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HomeMy WebLinkAbout0207 CLAMSHELL COVE ROAD - Health 207 Clamshell Cove Road i Cotuit . P A = 005 023 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION i f � W f Ii a W ' I. ' v0 Sy! ' qi . ;:+; TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 207 CLAMSHELL COVE RD COTUIT, MA 02635 W S —ce 3 L04-IS3 Owner's Name: GOLDMAN Owner's Address: 23 STRATHMORE RD WELLESLEY,MA 02181 RECEIVED Date of Inspection: 6/28/02 JUL 2 5 2002 Name of Inspector: (please print) . ; JOHN GRACI Company Name: SEPTIC'INSPECTIONS I C, TOWN OF BARNSTABLE Mailing Address: :, P.O. BOX 2119 TEATIC T,MA.02536 HEALTH DEPT. Telephone Number: 508-564-6813 FAX 508-564-7270 � CERTIFICATION STATEMENT 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,thcJime'.of the inspection.The inspection was performed based on my training and experience in the proper function':and itaintenance 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: X Passes j:.. 4 _ Conditionally P sses _ Needs Furt(` 'r valuation by the Local Approving Authority Fails Inspector's Signature: Date: 6/28/02 The system inspector shall submit r�opy 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 DEI'. The original should be sent to the system owner and copies sent to:the buyer, if applicable,and the approving authority. I; Notes and Comments R. SYSTEM PASSED TITLE V INSPECTION. RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE. ****This report only describes co�ndil,ions at the time of inspection and under the conditions of Ilse Ill Ihnl lime.This inspection does not address how the system will perform in the future under the same or different conditions of use. TitIP S Incnartinn Fnrm A/1 S/7n00I± ; I) I Page 2 of 1 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 207 CLAMS14ELL COVE RD COTUIT,MA 02635 Owner.: GOLDMAN Date of Inspection: 6/28/02 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: X 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 PASSED TITLE V INSPECTION. RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE. B. System Conditionally Passes: _ in the"Conditional Pass"section need to be replaced or repaired. The system, One or more system componeit ?as described upon completion of the replacement or-r4epI4ir;Cas 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. n/a 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 metall 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: n/a n/a 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): _ sbroken pipe(s)are replaced _ obstruction is removed _ distribution box is leveled or replaced ND explain: n/a n/a The system required pumpidg{more than=4'times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Bdafd of Health): _broken pipe(s)are replaced _obstruction is removed ND explain: n/a 01 Page 3 of 11 + OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A :.::.CERTIFICATION(continued) Property Address: 207 CLAMSHELL COVE RD COTUIT,MA 02635 Owner: GOLDMAN Date of Inspection: 6/28/02 C. Further Evaluation is Required by the Board of Health: _ Conditions exist which require fuhher 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 Boa'M 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 4 = 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 deterin'ine distance n/a "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 isequal 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: n/a r � F t l y'' r Page 4 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 207 CLAMSHELL.'COVE RD COTUIT,MA 02635 Owner: GOLDMAN 1.4l, Date of Inspection: 6/28/02 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for alLinspections: Yes No X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool' _ X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool X Liquid depth in cesspool is less than 6"below invert or available volume is less than ''/z day flow _ X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped nLa. X Any portion of the SAS,.cesspool or privy is below high ground water elevation. X Any portion of cesspool or p'rivy)s' within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a ce.sspgol.or privy:i� within a Zone 1 of a public well. X Any portion of a cesspool or privy is within 50 feet of a private water supply well. X 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 forma (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,s"y,'s,tem the,system',must serve a facility with a design 1 ow 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`Iarge systems in addition to the criteria above) yes no X the system is within 400 feet of a surface drinking water supply X the system is within 200 feel of a''tributary to a surface drinking water supply X the system is located inla'nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public w6iec1sdpply: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 sy's`tern'has failed. The owner or operator of any large system considered a significant threat under Section E or I:ailed under Sec't`io►i,D'sltall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. A Page 5 of 11 d.R ' OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 207 CLAMSHELL COVE RD COTUIT,MA 02635 Owner: GOLDMAN , I ;,;1 Date of Inspection: 6/28/01 Check.if the following have been done. You must