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HomeMy WebLinkAbout0077 DOGWOOD LANE - Health 77 DOGWOOD LANE, COTUIT A= 025 056 - ------ - - -- --- i I 1 I COMMONWEALTH OF'MASSACHUSETTS a� d Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form Inspection results must be submitted on this form. Inspection forms may not be altered in any way. A. General Information /)17 O; 5- /9p0 1. Property Information: �3 77 DOGWOOD LANE — COTUIT, MA 02635 Property Address SUSAN MOAKLEY b Z. S�o Owner's Name 77 DOGWOOD LANE Owner's Address COTUIT MA 02635 Cityrrown State Zip Code 9/20/07 Date 2. Inspector: JAMES D. SEARS w� Name of Inspector ) c" BLUE WATER CANCO Company Name 350 MAIN STREET ] -' Company Address 1 ;= WEST YARMOUTH MA 02673 ' Cityrrown State Zip Code 508-775-2800 Telephone Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. 1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The System: ❑X Passes Conditionally Passes ® Fails Needs F�yLervaluation by the Local Approving Authority Inspector' nature: Date: The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer,if applicable, and the approving authority. ""This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 1 of 16 f COMMONWEALTH OF MASSACHUSETTS Title 5 Official Inspection Form d nsp Not for Voluntary Assessments �+r yew Subsurface Sewage Disposal System Form D. Certification (cont.) 77 DOGWOOD LANE Owners Address COTUIT MA 02635 City/Town State Zip Code SUSAN MOAKLEY Owners Name 9/20/07 Date of inspection 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: B) System Conditionally Passes: N/A One or more system components as described in the"Conditional Pass"section need to be replaced or Repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Answer yes, no or not determined(Y, N, ND) in the for the following statements. If"not determined," please explain. ® The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of compliance indicating that the tank is less than 20 years old is available. ND Explain: Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 2 of 16 r COMMONWEALTH OF MASSACHUSETTS w Title 5 Official Inspection Form d Not for Voluntary Assessments S�a Subsurface Sewage Disposal System Form B. Certification (cont.) 77 DOGWOOD LANE Owner's Address COTUIT MA 02635 ------------- City/Town State Zip Code SUSAN MOAKLEY Owner's Name 9/20/07 Date of inspection B) System.Conditionally Passes (cont.): 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): y broken pipe(s)are replaced. ❑ obstruction is'removed distribution box is leveled or replaced ND Explain: The system required pumping more than 4 times a year due to broken or,obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced ❑ obstruction is:removed ND Explain: C) Further Evaluation is Required by the Board of Health: N/A 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 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 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 3 of 16 COMMONWEALTH OF MASSACHUSETTS o Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form B. Certification (cont.) 77 DOGWOOD LANE Owner's Address COTUIT MA 02635 Cityrrown State Zip Code SUSAN MOAKLEY Owner's Name 9/20/07 Date of inspection C) Further evaluation is required by the Board of Health (cont.): N/A 2.System will fail unless the Board of Health(and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health,safety and environment: The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply�well** Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less that 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3.Other: Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 4 of 16 COMMONWEALTH OF MASSACHUSETTS m d Title 5 Official Inspection Form d Not for Voluntary Assessments Subsurface Sewage Disposal System Form- B. Certification (cont.) 77 DOGWOOD LANE Owner's Address COTUIT MA 02635 Cityrrown State Zip Code SUSAN MOAKLEY Owner's Name 9/20/07 Date of inspection D) System Failure Criteria Applicable to All Systems: N/A You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ® XX Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ® 0 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 Q ®X Liquid depth in 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: Any portion of.the SAS, cesspool or privy is below high ground surface water elevation. NIA Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. N/A Any portion of a cesspool or privy is within a Zone 1 of a public well. NIA Any portion of a cesspool or privy is within 50 feet of a private water supply well. NIA Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] YES No The system is a cesspool serving a facility with a design flow of 2000 gpd—10,000 gpd. Yes No [X The system fails. 