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HomeMy WebLinkAbout0007 CONTENT LANE - Health 7 CONTENT LANE, COTUIT A= 040 046 i Commonwealth of Massachusetts Executive Office of Enviromiental Affairs Dept. of Environmental Protection One winter Street, Jolui Gradeet,Boston,Ma. 02108 D.E.P. Title V Septic Inspector P.O. Box 2119 Teaticket, MA 02536 WILLIAM F.WELD (508)564-6813 Governor ARGEO PAUL CELLUCCI Lt.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION V.- Property Address: 7 CONTENT LANE COTUIT MAP 040 PAR 046 LOT 82 Address of Owner: y tJ Date of Inspection: 9/22198 (If different) Name of Inspector: JOHN GRACI CHRIS PRYOR I am a DEP approved system inspector pursuant to Section 15.340 of Title%(310 CMR 15.000) �y© Company Name,Address and Telephone Number: 6 �9 S CERTIFICATION STATEMENT TV 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 Inspsctlon Is based on criterla defined In Title V Co all Passes code 310 CMR 16203.My findings are of how the system is performing atthe time of the inspection.My inspection does Needs ur er Evaluation By the Local Approving Authority not Imply any warranty or guarantee ofthelongevityofthe F'i 1, septic system and any of Its components useful Itre. Inspector's Signature: Date: 9122198 The System Inspector shall ubmit 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 3W 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 Compliance(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 rnetal, 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 04127,197)IJIlIfillilills One Winter Street • Boston,Massachusetts 0210E • FAX(617)556-1049 • Telephone(617)292-5500 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 7 CONTENT LANE COTUIT MAP 040 PAR 046 LOT 82 Owner: CHRIS PRYOR Date of Inspection:9122r98 — Sew.aae backup or.breakout or hiah.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 colifon 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. Discharge or ponding of effluent to the surface of the ground or surface waters rifle to nn wPllna<IPiI of Sloyyd!I cesspool. SAS is in hydraulic failure. (revised 04127)97) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 7 CONTENT LANE COTUIT MAP 040 PAR D46 LOT 82 Owner: CHRIS PRYOR Date of Inspection:0122198 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 1/2 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. �m (revised 04127197) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECLIST Property Address: 7 CONTENT LANE COTUIT MAP 040 PAR 045 LOT 82 Owner: CHRIS PRYOR Date of Inspection:9122199 Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following: _X_ — 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 NIA. 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)] (revlsedO4/27)97)Mll SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 7 CONTENT LANE COTUIT MAP 040 PAR 046 LOT 82 Owner: CHRISPRYOR Date of Inspection:9122199 FLOW CONDITIONS RESIDENTIAL: Design flow: 3m g•p•d./bedroom for S.A.S. Number of bedrooms: 3 Number of current residents: 2 Garbage grinder(yes or no): No 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): nla Sump Pump(yes or no): No Last date of occupancy: nIa COMMERCIAL/INDUSTRIAL: Type of establishment: nla 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: nre Last date of occupancy: nra OTHER:(Describe) nfa 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: THE SYSTEM IS APPRnXIMATELY20 YEARS OI.n. Sewage odors detected when arriving at the site: (yes or no) No e®®om (reylsed 04127)97) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 7 CONTENT LANE COTUIT MAP 040 PAR 046 LOT 82 Owner: CHRIS PRYOR Date of Inspection:9122198 SEPTIC TANK: x (locate on site plan) Depth below grade: 2' Material of construction:x concreate_metal_FRP_Polyethylene_other(explain) If tank is metal, list age nla . Is age confirmed by Certificate of Compliance No (Yes/No) Dimensions: L8'6"H5'T"W4'10^ Sludge depth:2" Distance from top of sludge to bottom of outlet tee or baffle: 32" Scum thickness:0 Distance from top of scum to top of outlet tee or baffle:6" Distance form bottom of scum to bottom of outlet tee or baffle:0 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 EVERYTWO YEARS. GREASE TRAP: (locate on site plan) Depth below grade: rda Material of construction: _concrete_metal_FRP_Polyethylene_other(explain) Dimensions: rda Scum thickness:rda 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: rva 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 llne:TOWN Diameter: - nla Qimments: (conditions of joints,venting,evidence of leakage,etc.) (revised 04127197)El SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 7 CONTENT LANE COTUIT MAP 040 PAR 046 LOT 82 Owner: CHRIS PRYOR Date of Inspection:9122198 TIGHT OR HOLDING TANK: (locate on site plan) Depth below grade: rda Material of construction:_concrete_metal_FRP_Polyethylene—other(explain) Dimensions: We Capacity: rja gallons Design flow: rda gallons/day Alarm level:_nra Alarm In working order?