indicate"yes" or"no"as to each of the following: Yes No ti X _ Pumping information was.provided by the owner,occupant,or Board of Health _ X Were any of the systern,components pumped out in the previous two weeks X _ Has the system received'normal flows in the previous two week period '? n _ X Have large volumes of water been introduced to the system recently or as part of this inspection ? ` '' ' available note as N/A X _ Were as built plans of the s `ystem obtained and examined. ([f they were not ava b ) X _ Was the facility or dwelling inspected for signs of sewage back up? X _ Was the site inspected for signs of break out'? X _ Were all system components,excluding the SAS, located on site'? X _ Were the septic tank manholes dncbvered,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? X _ 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 X _ Existing information. For'ek(imple,a plan at the Board of Health. 1. X _ Determined in the field(if any of th'e failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.30,2(3)(,b)J t ,, Page 6 of I t OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE'SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C ''SYSTEM INFORMATION Property Address: 207 CLAMSHELL COVE RD COTUIT,MA 02635 Owner: GOLDMAN Date of Inspection: 6/28/02 'FLOW CONDITIONS RESIDENTIAL ' Number of bedrooms(design): 4 k Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 145.203 (for example: 110 gpd x#of bedrooms): 440 Number of current residents:3 Does residence have a garbage grinder(yes or no): NO Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required] Laundry system inspected(yes or'no):'NO Seasonal use: (yes or no): NO Water meter readings, if available(last 2,yea s usage(gpd)):0/0-- ®C)— l�� �� Sump pump(yes or no): NO /� _ p / Last date of occupancy: n/a V I� o C)D 1 COMMERCIAL/INDUSTRIAL Type of establishment: n/a Ibs:. "` N Design flow(based on 310 CMR 15,.203,): n/a-gpd Basis of design flow(seats/persons/sgft,etc.): n/a Grease trap present(yes or no),NO Industrial waste holding tank present(yes or*no): NO Non-sanitary waste discharged to iW Title`5 system(yes or no): NO Water meter readings, if available: n/a Last date of occupancy/use: n/a OTHER(describe): n/a i• `GENERAL INFORMATION Pumping Records Source of information: n/a Was system pumped as part of the inspection(yes or no): NO If yes, volume pumped: n/agallo&-=Hdw'was quantity pumped determined? n/a Reason for pumping: n/a TYPE OF SYSTEM , X Septic tank,distribution Uox,soil absorption system _Single cesspool _Overflow cesspool _Privy _Shared system(yes or no)(if yes,attach,previous inspection records, if any) _Innovative/Alternative techno,71V:.Attach a copy of the current operation and maintenance contract(to be obtained From system owner) _Tight tank Attach a copy 6f the DEP approval Other(describe): n/a c . Approximate age of all components;date installed(if known)and source of information: 1982 BY OWNER "' Were sewage odors detected when arriving at-the site(yes or no): NO s t 6 Page 7 of I 1 Y�r OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS INSPECTION SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 207 CLAMSHELL COVE RD COTUIT, MA 02635 Owner: GOLDMAN Date of Inspection: 6/28/02. BUILDING SEWER(locate on site,plan) Depth below grade: 30" Materials of construction:_cast iron X40 PVC_other(explain): n/a Distance from private water supply well or suction line: n/a Comments(on condition of joints;venting,evidence of leakage,etc.): TOWN WATER SEPTIC TANK: X(locate on site plan) Depth below grade: 24" Material of construction: Xconcrete metal_fiberglass_polyethylene other(explain)n/a If tank is metal list age: n/a Is age'confi'rmed by a Certificate of Compliance(yes or no): NO(attach a copy of certificate) Dimensions: 150OG L 10' 6" H 5' 6"W.5',8t` Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle:32" Scum thickness: 2" a 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: MEASURED Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY. RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE. GREASE TRAP: _(locate on site plan) Depth below grade: n/a Material of construction:_concrete'—m eta l_fiberglass_polyethylene_other(explain): n/a Dimensions: n/a Scum thickness: n/a Distance from top of scum to top of,161et tee or baffle: n/a Distance from bottom of scum to bottom of outlet tee or baffle: n/a Date of last pumping: n/a Comments(on pumping recommendations; inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage;etc.'): n/a a, ... 