41 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 whatwill be necessary to correct the failure. Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 5 of 16 COMMONWEALTH OF MASSACHUSETTS d Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form B. Certification (cont.) 77 DOGWOOD LANE Property Address COTUIT MA 02635 Cityrrown State Zip Code SUSAN.MOAKLEY Owner's Name 9/20/07 Date of inspection 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. N/A For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the questions in Section D. Yes No ❑ the system is within 400 feet of a surface drinking water supply ❑ the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area- IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered"yes"in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 6 of 16 COMMONWEALTH OF MASSACHUSETTS i; Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. Checklist 77 DOGWOOD LANE Property Address COTUIT MA 02635 Cityrrown State Zip Code SUSAN MOAKLEY Owner's Name 9/20/07 Date of inspection Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No 0 Pumping information was provided by the owner, occupant,or Board of Health ® Were any of the system components pumped out in the previous two weeks? �X 0 Has the system received normal flows in the previous two week period? ® Have large volumes of water been introduced to the system recently or as part of 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? 0 Was the site inspected"for signs of break out? ®X Were all system components, including the SAS, located on site? Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction dimensions, depth of liquid,depth of sludge and depth of scum? �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: �X ® Existing information. For example, a plan at the Board of Health. 0 0 Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(5)]. Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 7 of 16 COMMONWEALTH OF MASSACHUSETTS a Title 5 Official Inspection Form d Not for Voluntary Assessments Subsurface Sewage Disposal System Form D. System Information 77 DOGWOOD LANE Property Address COTUIT MA 02635 City/Town State Zip Code SUSAN MOAKLEY Owner's Name 9/20/07 Date of inspection Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 Number of current residents: 2 Does residence have a garbage grinder? Yes No Is laundry on a separate sewage system?[if yes separate inspection is required] Yes �X No Laundry system inspected? ❑X Yes No Seasonal use? ® Yes ❑X No Water meter readings, if available(last 2 years usage(gpd)): N/A Sump pump? ❑ Yes ❑X No Last date of occupancy: PRESENT Commercial/industrial Flow Conditions: N/A Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.) Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? Yes M No Non-sanitary waste discharged to the Title 5 system? Yes No Water meter readings if available: Last date of occupancy/use: Date Other(describe): Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 8 of 16 r COMMONWEALTH OF MASSACHUSETTS d Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form D. System Information (cont.) 77 DOGWOOD LANE Property Address COTUIT MA 02635 Cityrrown State Zip Code SUSAN MOAKLEY Owner's Name 9/20/07 Date of inspection General Information Pumping Records: Source of Information: N/A Was system pumped as part of the inspection? ❑ Yes �X No If yes,volume pumped: gallons How was quantity pumped determined? Reason for pumping: 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): Approximate age of all components, date installed(if known) and source of information:. 1986 PERMIT#86-851 Were sewage odors detected when arriving at the site? Yes ❑X No Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 9 of 16 CH COMMONWEALTH OF M ASSA USETTS d Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form D. System Information (cont.) 77 DOGWOOD LANE Property Address COTUIT MA 02635 City/Town State Zip Code SUSAN MOAKLEY Owner's Name 9/20/07 Date of inspection Building Sewer(locate on site plan): Depth below grade: 20" feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain) Distance from private water supply well or suction line: feet Comments(on condition of joints,venting, evidence of leakage,etc.): Septic Tank (locate on site plan): Depth below grade: 2' feet Material of construction: �X concrete metal fiberglass ❑ polyethylene 0 other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1,500 GALLON PRE CAST Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle 28" Scum Thickness 1" Distance from top of scum to top of outlet