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HomeMy WebLinkAbout0135 CROCKERS NECK ROAD - Health jV[-1b-!5 Crockers `Neck Road tt P A 019 038 i COMMONWEALTH OF MASSACHUSE'Trl'S EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION e � i TITLE 5 OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address : 135 CROCKER NECK RD COTUIT 02635 M� 0`c1 QC( Owner's Name: VALENTE C/O BELL ONE Owner's Address: 5 MAIN ST COTUIT MA.02635 ATT. SUE SWEENF,Y �, + Date of inspection: 2/28/03 kw Name of Inspector: (please print) JOHN GRACI, INC. �003 SEPTIC INSPECTIONS L. - ., Company Name: P.O. BOX 2119 TEATICKET, MA.02536 Mailing Address: Telephone Number: 508-564-6813 FAX 508-564-7270 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at.this address and that the inform: ?ion reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on ni.v training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The systern: X Passes _ Conditionally/Passes _ Needs Fur r Evaluation by the Local Approving Authority Fails Inspector's Signature: % ' Date: 2/28/03 The system inspector shall submit a copy of this inspection report to then Appro i g n ft orityow of 10 000 (.)['Health _�I:�dlor greateDr,the within 30 days of completing this mspe ion. oai If the system is a shared system g inspector and the system owner shall submit the report to the appropriate regional office of the DEP. 'l he original should be sent to the system owner and copies sent to the buyer, if applicable, and the appruvinU authority. Notes and Comments TION. RECOMMEND PUMPING EVERY 'TWO YEARS TO PROLONG THI=, THE SYSTEM PASSES TITLE V 1NSPEC' SYSTEM'S USEFUL LIFE. ***This report only describes conditions at the time of inspection and nnder the conditions of use at that time.This e or different conditions of use. inspection does not address how the system will perform in the future under the sam i Page,2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 135 CROCKER NECK RD COTUIT 02635 Owner: VALENTE C/O BELL ONE Date of Inspection: 2/28/03 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: THE SYSTEM PASSES TITLE V INSPECTION. RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE. B. System Conditionally Passes: _ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined"please explain. 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 metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: 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): _ broken pipe(s)are replaced _ obstruction is removed _ distribution box is leveled or replaced ND explain: n/a n/a The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): _broken pipe(s)are replaced _obstruction is removed ND explain: n/a f Page 3 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 135 CROCKER NECK RD COTUIT 02635 Owner: VALENTE C/O BELL ONE Date of Inspection: 2/28/03 C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: _ Cesspool or privy is within 50 feet of a surface water _ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. _ The system has a septic tank and SAS and the SAS is within a Zone I of a public water supply. _ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance 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 is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: n/a Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 135 CROCKER NECK RD COTUIT 02635 Owner: VALENTE C/O BELL ONE Date of Inspection: 2/28/03 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all-inspections: 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'/2 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 NOT IN THE LAST YEAR. X Any portion of the SAS, cesspool or privy is below high ground water elevation. X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone I 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. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] _ W(Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no X the system is within 400 feet of a surface drinking water supply X the system is within 200 feet of a tributary to a surface drinking water supply X the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. d Page 5 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 135 CROCKER NECK RD COTUIT 02635 Owner: VALENTE C/O BELL ONE Date of Inspection: 2/28/03 Check if the following have been done. You must indicate "yes" or"no" as to each of the following: Yes No X _ Pumping information was provided by the owner,occupant,or Board of Health X Were any of the system components pumped out in the previous two weeks? X Has the system received normal flows in the previous two week period? X Have large volumes of water been introduced to the system recently or as part of this inspection? X _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) 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 uncovered,opened, and the interior of the tank inspected for the condition of the baffles or tees,material of construction, dimensions,depth of liquid, depth of sludge and depth of scum? 