_Yes_No Date of previous pumping: Comments: (condition of inlet tee,condition of alarm and float switches,etc.) Ma 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.) n1a 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.) nfa (revised 04127)97) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 7 CONTENT LANE COTUIT MAP 040 PAR 046 LOT 82 Owner: CHRIS PRYOR Date of Inspection:9122198 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: 6'X4•LEACHPIT leaching chambers,number:rue 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,THE PIT WAS EMPTY AT THE TIME OF THE INSPECTION.Prr HAS HAD SOME SOLIDS IN IT. CESSPOOLS:_ (locate on site plan) Number and configuration: rva Depth-top of liquid to inlet invert: rda Depth of solids layer: rda Depth of scum layer: rda Dimensions of cesspool: rda Materials of construction: rda Indication of groundwater: rda 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.) rda PRIVY:_ (locate on site plan) Materials of construction: rue Dimensions: rde Depth of solids: rda Comments: (note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.) rda (revised D4127197) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 7 CONTENT LANE COTUIT MAP 040 PAR 046 LOT 82 CHRIS PRYOR 9122198 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) !� C, $ i� A �1 l (revised04)27197y Pape ! of 20 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 7 CONTENT LANE COTUIT MAP 040 PAR 049 LOT 82 CHRIS PRYOR 9122198 Depth of groundwater 12, 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 (revised 04)27197 ?ago 10 of 10 /- TOWN OF BARNSTABLE "/ 940, LOCATION 4 SEWAGE # VILLAGE( DVf/c V • / ASSESS 'S MAP & LOT CO)V6 7J'1'?&X 'NAME&PHONE NO. SEPTIC TANK CAPACITY= QO LEACHING FACILITY: (type) t (size) NO.OF BEDROO BUILDER OWNER PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by Ito off �h 3, 3 BORTOLOTTI CONSTRUCTION,INC. /' cr ,A {� 765 WAKEBY ROAD, MARSTONS MILLS,MA 02648 [6,,: 0 � 508-771-9399 508-428-8926 FAX: 508-428-9399 F CT b d� t l SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ''s , � PART A CERTIFICATIO Property Address: Z-) p Date of Inspection: Inspector's Name: di U O ner's Name and Address: rIf 0Z2 LEE --- r 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 Ev tion By ie al Aproving Authority Fails Inspector's Signature: e" Date: 7 The System Inspector shall submit a ciof 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)SYS'TI PASSES: �1 Al 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 ND).Describe basis of determination in all instances. If "not determined",explain why not. The septic tank is metal,cracked, structurally unsound, shows substantial infiltration or exfiltration,or tank failure is imminent. The system will pass inspection if the existing sep- tic tank is replaced with a conforming septic tank as approved by The Board of Health. Sewage backkup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. The system will pass inspection if(with approval of The Board of Health): SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PAiRT A CERTIFICATION (cowinucd) Broken pipe(s)replaced Obstruction is removed Distribution Box is levelled or replaced The System required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of The Board of Health): Broken pipe(s)are replaced Obstruction is removed C)FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by The Board of Health in order to determine if the system is failing to protect tine public health,safety and the environment. 1)SYSTEM WILL PASS UNLESS BOARD OF HEALTH.DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 Feet of a surface water Cesspool or privy is within 50 Feet of a bordering vegetated wetland or a salt marsh. 