tee or baffle 12" Distance from bottom of scum to bottom of outlet tee or baffle 17" How were dimensions determined? ASBUILT,TAPE AND SLUDGE JUDGE Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 10 of 16 i COMMONWEALTH OF MASSACHUSETTS i; Title 5 Official Inspection Form w > Not for Voluntary Assessments Subsurface Sewage Disposal System Form D. System Information (cont.) 77 DOGWOOD LANE Property Address COTUIT MA 02635 City/Town State Zip Code SUSAN MOAKLEY Owner's Name 9/20/07 Date of inspection Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): TANK AT 2' BELOW GRADE WITH COVER AT GRADE, OUTLET BAFFLE NO SIGN OF LEAKAGE OR OVERLOADING. Grease Trap-(locate on site plan): N/A Depth below grade: feet Material of construction: concrete metal fiberglass ❑ polyethylene ❑ other(explain) Dimensions: Scum Thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping Date Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): N/A Depth below grade: Material of construction: 0 concrete ❑ metal ❑ fiberglass ❑ polyethylene ® other(explain) Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 11 of 16 COMMONWEALTH OF MASSACHUSETTS a Title 5 Official Inspection Form Not for Voluntary Assessments 5'a Subsurface Sewage Disposal System Form D. System Information (cont.) 77 DOGWOOD LANE Property Address COTU IT MA 02635 Cityrrown State Zip Code SUSAN MOAKLEY Owner's Name 9/20/07 Date of inspection Tight or Holding Tank(cont.) N/A Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: Yes ❑ No Alarm Level: Alarm in working order: ❑ Yes ® No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): *Attach a copy of current pumping contract(required). Is copy attached? ® Yes No Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover, any evidence of leakage into or out of box, etc.): DISTRIBUTION BOX IS 16"x16", 32" BELOW GRADE WITH COVER AT 8". ONE LINE IN, ONE LINE OUT. BOX IS CLEAN AND SOLID. NO SIGN OF OVERLOADING OR SOLID CARRYOVER. Pump Chamber(locate on site plan): N/A Pumps in working order: ® Yes No Alarms in working order: ❑ Yes No Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 12 of 16 I COMMONWEALTH OF MASSACHUSETTS d Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form D. System Information (cont.) 77 DOGWOOD LANE Property Address - COTUIT MA 02635 City/Town State Zip Code SUSAN MOAKLEY Owner's Name 9/20/07 Date of inspection Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: �X leaching pits number: 1 ® leaching chambers number: leaching galleries number: leaching trenches number, length: leaching fields number, dimensions: ® overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil, condition of vegetation, etc.): LEACHING IS ONE 1,000 GALLON PRE CAST PIT. INSPECTED WITH CAMERA. V WATER, STAIN LINE AT 2'. NO SIGN OF HIGHER STAIN LINE. NO SIGN OF OVERLOADING OR SOLID CARRYOVER. , Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 13 of 16 COMMONWEALTH OF MASSACHUSETTS d Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form D. System Information (cont.) 77 DOGWOOD LANE Property Address COTUIT MA 02635 Cityrrown State Zip Code SUSAN MOAKLEY Owner's Name 9/20/07 Date of inspection Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): N/A Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow Yes No Comments(note condition.of soil,signs of hydraulic failure, level of ponding,damp soil, condition of vegetation, etc.): Privy (locate on site plan): N/A Materials of construction: Dimensions Depth of solids Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation, etc.): Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 14 of 16 COMMONWEALTH OF MASSACHUSETTS - Title 5 Official Inspection Form d Not for Voluntary Assessments Subsurface Sewage Disposal System Form D. System Information (cont.) 77 DOGWOOD LANE Property Address COTUIT MA 02635 Cityrrown State Zip Code SUSAN MOAKLEY Owners Name 9/20/07 Date of inspection Sketch of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. . rat Div o V- �� ' r 5 57 O Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 15 of 16 COMMONWEALTH OF MASSACHUSETTS Title 5 Official Inspection Form Not for Voluntary Assessments . Subsurface Sewage Disposal System Form D. System Information (cont.) 77 DOGWOOD LANE Property Address COTU IT MA 02635 Cityrrown' State Zip Code SUSAN MOAKLEY Owner's Name 9/20/07 Date of inspection Site Exam: Slope Surface water Check cellar Shallow wells- Estimated depth to no ground water: 12' Please indicate all methods used to determine the high ground water elevation: Obtained from system design plans on record If checked,date of design plan reviewed: Date ❑x Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health—explain: ® Checked with local excavators, installers—(attach documentation) Accessed USGS database—explain: You must describe how you established the high ground water elevation: TEST HOLE 12' NO WATER,TEST HOLE AT 4' BELOW BOTTOM OF PIT. BOTTOM OF PIT AT 8'. VY i 0 16-o 60 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 16 of 16 CERTIFIED SEPTIC SYSTEM REPORT LOCATION 77 DOGWOOD LANE COTUIT, MA MAP 025 PARCEL 056 LOT 7 PREPARED FOR SELLER MS . ANNETTE GINNETTY EXECUTRIX FOR THE ESTATE OF HERBERT CARROLL 121 LOVELL 'S RD COTUIT , AM FRE I �; BUYER � 1995 MS . E . SUSAN PERCOCO MR. 