1� t I� t 7 Page 8 of I I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 207 CLAMSHELL COVE RD COTUIT,MA 02635 Owner: GOLDMAN Date of Inspection: 6/28/02 ; TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: n/a Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a Dimensions: n/a Capacity: n/a gallons Design Flow: n/a gallons/day Alarm present(yes or no): N/A Alarm level: N/A Alarm in working order(yes or no): NO Date of last pumping: n/a Comments(condition of alarm and float switches,etc.): n/a DISTRIBUTION BOX: X(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: n/a 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.): NO D-BOX PUMP CHAMBER: _(locate on site,plan) Pumps in working order(yes or no): NO Alarms in working order(yes or no):NO Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): n/a <<r; R Page 9 of I I OFFICIAL INSPECTION-FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 207 CLAMSHELL.COVE RD COTUIT,MA 02635 Owner: GOLDMAN Date of Inspection: 6/28/02 SOIL ABSORPTION SYSTEM (SAS): X (locate on site plan,excavation not required) If SAS not located explain why: n/a Type 1000 GAL 6' X 6' leaching pits, number: 1 n/a leaching chambers, number: n/a n/a leaching galleries, number: n/a n/a _ leaching trenches, number, length: n/a n/a leaching fields, number: n/a n/a overflow cesspool, number: n/a n/a r innovative/alternative system .Type/name of technology: n/a t Comments(note condition of soil,signs"of hydraulic failure, level of ponding,damp soil,condition of vegetation,etc.): LEACH PIT IS STRUCTURALLY SOUND AND FUNCTIONING PROPERLY.SYSTEM SHOWS NO SIGNS OF FAILURE. PIT HAD 6" IN IT AT TIME OF INSPECTION. STAIN LINES INDICATE PIT HAS NEVER HAD MORE THAN 2' OF LIQUID IN IT. BOTTOM IS AT 8'. CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: n/a Depth—top of liquid to inlet invert: n/a Depth of solids layer: n/a Depth of scum layer: n/a Dimensions of cesspool: n/a Materials of construction: n/a Indication of groundwater inflow(yes or no): NO Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation,etc.): n/a PRIVY: (locate on site plan) Materials of construction: n/a Dimensions: n/a Depth of solids: n/a Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): n/a 4 Page 10 of I I OFFICIAL INSPECTIW FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continucLI) Property Address: 207 CLAMS,1-TELL-COVE RD COTUrr, MA 02635 Owner: GOLDMAN Date of Inspection: 6/28/02 SKETCH OF SEWAGE DISPOSAL 'SVSTFM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. 'I I, tt �,t. c�. 0. AA �y AF 361 CA aa� C.g 30 . i L . in f . Page I I of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 207 CLAMSHELL COVE RD COTUIT,MA 02635 Owner: GOLDMAN Date of Inspection: 6/28/02 SITE EXAM _Slope Surface water Check cellar _Shallow wells Estimated depth to ground water 12+feet Please indicate(check)all methods used to determine the high ground water elevation: NO Obtained from system design plans on record- If checked,date of design plan reviewed: n/a YES Observed site(abutting property/observation hole within 150 feet of SAS) NO Checked with local Board of Health-explain: n/a NO Checked with local excavators, installers-(attach documentation) NO Accessed USGS database=explain: n/a You must describe how you established the high ground water elevation: HAND AUGER- 12+FT. s 4; s, 't ° �` TOWN „OF BARNSTABLE LOCATION a of aC`'M yl y�,J` CCkFC, SEWAGE # VILLAGE `JC vN i ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. ((�� SEPTIC TANK CAPACITY 1 �k LEACHING FACILITY: (type) Q\2�CcS�Q (size) J ON NO.OF BEDROOMS BUILDER OR OWNER PERMITDATE: COMPL 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 r ��►�Ic SCrt� OTT Qe� AA Will t Tc �9 CA L C. 30 C��7 Commonwealth of Massachusetts Executive Office of Enviromnental Affairs Dept. of Environmental Protection .lithe Grad One winter Street'Boston Ma. 02108 Septic D.E.P. Title V Septic Inspector tj,"'P.() Box 2119 r Udticket, MA 02536 WILLIAM F.WELD (508) 564-680' Governor ARGEO PAUL CELLUCCI Lt.Governor �t SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION M LMT 1�d1 �4 1 PART O CERTIFICATION TOWN OF BARNS' ? , HEALTHDr--T Property Address: 207 CLAMSHELL COVE RD.COTUIT Address of Owner: N� ." Date of Inspection: 919/98 (If different) Name of Inspector: JOHN GRACI KENNEDY i am a DEP approved system inspector pursuant to Section 15.340 of Title%(310 CMR 15.000) Company Name,Address and 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 inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: X Passes This Inspection Is based on criteria defined In Title V Conditi0 all Passes code 310CMR16.303.My findings are of how the system is y performing at the time of the inspection.My inspection does _ Needs further Evaluation By the Local Approving Authority not Imply any warranty or guarantee ofthe longevity ofthe Fails septic system and any of Its components useful life. Inspector's Signature: Date: 91919s The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this inspections. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer,if applicable and the approving authority. INSPECTION SUMMARY: Check A, B, C,or D: A] SYSTEM PASSES: x I have not found any information which indicates that the system violates any of the failure criteria defined as in 310 CMR 15.303. Any failure criteria not evaluated are indicated below: COMMENTS: B] SYSTEM CONDITIONALLY PASSES: One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair,passes inspection. Indicate yes,no,or not determined(Y, N, or ND). Describe basis of determination in all instances. If "not determined",explain why not. The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of Co'htpliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection-, or the septic tank,whether or not metal, is cracked,structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent.The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 04127197) One Winter Street • Boston,Massachusetts 02108 • FAX(617)556-1049 • Telephone(617)292-5500 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 207 CLAMSHELL COVE