved'for the following reasons:.............. ..............•- --..................•--•......•--.... ............... ......... .............•-•....'•-••• . •• •-• ................._.. - ............ Date _ PermitNo.'............................................----_-..__ Issued_................................................ ..... V I'�C EFAA9/AX_oC u�r � dv U�IN, Dace 5el _ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH , pplirati,ont for Disposal Works Tonstrttrtion f rrmit Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal System at: ...t .c��— Cp............ T_.:-�o.... .........................................ST' ' ..!:-l`r'9?�!!.....!5....... ---- ... .. Location Address or Lot No. n nn. -1. ...................... ..... ...... ........_.. ._.._................. OwnerAddress a ........................................S --•--•-'V,-!d• -- ...........'......... •_^^-----•-•--•-------..._...........---•--................__-__.._..............-••.. .._...... Installer Address Type of Building - Size Lot__..�Z-;' .._Sq. feet Dwelling—. No. of Bedrooms............. .........................Expansion Attic ( ) Garbage Grinder ( ) a 04 Other—Type of Building ............................ No. of persons................._:......... Showers ( ) — Cafeteria ' hr Other fixtures ..:.........................•----...._... Q - ...... .................••--••. ----....----........._..._............. ,..� Design Flow.............��_.�..............._.__gallons per person-per day. Total daily flow............................................-�3© gallons. - Septic Tank—Liquid capacltyl4T .gallons' Width-9r_.!._ Diameter:_______________ Depth}'_l F1= x Disposal Trench—No..................... Width�..-_..._...__.__.. Total Length___.....,......._... Total leaching area....................sq. ft. 3 Seepage Pit No._d _.: Diameter.Jo_.cFF.. Depth below Total leaching area. .....sq. ft. Z Other Distribution box (SC) Dosing tank ( ) '-' Percolation Test Results Performed by...�._....=�.�..��.....°.N1�. * �= Date.. ,_a Test Pit No. L_______________minutes per inch } Depth of Test Pit.... _.._:_. Depth to ground water._�5;?tl Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ ;i.._....••------.�..___-_---•-••---------------••--•-•-•- ..................................................................... O Description of Soil.......c?c�-... ......._.40�. .`....Sv .................... x4�►/. .. . v f- ......1.!..?:�` 1_.. !` -y...N....0....F1,ZS.?..... .:. 1_C..�T1— �?ial�......................... U Natured Repairs or Alterations-Answer when applicable.............................:_...__.__._._.__.____..._.....________._.__...__.............._.. •.............................•-•••••-...•-•---•--•-•---•--=----------•---....._._._.....-••--....---•.._.._...---•----------------------------------------•---------------............_............_. Agreement The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TI;'L: 5 of the State Sanitary Code— The undersigned further agrees npt to olacethe system in operation,until a-Certificate of Compliance has been issued by the board of health. Signed.... ................................ .......................... �r/f Date Application Approved By....... ._......... .:: /� a.............. .....------••. ............... ........: .--•- Date Appl>cation Disapproved for the following reasons:...............................................................•__:_______...________.____......._...........,.. ...... ............... #•--......_..........--- ----•-•••-•- _.. ..... ... ......_-----.......c ......__.._......._...._.............-----..- -•------•-- Date — ,Permit No. ..... -.�.. Issued................ ........ ........ r �A)& ���'.�/N��� �v�T +C�� •Z S� 9tJ i Date . ,.... .. ............... ............... ............a THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .... ... ..........O F..:.... .............................. = 0'rrtif uttte of Tautirliana THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) by. ..... ................: .���...... ti. .L_............ ...._-•-----•--•-•--:.........._....._--__-• •---------.:......... .---...............................•••••. Installer at........__.�. ..........CQ_........ ?.. .-_- fi..._._.' C!1 -•- --------------•------•-------•_---•-----•••--------•- has been installed in accordance with:the provisions of Tl 'LE 5 of he State Sanitary Code as described in the application for Disposal Works Construction Permit No ___.._._�� __�4?b..:. dated....