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 example,a plan at the Board of Health. X _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)] Page,6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 135 CROCKER NECK RD COTUIT 02635 Owner: VALENTE C/O BELL ONE Date of Inspection: 2/28/03 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):3 Number of bedrooms(actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Number of current residents: 0 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): YES Water meter readings, if available(last 2 years usage(gpd)):iA 0 — `(�a 1 WU Sump pump(yes or no): NO Last date of occupancy: n/a o1000 COMMERCIAL/INDUSTRIAL Type of establishment: n/a Design flow(based on 310 CMR 15.203): n/agpd 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 the 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 GENERAL INFORMATION Pumping Records Source of information: NOT IN THE LAST YEAR Was system pumped as part of the inspection(yes or no): NO If yes,volume pumped: n/agallons--How was quantity pumped determined? n/a Reason for pumping: n/a TYPE OF SYSTEM X Septic tank,distribution box,soil absorption system _Single cesspool _Overflow cesspool _Privy _Shared system(yes or no)(if yes,attach previous inspection records, if any) _Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) _Tight tank Attach a copy of the DEP approval Other(describe): n/a Approximate age of all components,date installed(if known)and source of information: INTALLED 1988,SEPTIC REPORT DATED 5-6-00 Were sewage odors detected when arriving at the site(yes or no): NO Page.7 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 135 CROCKER NECK RD COTUIT 02635 Owner: VALENTE C/O BELL ONE Date of Inspection: 2/28/03 BUILDING SEWER(locate on site plan) Depth below grade: 9" 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: 5" Material of construction: Xconcrete_metal_fiberglass_polyethylene other(explain)n/a If tank is metal list age: n/a Is age confirmed by a Certificate of Compliance(yes or no): NO(attach a copy of certificate) Dimensions: L 8' 6" H 5' 7" W 4' 10"" Sludge depth: 1" Distance from top of sludge to bottom of outlet tee or baffle: 33" Scum thickness: 0" 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: 18" 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 SEPTIC TANK COMPONENTS ARE STRCTURALLY 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_metal_fiberglass_polyethylene_other(explain): n/a Dimensions: n/a Scum thickness: n/a Distance from top of scum to top of outlet 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 7 Page,8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 135 CROCKER NECK RD COTUIT 02635 Owner: VALENTE C/O BELL ONE Date of Inspection: 2/28/03 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: LEVEL WITH BOTTOM OF PIPE 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.): D-BOX WAS VIDEO INSPECTED AND APPEARS TO BE STRUCTURALLY SOUND AND SYSTEM SHOWS NO SIGNS OF FAILURE. 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 Page,9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 135 CROCKER NECK RD COTUIT 02635 Owner: VALENTE C/O BELL ONE Date of Inspection: 2/28/03 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 innovative/alternative system Type/name of technology: n/a Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation,etc.): THE LEACH PIT IS STRUCTURALLY SOUND AND FUNCTIONING PROPERLY.THE PIT WAS EMPTY AT THE TIME OF THE INSPECTION. SYSTEM SHOWS NO SIGNS OF FAILURE. BOTTOM IS AT 8' -PIT HAS NO VISABLE STAIN LINES. 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 9 I'a ge 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 135 CROCKER NECK RD COTUIT 02635 Owner: VALENTE C/O BELL ONE Date of Inspection: 2/28/03 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landim.irks or benchmarks. Locate all wells within 100 feet. Locate where publicwater supply enters the building. �eel 9 r � 30. L in Page I 1 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 135 CROCKER NECK RD COTUIT 02635 Owner: VALENTE C/O BELL ONE Date of Inspection: 2/28/03 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) YES Accessed USGS database-explain: n/a You must describe how you established the high ground water elevation: GROUNDWATER DETERMINED FROM HAND AUGER-NO WATER AT 12' tt TOWN OF BARNSTABLE LOCATION -e? N,,ch Re) SEWAGE VILLAGE �� � ASSESSOR'S MAP & LOT INSTALLER'S NAME & PHONE NO. J'J`" SEPTIC TANK CAPACITY /000 LEACHING FACILITY:(type) /�0�. (size) GytIy NO. OF BEDROOMS 2, PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER M /,y CDh DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: 3 —30 '' VARIANCE GRANTED: Yes No �/ .�q ���} � , ic w � �� \ �.� p �� � �a. i ,3 � � _. '� of r' -- C01Ib10NWEALTH OF ir1ASSACH:�SETTS j,s WIVE9 EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAULWUAf j DEPARTMENT OF ENVIRONMENTAL PROTECTION 5 ZQQQ t ONE WINTER STREET, BOSTON MA 02108 (617)292-55000FQq IS 01a trnY cO)m i Secretary ARGEO PAUL CELLUCCI DAVID B. STRUHS Governor Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION - Property Address:) KC-e I'CCk bC 0, Name of Owner y Address of Owner: Date of Inspection: 0v Name of Inspector:(Please Print) CDW lg RD C, 80 am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000) Company Name: 006UA20 C,[gipilSti C/) Mailing Address:' 62 y ryc i�, Aq yF"S5IIVOW lec4 p, O Z5 3 Telephone Number: 5'T, -,Z 3.2 CERTIFICATION STATEMENT I certify.that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system:. Passes Conditionally Passes Needs Further Evaluation By the Local Approving Authority _ Fails_ Inspector's Signature: �—�/��� ��� Date The System Inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within thirty(30)days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. NOTES AND COMMENTS f O0D CAS(dIv sEiol/� T%I�tJK /coo G�LLCni LE.9C�/ fir t revised 9/2/98 Pagel of11 A it Printed on Recycled Paper r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: t 3 S C Roc le,670-S 66 K RO, Owner: it Date of Inspection: -00 INSPECTION SUMMARY: Check tEi/8, C, or D: 4`' A. SYSTEM PASSES: I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist. Any failure criteria not evaluated are indicated below. COMMENTS: B. SYSTEM CONDITIONALLY PASSES: One or more system components as described in the "Conditional Pass"section need to be replaced or repaired. The system, upon completion of.the replacement or repair,as approved by the Board of Health, will pass. Indicate yes,no, or not determined(Y, N,or NO). 