RD.COTUIT Owner: KENNEDY Date of Inspection:919198 _ Sew.age backuo or.hreakoutor high static water level observed.in.the distribution box is due to a broken. or obstructed pipe(s)or due to broken,settled or uneven distribution box.The system will pass inspection if (with approval of the Board of Health). Describe observations: broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced _The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed C] FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: _ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER,IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: _ The system has a septic tank and soil absorption system and is within 100 feet to a surface of water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and is within a Zone 1 of a public watersupply 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 the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presense of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method usedto determine distance (approximation not valid) 3)Other D] SYSTEM FAILS: You must indicate either"Yes"or"No"as to each of the following: _ 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. Yes No Backup of sewage in facility or system component due to an overloaded or clogged SAS or cesspool. DiSrhtirae or ponding of effluent to the surfPre of the ground or stirfnce waters diie to an overloaded or clogged cesspool. SAS is in hydraulic failure. (revised 04127)97) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 207 CLAMSHELL COVE RD.COTIIIT Owner: KENNEDY Date of Inspection:919198 D]SYSTEM FAILS(continued) Yes No 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 112 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Numbers of times pumped 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 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. 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: You must indicate either"Yes"or"No"as to each of the following: The following criteria apply to large systems in addition to the criteria: _ The system serves a facility with a design flow of 10,000 gpd or greater(Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: 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) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (reyleed 04127197) r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECLIST Property Address: 207 CLAMSHELL COVE RD.COTUIT Owner: KENNEDY Date of Inspection:919f98 Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following: _c_ — Pumping information was requested of the owner, occupant,and Board of Health. x None of the system components have been pumped for at least two weeks and the 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. x As built plans have been obtained and examined. Note if they are not available with N/A. x The facility or dwelling was inspected for signs of sewage back-up. x — The system does not receive non-sanitary or industrial waste flow. _c_ — The site was inspected for signs of breakout. x All system components,excluding the Soil Absorption System, have been located on the site. x The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid,depth of sludge,depth of scum. x The size and location of the Soil Absorption System on the site has been determined based on The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of Sub-Surface Disposal Systens. x Existing information. Ex. Plan at B.O.H. x Determined in the field(if any failure criteria related to Part C is at issue, approximation of distance is unacceptable)[15.302(3)(b)] trevlaed 0412T187) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 207 CLAMSHELL COVE RD.COTUIT Owner: KENNEDY Date of Inspection:918198 FLOW CONDITIONS RESIDENTIAL: Design flow: sso g•p•d./bedroom for S.A.S. Number of bedrooms: 6 Number of current residents: 6 Garbage grinder(yes or no): Yea Laundry connected to system(yes or no): Yes Seasonal use(yes or no): No Water meter readings, if available:(last two(2)year usage(gpd): rda Sump Pump(yes or no): No Last date of occupancy: n1a COMMERCIAL/INDUSTRIAL: Type of establishment: nro Design flow:0 gallons/day Grease trap present:(yes or no) No Industrial Waste Holding Tank present:(yes or no) No Non-sanitary waste discharged to the Title 5 system:(yes or no) No Water meter readings, if available: n1a Last date of occupancy: n1a OTHER:(Describe) rda Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: Na System pumped as part of inspection: (yes or no)No If yes,volume pumped:0 gallons Reason for pumping: rda TYPE OF SYSTEM x Septic tank/distribution box/soil absorptions system Single cesspool Overflow cesspool Privy Shared system(yes or no) ( if yes, attach previous inspection records, if any) I/A Technology etc.Copy of up to date contract? Other: APPROXIMATE AGE of all components,date installed(if known)and source Information: 1 R YEARS Olo Sewage odors detected when arriving at the site: (yes or no) No (revised 04127)97) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 207 CLAMSHELL COVE RD.COTUIT Owner: KENNEDY Date of Inspection:919198 SEPTIC TANK: x (locate on site plan) Depth below grade: 2' Material of construction: concreate_metal FRP Polyethylene—other(explain) If tank is metal, list age nIa . Is age confirmed by Certificate of Compliance