____ . � .. PP 1 Xj f, -a 5.r._........ THE ISSIJANCVOF THIS CERTIFICATE SHALL NOT BE CO STRUED AS GUARANTEE THAT THE- '` i SYSTEM WILL FU CTIONi....SATISFACTORY.r DATE...................lgt t1- �r" -- .......s.._............ Inspector -- ._ ............................. f , THE COMMONWEALTH OF MASSACHUSETTS p BOARD OF HEALTH o� . ............ ......------..............---- _.... ..._.... No... :. .lISC> FEE.........J .. Disposal Varks Tunutrudiort 11rrmit Permissionis hereby granted........................................................................................................_..........._..._......_............... to Construct ( ) or Repair ( ) an Individual Sewage Disposal System atNo........... ,..4,.. _(0........... ...--Z�-,' ........... xx�.-•-•--------•-----•---------••-----------------------•--•-- ...... ee as shown on the application for Disposal Works Construction 'g- N(o 4bated.....Z.;. 44__ ............. ® ,::•-- �-------=--------------'.� -- --- ------_______--_-_----------- J Board of.health 1+ - DATE.........0-- ._ _I � � , , ... .._..... /vr NG 4z 3 iN` rz 1Z IJ.�915 _ N , D T i I .:. i t oN 1 G pro 362-4541 926 main street yarmouth mass. 02675 dOW/! CQpe en�'idee�ing civil engineers& land surveyors structural design Arne H.Ojala P.E.,R.L.S. land court Richard R.Fairbank P.E. surveys site planning f sewage system September 4, 1985 designs i Barnstable Board of Health inspections Barnstable Town Hall South Street Hyannia,,-�, MA 02601 permits This is to certify that on September 3, 1985,. Down Cape Engingeering inspected the construction df the sewage systems for lots 5,6, & 7 on St. John Street and that they are installed in accordance wiht our plans # 84-42T dated March 19, 1985. I Sincerely, Arne ."vO' a P.E. , .L r. RDO/kmk- f" cc: Steve Seymour r • I w yarmouth mass. 02675, , down cape, engineering civil engineers& land surveyors ructural design Arne H.Ojala P.E..R.L.S. Richard R.Fairbank P.E. Ind court irveys to planning wage system September 4, 1985 signs Barnstable Board of Health spections Barnstable Town Hall South Street Hyannisy , MA 02601 rmits This is to certify that on September 3, 1985, Down Cape Engingeering inspected the construction of the sewage systems for lots 5,6, & 7 on St. John Street and that they are installed in accordance wiht our plans #/ 84-427 dated March 19, 1985• Sincerely, Arne 0 a P.E. , .L RDO/k,mk cc: Steve Seymour vccu mstaned in accordance with the provisions of TT^application for Disposal Works Construction Permit No......��- of the State Sanitary Code as described in the THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A U, SYSTEM WILL FUNCTION SATISFACTORY. R, 3N . ,,_ GU;__RANTEE THAT THE DATE f SECTION - SEWAGE ti( -SEPTIC TANK- - "D"BOX - -LEACH 2 TOP OF FON (MSQ# -----,.2"OF VeTO V2" WASHED STONE i I So 47 I �L' IN- OUT- IN• \ OUT• IN• LULL L 48.0 SEPTIC e ` - 7 �^ �r1.'1S TANK q�1.`� y--1 0 „1� I 1 c_ -7 _`�� ��T z� / ) ELEV. ELEV. ELEV. co ) ELEV. cirri l 4-1.Z ELEV. ELEV. Il/ ? - OF-V4"-1V2" WASHED STONE TEST HOLE LOG. T' TEST BY 2 .�-ia2f� ��v� - co.��c» 3.0. r� O TO A.-� Zr� WITNESS TEST DATE DESIGN BEDROOM HOUSE T.K 1 T.H. 2 ELEV. . ELEV. NO a PERC RATE �Z MIN IN. DISPOSER DISPOSER t Z4 c `-'�' 4-1 -� FLOW RATE JYs SEPTIC TANK 330 (�.s►= < o�� U l� ��,.�-�- // `� Q Ltl REQ D SEPTICTANK SIZE �z i Q� LEACH FACILITY SIDE WALL G/D. ( 1 I r t<S BOTTOM ��'��/�'c = 1�- ( ti ) _. 2C-` - G/D. In , n 1 Z-k b' n« TOTAL 1 USE: LEACHING C� _ I. l44 3'1.�O C GR— =—i� r �C 1�"�1/ZA \ 1 WATER ENCOUNTERED NOTES: (UNLESS OTHERWISE NOTED) 1.DATUM(MSL)+TAKEN FROM_._� �`ti `_ ..QUADRANGLE MAP 2.MUNICIPAL WATER --.---.--.AVAILABLE f 3.PIPE PITCH:V4"PER FOOT U 4.DESIGN LOADING FOR ALL PRE-CAST UNITS:AASHO- -44 U 5.MIN.GROUND COVER OVER ALL SEWAGE FACILITIES: (1) FT.6.PIPE INTS SHALL BE MADE WATER TIGHT 7.CONSTORUCTION DETAIL r S TO BE ACCORDANCE WITH COMM.OF MASS. �t �f �q`i�' STATE ENVIRONMENTAL CODE TITLE 5 SITE PLAN AR NE hl VA _ LOCUS: I �� - �_ VI77t(��}-- _y _____ ��N 0i Mqs R G.0�{OFES ON ENGINEER ARNE yG REF: �-� �- t�L='. 9F�lSTERtiO �`4� H. v � T� '��sslpNAl G\� down cape eng OJA PREPARED FOR: G CIVIL ENGINEERS r LAND SURVEYORS ^ups --- BOARD OF HEALTH EYOR (EXISTING)------------- _ _ _ an Main 8t., ti[. !C.9:`� i CONTOURS (PROPOSED)—O—O—O�— APPROVED DATE ���'� —' MA Y> SCALE — Z�' �j 1� BS DATE