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 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 complying septic tank as approved by the Board of Health. Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) _ 9 P 9 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 revised 9/2/98 Page2of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(contirxied) Property Address: I3.SCi?OCKCes ruFCK 01 Owrw: J•CCrvLv y Date of Inspection: .— -� C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 15.303(1)(b)THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND,THE ENVIRONMENT: Cesspool or privy is within 50 feet of surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER,IF ANY DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE 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 soil absorption system and the SAS is within a Zone I of a public water supply well. _ The system has a septic tank and soil absorption system and the SAS 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 presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine distance (approximation not valid). 3) OTHER ' r revised 9/2/98 Page 3or11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: Owner: J,(p711W�4 Date of Inspection: D. SYSTEM FAILS: (� You must indicate either"Yes" or"No" to each of the following: I have determined that one or more of the following failure conditions exist as described 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 into 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 due to an overloaded or clogged SAS or cesspool. Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6" below invert or available volume is less than 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: You must indicate either"Yes" or "No" to each of the following: . The following criteria apply to largo systems in addition to the criteria above: 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 If of a public water supply well) The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional office of the Department for further information.. 4 revised 9/2/98 Page 4of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: Owner: J C071Ir`� Date of Inspection: Check if the following have been done:You must indicate either "Yes" or"No" as to each of the following: Yes No Pumping information was provided by the owner,occupant,or Board of Health. _ None of the system components have been pumped for at least two weeks and the system has been receiving normaf flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. _ As built plans have been obtained and examined. Note if they are not available with N/A. The facility or dwelling was inspected for,signs of sewage back-up. _ The system does not receive non-sanitary or industrial waste flow. The site was inspected.for signs of breakout. _ All system components,a have been located on the site. The septic tank manholes were uncovered, opened,and the.interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions,depth of liquid,depth of sludge, depth of scum. The size and location of the Soil Absorption System on the site has been determined based on: . _ Existing information. For example, Plan at B.O.H. _ Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable) yT 115.302(3)(b)1 The facility owner(and occupants,if different from owner) were provided with information on the proper maintenance of SubSurface Disposal Systems. revised 9/2/98 Pages of II SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: CA16 4l�5/&,Fc � Owner: j 607UOtr3 U Date of Inspection: 6�Q FLOW CONDITIONS RESIDENTIAL: Design flow: /10 g.p.d./bedroom. Number of bedrooms)design):- Number of bedrooms(actual): Total DESIGN flow 3 30 Number of current residents:_ Garbage grinder(yes or(o)% /t/a Laundry(separate system) (yes or(Q:ND; If yes,separate inspection required Laundry system inspected (yes or no) Seasonal use C es-or no): T��$ Water meter readings,if available(last two year's usage(gpd): Sump Pump(yes or(fFd Last date of occupancy: ST/tLo<ci?r(=U, COMMERCIAL/INDUSTRIAL: Type of establishment: Design flow: qpd ( Based on 15.203) Basis of design flow Grease trap present: (yes or no)_ Industrial Waste Holding Tank.present: (yes or no)_ Non-sanitary waste discharged to the Title 5 system: (yes or no)_ Water meter readings,if available: Last date of occupancy: OTHER:(Describe) Last date of occupancy: • GENERAL INFORMATION PUMPING RECORDS and source of information: System pumped as part of inspection: (yes or�/(/D If yes, volume pumped: gallons Reason for pumping: TYPE )F SYSTEM Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no) (if yes,attach previous inspection records,if any) I/A Technology etc.Attach copy of up to date operation and-maintenance contract Tight Tank Copy of DEP Approval Other APPROXIMATE AGE of all components, date installed(if known)and source of information: e 66W 157Sef , qS-8UX 7- Sewage odors detected when arriving at the site: (yes oxig NO s revised "2/98 9 / Page 6 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: C 3 S C aeoc fi E ie /(/CC/< Owner: u(�GC7ttw7g Date of Inspection: BUILDING SEWER: (Locate on site plan) Depth below grade:_ Material of construction:_cast iron 40 PVC_other(explain) Distance from private water supply well or suction line Diameter Comments: (condition of joints, venting, evidence of leakage,etc.) SEPTIC