No (Yes/No) Dimensions: I I0'6'-Hs-7^w4'Io^ Sludge depth:2" Distance from top of sludge to bottom of outlet tee or baffle: 32" Scum thickness:3" Distance from top of scum to top of outlet tee or baffle:e" Distance form bottom of scum to bottom of outlet tee or baffle: 15" How dimensions were determined: MEASURED Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND.RECOMMEND PUMPING NOW AND THEN MAINTAINED EVERY TWO YEARS. GREASE TRAP: (locate on site plan) Depth below grade: rda Material of construction: _concrete_metal_FRP_Polyethylene_other(explain) Dimensions: rda Scum thickness:We Distance from top of scum to top of outlet tee or baffle:rda Distance from bottom of scum to bottom of outlet tee or baffle: nla Date of last pumping;,, Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) nla BUILDING SEWER: (Locate on site plan) Depth below grade: 2' Material of construction:_cast iron x 40 PVC_other(explain) Distance from private water supply well or suction line•TOWN Diameter: Ma �Veimments: (conditions of joints,venting,evidence of leakage, etc.) I (revised 04127)971 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 207 CUWISHELL COVE RD.COTUIT Owner: KENNEDY Date of Inspection:919199 TIGHT OR HOLDING TANK: (locate on site plan) Depth below grade: rda Material of construction:_concrete_metal_FRP_Polyethylene—other(explain) Dimensions: era Capacity: rda gallons Design flow: rda gallons/day Alarm level:_n1a Alarm In working order?_Yes_No Date of previous pumping: Comments: (condition of inlet tee,condition of alarm and float switches,etc.) rda DISTRIBUTION BOX: (locate on site plan) Depth of liquid level above outlet invert: n1a Comments: (note if level and distribution is equal, evidence of solids carryover,evidence of leakage into or out of box etc.) rda PUMP CHAMBER: (locate on site plan) Pumps in working order:(yes or no)No Alarms in working order(yes or no)_Ye: Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) rda (revlaed 04117)97) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 207 CLAMSHELL COVE RD.COTUIT Owner: KENNEDY Date of Inspection:919199 SOIL ABSORPTION SYSTEM (SAS):x (locate on site plan, if possible;excavation not required, but may be approximated by non-intrusive methods) If not determined to be present,explain: rda Type: leaching pits,number: 1000LEACHPIT leaching chambers,number:Na leaching galleries,number: rda leaching trenches, number,length: rda leaching fields, number,dimensions:rda overflow cesspool, number:nla Alternate system: rda Name of Technology:_rda Comments: (note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.) THE LEACH PIT IS STRUCTURALLY SOUND AND FUNCTIONING PROPERLY.PIT HAD T OF WATER IN IT.PIT HAD SOME SOLID CARRYOVER,RECOMMEND PUMPING SYSTEM. CESSPOOLS:_ (locate on site plan) Number and configuration: rda Depth-top of liquid to inlet invert: nia Depth of solids layer: rda Depth of scum layer: rda Dimensions of cesspool: rda Materials of construction: rda Indication of groundwater: nla inflow(cesspool must be pumped as part of inspection) rda Comments: (note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.) n!a PRIVY: (locate on site plan) Materials of construction: rda Dimensions: nla Depth of solids: rda Comments: (note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.) rda (revised 04127197) I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 207 CLAMSHELL COVE RD.COTUIT KENNEDY 919198 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references, landmarks or benchmarks locate all wells within 100'(Locate where public water supply comes into house) ecr P7 �c �6-0 AA A � I cF CC �7 Pay ! of 30 (revised 0427197) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 207 CLAMSHELL COVE RD.COTUIT KENNEDY 919198 Depth of groundwater 72 Please indicate all the methods used to determine High Groundwater Elevation: Obtained from design plans on record. Observation of Site(Abutting property, observation hole, basement sump etc.) Determine it from local conditions Check with local Board of Health Check FEMA Maps Check pumping records Check local excavators, installers X Use USGS Data Describe in your own words how you established the High Groundwater Elevation.(MUST be completed) USGS MAPS AND CHARTS (revised04127197) page 10 a[ 10 /' Commonwealth of Mossachusetts Executive Office of Environmental Affairs John Grad De 01'f11t@!1f ® D.E.P. Title V Septic Inspector D �. P.O. Box 2119 11Y1r01l1l1�tsf�_ � feEfl®�1 Teaticket, MA 02536 W1111am F.weld (508) 564=6813 0"M^o-r Trudy Wx0 8acntary,EOFA David B.Struhs Comminioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION " 3 II Property Address: cjld`1 C�G,MSh2\� CO.I�� � C rd ess of Owner: � MA Y � Date of Inspection: rJ'o�\\�lv (If different) 1956, Name of Inspector: �. Company Name, Address and 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 inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.,The system: _/Passes _, Conditionally Passes — Needs Needs Fu her valuation By the local Approving Authority _ Fails 'Ins ectors Signature:p g � Date: `P The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (30) days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall-submit the report to the appropriate regional office of the Department of Environmental'Protection. The original should be sent to the system owner and copier ben; to the Lu)ei, if applicable and the appro.ing authority. INSPECTION SUMMARY: ChecQB, C, or D: AJ SYSTEM PASSES: I have not found any information which indicates that the system violates any of the failure criteria as defined.in 316 CMR 15.303. Any failure criteria not evaluated are indicated below. BJ SYSTEM CONDITIONALLY PASSES: One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair, passes inspection. 