2)SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER,IF APPROPRIATE)DETERMINES THAT THE SYSTEM IS FUNCTION- ING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system and is within 100 Feet to a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and is with a Zone I of a public water supply well. The system has a septic tank and soil absorption system and is within 50 Feet of a private water supply well. The system has a septic tank and soil absorption system and is less than 100 Feet but 50 Feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from the facility and the presence of ammonia: nitrogen and nitrate nitrogen is equal to or less than 5 ppm. D)SYSTEM FAILS: 1 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 eIIuent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. Static liquid level in the distribution box above outlet invert due to an overloaded or clog- ged SAS or cesspool. Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day slow. Required pumping more than 4 times in the last year NO'h due to clogged or obstructed pipe(s). Number of times pumped -2- SUBSURFACE SEWAGE.DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 Feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I of a public well. Any portion of a cesspool or privy is within 50 Feet of a private water asupply 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: 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 Il of a public water supply well. The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Check if the following have been done: t,�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. _,,GThe system does not receive non-sanitary or.industrial waste flow. _ The site was inspected for signs of breakout. _gAll system components,excluding the Soil Absorption System, have been located on site. _,,--The septic tank manholes were uncovered,opened,and the interior of the septic tank was in- spected for condition of baffles or tees, material of construction,dimensions,depth of liquid, deOh of sludge,depth of scum. ,he size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods. -3 ,, SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST(continued) L/he facility owner( occupants,ants,if different front owner)were provided with information on p the proper maintenance of Subsurface Disposal System S SUBSURFACE SEWAGE DISPOSAL AL SYSTEM INSPECTION FORM PART C .. SYSTEM INFORMATION FLOW CONDITIONS RESIDENTIAL Design Flow:3a0 gallons Number of Bedrooms: '_3 Nuthger of Current Residents:(J_ (Q9 4 Garbage Grinder:_ Laundry Connected'fo System:-tlg Seasonal Use: A Water Meter Readings, if available: Last Date of Occupancy: ['2Csr cx4ce_ COMME.RC'IAL11NDUSTRIAL A)o Type of Establishment: Design Flow: gallons/day Grease Trap Present: (yes or no) Industrial Waste Holding Tank Present: Non-Sanitary Waste Discharged To The Title V System: Water Meter Readings,If Available: Last Date of Occupancy: OTHER: Describe) Last Date of Occupancy: GENE . INFORMATION PUMPING RECORDS and source of information: /Y— / ���. System Pumped as part of inspection: 06 If yes,volume pumped: gallons Reason for pumping: TYPE 9F SYSTEM: t/Septic Tank/Distribution Box/Soil Absorption System Single Cesspool Overflow Cesspool Privy Shared System(If yes,attach previous inspection records, if any) Other.(explain): APPROXIMATE AGE of all components,date installed(if known)and source of information: S Sewage odors detected when arriving at the site: A�� -4- i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C GENERAL INFORMATION (continued) SEPTIC TANK: I/ Depth below grade: Material of Construction: concrete metal FRP Other (explain) Dimisions: Sludge Depth: Scum Thickness A,Goil (E— Distance from top of sludge to bottom of outlet tee or baffle: Distance from bottom of scum to bottom of outlet.tee or baffle: i(/4r1 Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation t outlet invert,structural inte rity,evidence of leakag ,etc.) 2. /coo AQdZu/7, v GREASE TRAP: Depth Below Grade: Material of Construction:_concrel.e_metal_FRP_Other (explain) Dimensions: Scun►Thickness: Distance from top of scum to top of outlet tee or baffle: Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert, structural integrity,evidence of leakage,etc.) TIGHT OR HOLDING TANKA 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 Iloal,switches„etc.).._ DISTRIBUTION BOX: Depth of liquid level above outlet invert: ( Comments: (note ' vel and distribution i equal,ev► ence of solids carrygver,evi ence o leakage injo or t of box,etc. vyr ,� PUMP CHAMBER: Pump is in:working order: Comments: (note condition of pump chamber,condition of pun►ps and appurtenances,etc.) ' -5- SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) 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:____Leaching chambers, number: Leaching galleries,number: Leaching trenches,number, length: Leaching fields, number,dimensions: Overflow cesspool, number: Comments: (note condition of soil, igns of hydraulic failur