TANK:_X, (locate on site plan) Depth below grade: Material of construction:_(concrete_metal_Fiberglass _Polyethylene_other(explain) If tank is metal, list age_ Is age confirmed by Certificate of Compliance_(Yes/No) Dimensions: Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: 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: How dimensions were determined: 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.) i 1ld S0LIDS C= GREASE TRAP: (locate on site plan) Depth below grade:_ Material of construction:_concrete—metal_Fiberglass. _Polyethylene_other(explain) Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments: (recommendation for pumping,condition of inlet and outlet tees'or baffles,depth of liquid level in relation to outlet invert,structural integrity, evidence of leakage,etc.) revised 9./2/98 Page 7of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: C Owner: TilltJ b� Date of Inspection:S /'6C TIGHT OR HOLDING TANK: (Tank must be pumped prior to, or at time of, inspection) (locate on site plan) Depth below grade:_ Material of construction:_concrete_metal_Fiberglass_Polyethylene_other(explain) Dimensions: Capacity: gallons Design flow: gallons/day Alarm present Alarm level: Alarm in working order:Yes No_ Date of previous pumping: Comments: (condition of inlet tee, condition of alarm and float switches,etc.) DISTRIBUTION BOX: (locate on site plan) Depth of liquid level above outlet invert: Comments: (note if level and distribution is equal,evidence of solids carryover, evidence of leakage into or out of box, etc.) ©/UE PIRE 11V — o,'vE- 1'01P67 OvT /U"O SOL/OS PUMP CHAMBER:_ (locate on site plan) Pumps in working order:(Yes or No)__ Alarms in working order(Yes or No) Comments: (note condition of pump chamber,condition of pumps and appurtenances,etc.) revised 9/2/98 Pages of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:. >'.�S 20C1�.t✓2 tv CGtc Oe D Owner: J; COAJ U.I4�( Date of Inspection: SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,if possible;excavation not required,location may be approximated by non-intrusive methods) If not located, explain: Type: leaching pits, number: ) 007- 1/000 .GALLON '0j'7' leaching chambers,number._ leaching galleries;number:_ leaching trenches,number,length: leaching fields, number,dimensions: overflow cesspool,number:_ Alternative system: Name of Technology: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.) (_C-404 (D/r- iS 0"2y n%o 4uifD CESSPOOLS:_ (locate on site plan). Number.and configuration: Depth-top of liquid to inlet invert: Depth of solids layer. Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater. inflow (cesspool must be pumped as part of inspection) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY: (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments: (note condition of soil,signs of hydraulic failure,level of ponding, condition of vegetation,etc.) revised . 9/2/98 Page 9of11 f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) ru Property Address: Owner: J;COYl O A Y Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100'(Locate where public water supply comes into house) 3 revised 9/2/98 Page ioorn I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C n p SYSTEM INFORMATION(continued) Property Address: Owner: J . Cofuw Date of Inspection: b r NRCS Report name Soil Type_ Typical depth to groundwater USGS Date website visited Observation Wells checked Groundwater depth: Shallow Moderate ' Deep SITE EXAM Slope Surface water Check Cellar Shallow wells Estimated Depth to Groundwater Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observed Site(Abutting property, observation hole, basement sump etc.) Determined from local conditions Checked with local Board of health Checked FEMA Maps Checked pumping records Checked local excavators,installers Used USGS Data Describe how you established the High Groundwater Elevation. (Must be completed) revised 9/2/98 Page 11oru No...9•49::J.3a 7;.6..... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ._......._./.0... .y'.............OF.... ���r f/as..� Appliratiun for Diilruuttl Works Tonstrnr#ion ernti# Application is hereby made for a Permit to Construct (>.�, or Repair ( ) an Individual Sewage Disposal System at: �� ... .....e -- ....•--•--••--•... ....-••-••..._.... �. .......... --- _-- ----------- or . � Location-Address ................Lot No. ............................ . - ..._.. ................ WO ner .........•------ -------Addddreress a .174 •••••-.. A . ....... Installer Address dType of Building Size Lot. 6f.0A--------_Sq. feet U Dwelling—No. of Bedrooms....�..................................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers (' — Cafeteria ( ) a Other fixtures -------------------------------•-•------------ - -----•-----•----•-'----------------------------------------•----------------------------•-•........... W Design Flow............................................gallons per person per day. Total daily flow.._.............._......_..._............._.gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................ xDisposal Trench—No. .................:.. Width.................... 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 ( ) Percolation Test Results Performed bY...............................................--••••-•-•••-•••-••-•_•••-• Date........................................ aTest Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 1 fi, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ ' •--..... •-••--•---•--••--•-•••••-••--•--•••-•-•••••••-•-••••-•••-•-•-•••-----•--•..........................••--._...---•--•••........_.........-•••-..