7 Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain why not) The septic tank is metal, cracked, structurally unsound, shows substantial infiltration or exfiltration,or tank failure is- imminent. The system will pass inspection if the existing septic tank,-is replaced'with a conforming septic tank as approved by the Board of Health. (revised 6/15/95) One VAnter Street a Boston,Massachusetts 02108 a FAX(617)GWIoa9 • Telephone(417)2B2-Sa00 0 Printed on Recycled Paper - SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION.FORM PART A CERTIFICATION (continued) Property Address: Owner: Date of Inspection: B) SYSTEM CONDITIONALLY PASSES (continued) Sewage backup or breakout or high static water level observed in the distribution box is due to broken_or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed C) FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 1) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC,HEALTH AND SAFETY AND.THE ENVIRONMENT: _ Ine >%slen) nd, a +e01i( tanh anui 5u1i absorption sy:iten, alit/ Is Vr ih Il iuv (Ee, to o a surface water supply. _ The s�qen hj� a septic tank and soil absorption system and is within a Zone I of a public water supply well. _ The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. _ The s,stem has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal.to o,!_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 dogged 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. (revised 6/15/95) 2 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Owner: Date of Inspection: D] SYSTEM FAILS (continued): — Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is Jess 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 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 large systems in addition to the criteria above: The design floe+• of system is 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area (IWPA)or a mapped Zone 11 of a public water supply well'. The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 8/15/951 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST. Property Address: 070-1 Owner: Date of Inspection: 5\ Q Go.= Check if the following have been done: _Le mping information was requested of the owner, occupant, and Board of Health. m rates and the tem has been receiving nor al flow N6ne of the system components have been Pq ped f been introdu ed Inroor at least two sthe systemsrecently or as part of this inspection.during that period. Large volumes of water have not (-_N�,Ms built plans have been obtained and examined. Note if they are not available with N/A. L-Tfie facility or dwelling was inspected for signs of sewage back-up. t/fhe system does not receive non-sanitary or industrial waste flow the site was inspected for signs of breakout. _AFf-system components, excluding the Soil Absorption System, have been located on the site. �1ie septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. the size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods. _—The c'"" ;;� n 07 rants if difiprPml frnrn ownR!1 were provided with information on the proper maintenance of Sub Surface Disposal System. a (revised 8/15/95) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C �,�n SYSTEM INFORMATION Property dress: �/V� Caa � -5-,N \ Owner: �� Date of Inspect of Z1`� FLOW CONDITIONS RESIDENTIAL: Design flow: 'i Itu Rallons Number of bedrooms: Number of current residents: r� Garbage grinder (yes or no):U2C Laundry connected to system (yes or no):LS. Seasonal use (yes or no):Ux-'�3 Water meter readings, if available: Last date of occupancy: �XC =��Lp SC } S -4sl- JAr COMMERCIAUINDUSTRIAL: 6VA Type of establishment: Design flow:_ al►ons/day Grease trap present: (yes or no)_ Industrial Waste Holding Tank present: (yes or no)_ Non-sanitary waste discharged to the Title 5 system: (yes or no)_ Water meter readings, if available: Last date of occupancy: OTHER: (Describe) Last elate of occupancy: GENERAL INFORMATION PUMPING RE.CORDS and source of infor ti n: ,gym QS � R - d System pumped as pan of inspection: (yes or no) es If yes, volume pumped _� zC� 1. gallons Reason for pumping: TYPE OF SYSTEM l�Septic tank/distribution. box/soil absorption system Single cesspool Overflow cesspool Privy Shared system (yes or no) (if yes, attach previous inspection records, if any) Other (explain) APPROXIMATE AGE of all components, date installed (if known) and source of information: Sewage odors detected when arriving at the site: (yes or no) ►J (revised 8/15/95) S SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION 'FORM PART C, SYSTEM INFORMATION (continued) Property dress: Owner: Date of Inspection Nil ` SEPTIC TANK: (locate on site plan) t Depth below grade: Material of construction: —concrete _,metal _FRP_pther(explain) Dimensions: tAM911, r} ►► I' Sludge depth: S Distance from top of sludge to bottom of outlet tee or baffle: Qc—)►t Scum thickness:_ Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: _ Comments: (recommendation for pumping, conditio f inlet and outlet tees or ba es, depth of liquid level in relation to o_utlet,invert,structural integrity, evi enc leakage, etc.) t�(1� A-� nW na('<Q GREASE TRAP: (locate on site plan) Depth below grade: Material of construction: _,concrete _metal _FRP _other(explain) Dimensions: Scum ihichne». Distance from top of scum to top of outlet tee or baffle: Distance from bottom ni «r gym r^ bottom of outle! tee or baftle 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, e►c.i (revised 8/.5/95) 6 r7 ................ ......... SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) . Property Address: �� Owner: � Date of Inspe i TIGHT OR HOLDING TANK:�`A (locate on site plan) 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: (locate on site plan) Depth of liquid level above outlet invert Comments: (note if levei and distnbuliur- a eyudi, e-jolce of sul)d� carr,�J,er, evidence of leakage into or out of box, etc.) PUMP CHAMBER:-UN (locate on site plan) Pumps in working order.(yes or no) Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) 7 (revised 6/15/95) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property ddress:.Q�(,� Owner: Date of Inspection ; SOIL ABSORPTION SYSTEM (SAS):--- --- approximated b non-intrusive methods) be ro Y f possible; excavation not required, but may app (locate on site plan, t po , If not determined to be present, explain: Type: O�\CX`1 �,1� aC—r\�)Xv leaching pits, number:�� � leaching chambers, number._ leaching galleries, number: leaching trenches, number,length: leaching fields, number, dimensions: overflow cesspool, number: me s: (note condition of soil, signs of hydraulic ilur , level of ponding, conditi . vegetation,etc.LL -L. Com �r}E� � �3 J 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: Indicat,on of ground,:a:c- inflow (cesspool must be pumped as part of inspection) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY: �`qq (locate on site plan) Dimensions; Materials of construction: _. Depth of solids: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, Fondition of vegetation,.etcJ 8 (revised 8/15/95) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) :)perty Address: 8Q-, C- Ga s:so, 4 C(� e� caner: ,� ,te of Inspedidn:1sG ,ETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' of ' pA 64 50 DEPTH TO GROUNDWATER groundwater.Depth to g ' feet w •-� method of determination or approximation: 9 (revised 8/15/95) Y No.j�-3 FEs../.....O..Y........... THE COMMONWEALTH OF MASSACHUSETTS �t t a' BOARD OF HEALTH ............................OF......................................................................................... Appliratiun for Biupuuttl Workii Tunutrnrtiun Errant Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: lG. ►.s17�.11re.../� .l�fv�7`.... ��-�----�-6-3 ..............................................................lion-Address Lot No. � `J...... :s Za.r ................... Owner .---..Address ----------•...................................................... •---•.....• ....................... Installer Address d Type of Building Size Lot...3c�..........___.....S et U Dwelling—No. of Bedrooms.......................................Expansion Attic ( ) Garbage Grin r . aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafete 'a Ga Ot r ores .................................. Design Flow..... . ................................gallons per person per ay. Total da' flow..... .. gal S. WSeptic Tank—Liquid capacity/gallons �xlgth...... ........ Width.__._.. Diameter................ D'e�th__ x Disposal Trench—No. ..-./........... Width......�._...... Total Length........:........... Total leaching area..9...--__.sq.ft. Seepage Pit No---------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) , Percolation Test Results Performed by.......................................................................... Date........................................ aTest Pit No. ]................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a ........_--•---......................--........ •-----•------------ 0 Description of Soil........................................................................................................................................................................ ------------------------------------•-------------------------------•--------...---•------------------------•-------------------------------•------------------------•-------------------------•------•- U Nature of Repairs or Alterations—Answer when applicable............................................................................................... ---------------------------------------------------•----••-•-••-••--•-•---•-••---•••------•........••-----••--••-••••---•••--•---••-••-•-•----•-••••-•••••--•---••••-•-•••------•-•--•..._............. Agreement: The undersigned agrees to install the afor described Individual Sewage Disposal System in accordance wi i the provisions of iITLL 5 of the State Sanitary Code—The undersigned further/ `'" top ce syst operation until a Certificate of Compliance has b n i e the board of health. Date Application Approved By---- --- ................................ • Date Application Disapprove or a following reasons-............................................................................................................... a' ••-----------------•------••---------•-•-•-•-•-•----•----------•----------------------------------.----------•--•--------------•---•-•-------••------•---------- Date ... PermitNo......................................................... Issued_....................................................... Date Y i .�../ Fss..1......_. THE COMMONWEALTH OF MASSACHUSETTS : BOARD OF HEALTH .................................OF......................................... ......... Application for Diupnuttl Workii Tonotrurtiun ranfit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: v� ..7......L./.�xn..zts /✓�,-�e._A .....:7.w,.....-•-• ................................................................................................. Location•Address t No. Dr��� ----- Lo ---s-fcr uf � .�'c�! ...... r.� � .... ................ Owner Address' v. --------------------------------------------------------------- -------------/-----------------------............... Installer Address Type of Building Size Lot_.:.?,& ..........S t U Dwelling—No. of Bedrooms........................................Expansion Attic ( ) Garbage GrinM'a --_" aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafete PA Oth r fixtures .....------•................... . . W Design Flow..... ...5Ae......................gallons per person per ay. Total dai flow....... ... _..CD................gall s. WSeptic Tank—Liquid capacityA gallons ength...... ........ Width....__.. Diameter__-_--__--_--_- Depth._. _...�... x Disposal Trench—No._._./'�........_. Width....._.�r.._...... Total Length.................... Total leaching area___% : ....sq. ft. Seepage Pit No..................... Diameter-------------------- Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by........................................... Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ GX, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ LY ....•-•-----------------••....---••••-•--•-••---....--•------•.....---•----•.....-----...:_......................................................... 0 Description of Soil........................................................................................................................................................................ x W VNature of Repairs or Alterations—Answer when applicable._.............................................................................................. ---.._----••.....................•••-•-•--------•----•-•---•---•-----•-•------••-•.......•-••-•--•--••••---••-••••••-••••••••---•------•---••-•-------•----•-•---•---•-•--••-•-•-•--•...---•--•-•-...... Agreement: The undersigned agrees to install the afor described Individual Sewage Disposal System in accordance wi i the provisions of TITIZ 5 of the State Sanitary Code— The undersigned further a trot to p e tj syste i operation until a Certificate of Compliance has b en i sued b th b rd of Health. L- ✓ of -- -- .................... - Date Application Approved ZBy •. ---- Gtra:. -•---•--.......-•-----------•-•-••---•---•:..................• kDate Application Disapprovfollowing reasons:..................-......................................-..................................................... - ....................................................... --•-•••--•-•-------•••••......................................-•••--••-••--•-•-•----•--•--•---•-----•••--•---•-•---•--•--•---••--••-••........--- Date PermitNo......................................................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................OF..................................................................................... �Tnrtif irate of Tompliatta THIS I (�"`C IFY,,+That the Individual S age D' osal System constructed ( �r Repaired ( ) by.............� . .... 1�M.7 •••••..---...--- r--_..,/�...-- •-----••------•--•-•-----•----...•---••......---•-•......---..-- at .e� . In taller',y ............................................. has been installed in accordance with the provisions of TIT ofhe State Sanitary Code s de i to the application for Disposal Works Construction Permit No----- -W._5___._r�.�...._. dated__.. ../_�� ... ............. THEIS*SONCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® WA UARANTEE THAT THE SYSTEI F �CjTION SATISFACTORY. DATE ... Ins d pector....... .......... -...................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH No .`.r ..........................................OF................................---.................................................. FEE.... v............ t iro 1 0 . otrurttion rrmi Permission '. hereby granted•. >< to Constru or a it ( 'a ndlvl. al `age s oral System atNo.�Cx �'= .................. = ................ ................................................ Street ` as shown on the application for Disposal Works Construction Permit No.......�r^r ..... Dated.......................................... ..........................•-.. ... ---•---•----------.......--••-•......---.._........•... Board of Health DATE........................... ........................ FORM 1255 A. M. SULKIN, INC.. BOSTON LOCATION r� 7 SEWAGE PERMIT NO. 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