level of ponding,condition of vegetation, etc. 5 OU ems' ii e' ' Lj - CESSPOOLS:�(� Number and configuration: Deptli-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: /Y u Materials of construction: Dimensions: Depth of Solids: Comments: (note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.) -6 - SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (confirmed) SKETCH OF SEWAGE DISPOSAL SYSTEM: Include ties to atleast two permanent references, landmarks or benchmarks. Locate all wells within 100 Feet. Y 0 0 �s4 DEPTH TO GROUNDWATER: i Depth to groundwater: Z/ Feet Meth of Determination or Approx'mation: // J?'iY��?l� /—/''�� u'S® T -T- l L THE COMMONWEALTH OF MASSACHUSETTS APPR VED BOARD OF HEALTH Barnstable conservation Department TOWN OF BARNSTABLE Appliratintt for Di�ipwial 1nnrk,i Towitrnrtint ' rmit Date Application is hereby made for a Permit to Construct ( ) or Repair ( an Individual Sewage Disposal System at: P 7 C©-1r N 7- L09 ,✓� �< � i1 ! j •-fit• Add less ...1. .................... ..................... .... -••------...........---•--.....__ ......................... -- --•........__------------ L Vic• s„�c !-r y/ f4/�odj� L�r r°e it ------------------- Owiler f Address a _PA ry...--..... ---".°1.__-� Y 9_sl/A%f J Installer Address UType of Building Size Lot............................Sq. feet Dwelling— No. of Bedrooms.....................................__---Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............_............... Showers ( ) — Cafeteria ( ) d Other fixtures ......... - -------------------------------------------------------- W Design Flow............................................gallons per person per day. Total daily flow..............._..._........_.._..........__gallons. WSeptic Tank—Liquid capacity._....--_-gallons Length..... .......... Width......---------- Diameter_---_--------_ Depth.............. ry x Disposal Trench—No. .................... Width--------------------- Total Length......._._.,........ Total leaching area....................sq. ft. 3 Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by-------------=............................................................ Date......................................04 .. Test Pit No. I................minutes per inch Depth of Test Pit--------_........... Depth to ground water........................ 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a ------------................................................................................................................................................ 0 Description of Soil........................................................................................................................................................................ x W •----........ a U Nature of Repairs or Alterations—Answer when applicable...l.7 Y_ ST Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned f rther agrees not to place the system in operation until a Certificate of Complia ce h been 'shied alth. Signede� .�"� .. ............. ..g.. � ./...�� .... ' Date Application Approved By . .. .. ........ .... .. .............. .. . Dare Application Disapproved for the following reasons: ......................................................................................................................................... .............................................. ---------------------.--------------------------------------------. �- -. ............ Da........ te Permit No. ....... .............. Issued ................ . . ?.................. . . ate i �i �1Y t«'ti„1 �.-.,.._,�.r -. -...-„,-..- .ti.....,-.... � � ..._..ry _ .-..._..-_ __.�.. .�._..^-....�r•_�-..._ .-�:....-...-r-Tr..� _ � ...� �w ..�.� .,� nrt*..� ....,nn.. .....-..... t V s a o / Fss No... ---- --_...._.. _............_. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE AVV iratiun for Difivasal Wnrk,i C omitrnrtinn� " rrmit Application is hereby made for a Permit to (.construct ( ) or Repair ( an Individual Sewage Disposal System at: .......................................•---••----...---------------------...._........--•---...... --•-•-------------•------•-:.....-••-•----•-•-----••----..............----------•---••------------ Location- \ddicss or G w� � c � 7 c / !`-' y/ 1;2�.3 v✓7,!l L?/..-,_ Lot d ............................. � .............- -•---•-•--- Owner // ' Address a ......................r�v2-G/"/ C�,� S l7`Y S Installer Address UType of Building Size Lot............................Sq. feet ►� Dwelling—No. of Bedrooms.