-•-- ODescription of Soil.................... n �--------------------.......................................................................................... W •-•---•---•--• ------------•-----------•---•-..-••--••--•--•--••----••--•--••--•-••••-•-•-•-•••......-••-------••---- --•----- • ••-••-••--•-••...•••••••-•--••-•-•-•--••-•-•-•-......-••-•--_..... VNature of Repairs or Alterations—Answer when applicable______,r!> .•.�1�� ._s T l Qob .� ............ _ /� c_ ........ ep - Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITIE 5 of the State Sanitary Code—.The undersigned further agrees not to place the system in operation until a Certificate of Compliance has ben issjded by the board of iealth. Signed: .5? . �.¢� Date - Application Approved BY C� V �.�' -.� a"'M'....�, ......... 3..-..a- -,.. .�. Date Application Disapproved for the following reasons:.......................................................................................................... -----•............................•----------•-------------•---•--------------._.............-----------.I.......-•-••----•.... Date Permit No.... .............................. Issued---•----------...--------..._ e ....................................................... Date NO.._� :__�.3. Fss..... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .............0F... .��!s i�.r.S�� Application for Disposal Works (Construction Prrnnit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: ....../3 s. d �lt:?..:....15/>e .......,QC/................... ...........................C, .. --...••-•••------•-•..................--- Location_Address or•Lot No. .. .aS..� �_..... .Qn - ------------------------------------------ ............................................. wir-e-•---••••-••••-•-•-•___----_------........ ner Address ........... .... ....... ----•--....._.. ............ Installer Address Type of Building Size Lot............................Sq. feet aDwelling—No. of Bedrooms.......................:....................Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) 04 Other fixtures .-------•..........................••-••--_.... Design Flow........................:...................gallons per person per day. Total daily flow............................................gallons. Septic 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........................................ aTest Pit No. I................minutes per inch Depth of Test Pit..................... Depth to ground water........................ f4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a ............................••---........................••-••-••••-------------------------•----------•--------•------•---------------•-•................... D Description of Soil.................... r n �_ U ........... -------- •--•••••_...-----....------- •-------------------- ------- •••............. --•...... _...... ---------•------ ---------- -._----•------------•---••----•-•- W ....----•-•------••--•--••----•-----•------•----...-••----•--••-----•-------••.............•---•--•----....._...-•••--•---•-------•-•--•-----------.........:.......••-•----••-••---.....----•-=--__.._. x U Nature of Repairs or Alterations—Answer when applicable...... ...1 .l1 ,,,•,-,-•,,, Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITIS 5 of the State Sanitary Code—.The undersigned further agrees not to place the system in operation until a Certificate of Compliance has AbDen is ed by the board of ealth. Signed_. ............ .......................................... �. .f1. .... Date Application Approved By............... ..--••-•• ..� --/.... . _I _ Date Application Disapproved for the following reasons:_____________________`__J______-____..........___..........___-______________________.___...._____-____.....___ ••......................................................•--•---....----•------....----........................---.....------------------............------------•-------•--•----•........_•----........_ Date PermitNo.__.ql_:.13.2----------------------------- Issued........................................................ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD yOF HEALTH ......... Ctl OF.......... ................................... Trrtif iratr of Tomplianrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (x) by............ .. Q C-4............ „�,.P. :'....... ....--Installer ...... •-..__...:................... .......... ....... ....... ._...._ at...............-�-3_5...... -----/lg-". ....... -------_---___--- ...................................................... has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No........3t-...1.,}_:-.1.._......... dated.............................:.................. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE....................... ................................. Inspector..................... ......................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH OF......... �. cr ,.v �. %.......................................... : Big Works (Construction rrrmit Permission is hereby granted.. �E� - ---•-••-•---•---•-••------••-•..............................................__.. to Construct ( ) or Repair ) an ividual Sewage Disposal System at No..---•--......L.3.- • 4�---- - .�Q• - -----.� ............. . _. .- street as shown on the application for Disposal Works Construction Permit NOFSJ_:1.3_1...... Dated.......................................... r .................... _.;`��_ , L • _ ........._--------................... •• Board of Ht�1 eal h DATE........... :'..1-1......t .------•----•........................•-= FORM 1255 A. M. SULKIN, INC., BOSTON