___ .................................Expansion Attic ( ) Garbage Grinder ( ) f' a Other—Type of Building ............................ No. of persons---------------------------- Showers ( ) — Cafeteria ( ) a' Other fixtures __________________________ d -------------------- ----------------------------•-------------------•-•---------- w Design Flow..............................._------------gallons per person per day. Total daily flow..........__._._......._.__...._............gallons. WSeptic Tank—Liquid capacity------------gallons Length---------------- Width---------------- Diameter................ Depth................ x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. 3 Seepage Pit No..................... Diameter------------------._ Depth below inlet..__.._._.._.._.__.. Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date......................................... 4 Test Pit No. I................minutes per inch Depth of Test Pit-----------......... Depth to ground water........................ �rq Test Pit No. 2................minutes per inch Depth of Test Pit._.____--...____.__. Depth to ground water........................ a -----------------------------------•----------------------------•-••------------•---•---.........•...........---....................................__...._.. 0 Description of Soil........................................................................................................................................................................ w _x ---- ----S--------- ........................••----------..... U Nature of Repairs or Alterations—Answer when applicable. /!.7. ____________________Y.>..?. .'.................................._.. .......................... ..................... ` rf7 _P_�o©v_.....5...o........._l'..�c -- =- J---------------------------------......---- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance ha been issudedd`by rhe�boa .d of_health. Signed/ t// f � Application Approved By .r... -.�j/J �'�/ .! ._. v .............✓...d._...--...--..;,... -------------...----............. ........................................ Dace Application Disapproved for the following reasons: .......................:.::.. ............................................ ..............---....................... ................................................�... ---'-------------'--�......................-. �'- - / Dace Permit No. / ................. Issued ......... ..1../ .......................... � Dare —.---.-. ------- - .--------_---p. --._-- _._,e. - -- --------------------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH, " TOWN OF BARNSTABLE (9jertifirate of vT1ontpliattric THIS IS TO CERTIFY, That the- r>dividual Sewage Disposal System constructed ( ) or Repaired by .. ... ...... . ......_................ - - ................ .....- -................................. ._..... Installc•�^ r at .. 7...... 7 a:.. .. -.-G ....J ..'?.v.j_. ................................ .................. . has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in the application for Disposal Works Construction Permit No. ------------------------__.... .............. dated __.__................._--------_--__ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION�SATISFACTORY. DATE-----.......................u.........1...........1 Inspector ......... ................................ --------------------.------------------------------------------------ ,_.em �— r , .-THE COMMONWEALTH OF MASSACHUSETTS j BOARD OF HEALTH f TOWN OF BARNSTABLE �j /_.• FEE.3.................. � �i��n�ttl nrk� �.un�tr�rtinn �rrmit Permission is hereby granted ----------------------------- ----------------------------------•----....-•-..........._.... to Construct (_) p (............................................... ,, 1 System r '7 CJ / % n---------------------------•----.----•---•--•---- Stre at No............... _ �1. <:... an Imlivi�]I��'aae ---is Disposal, �� as shown on the application for Disposal Works Construction Per it No... _�,1. .__Dated.......................................... � � �- v Board of Heal'tIf DATE. � Iq -----------------•----•------- FORM 36508 HOBBS&WARREN-INC..PUBLISHERS TOWN OF BARNSTABLE LOCATION 7 CG,-oyj��v% �/t/ SEWAGE # 93" lzlq VILLAGE Cd 161 / J- ASSESSOR'S MAP & LOT !� INSTALLER'S NAME & PHONE NO. '2 SEPTIC TANK CAPACITY lj G y t9 C=-6} ��d i✓S LEACHING FACILITY:(type) (size) .� NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER/ ci b/ice BUILDER OR OWNER GZ Y / e DATE PERMIT ISSUED: Z74 DATE COMPLIANCE ISSUED: _ �I VARIANCE GRANTED: Yes No �`'�� �� ��� .�� �� �� �� '� �" � �. -� �r�' �