'J . CHARLES MOAKLEY HDEPT.24 DOLLY ST WNSTABLE f S . DENNIS, MA 177 PREPARED BY HILLIARD HILLER, JR. r P .O . BOX 250 , CENTERVILLE, MA 02632 a r: 508-778-1472 m SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Address of property 77 o�c.�ooA z As�i£ CowlT �y�, owner's name !•i.Q. /t�%Cl�F/Li F. c�9i1/1oGG Date of Inspection PART A CHECKLIST Check if the following have been done: y Pumping information was requested of the owner, occupant, and Board of Health. . V None of the system components have been pumped for at least 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. i/ As built plans have been obtained and examined. Note if they are not available with N/A. , r/ The facility or dwelling was inspected for signs of sewage back-up. The site was inspected for.,signs of breakout. All system components, excluding the SAS , have been located on the site. v 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. �G The size and location of the SAS on the site has been determined based on existing information or approximated by non-intrusive methods. V" The facility owner (and occupants, if different from owner) were provided with information . on the proper maintenance of SSDS . SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION 77 Oarvoda L�.�� G oTvrT �irj� FLOW CONDITIONS If residential _3 number of bedrooms — 9 number of current residents YXS garbage grinder, yes or no _YZ5 laundry connected to system, yes or no seasonal use, yes or no If nonresidential, calculated flow: Water meter readings, if available: �q9�/ 8,oab G✓9[ Wyss �s;o� cy� Last date of occupancy GENERAL INFORMATION Pumping records and source of information: Nzv144 Aelt 6-,�,y- 1A -G.9dy yl'S System pumped as part of inspection, yes or no if yes, volume pumped /0,vc. G?' Reason for pumping: To F/•�� L E'�Pfr Type of system r/ 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. Source of information: �8 7 A10 Sewage odors detected when arriving at the site, yes or no I� SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION continued SEPTIC TANK: (locate on site plan) depth below grade: 7�' material of construction: 4/ concrete metal FRP other(explain) dimensions: //'o° xS �y' (o✓Jl� %o" dE.C'a 7�"� I sludge depth -R' /L' distance from top of sludge to bottom of outlet tee or baffle D 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, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, recommendations for repairs, etc. ) T�£S 4c9K1-o 6a4 l/l�v/� c��'� G U u� Tr/.u!" �✓�9s �U�i�,�o �l�O _ �Pis��1s W�,�E �►,bn,�o DISTRIBUTION BOX: (locate on site plan) d— depth of liquid level above outlet invert Comments: (note if level and distribution is equal evidence of solids carryover,. evidence of leakage into or out of box, recommendation for repairs, etc. ) GnX GoDK ,(i0 PUMP CHAMBER' (locate on site plan) pumps in working order, yes or no Comments: (note condition of pump chamber, condition of pumps and appurtenances, recommendations for maintenance or repairs,etc. ) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION continued° SOIL ABSORPTION SYSTEM (SAS) : y (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 and number leaching chambers and number leaching galleries and number leaching trenches, number, length leaching fields, number, dimensions overflow cesspool, number Comments: (note condition of soil , signs of hydraulic . failure, level of ponding, condition of vegetation, recommendations for maintenance or repairs, etc. ) iW 51'1�'Al OG 1_d91Z-e1K,E c.yr9T,elt Rvv ,,vim y /017. 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, recommendations for maintenance or repair.s,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, recommendations for maintenance or repairs, etc. ) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION continued SKETCH OF SEWAGE DISPOSAL SYSTEM: 77 Oek;e�za2a c�T�'i� �I/y include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' lr, �a DEPTH TO GROUNDWATER depth to groundwater method of determination or approximation: / �,�isi 3GL his Si,� s i,1W —r6X-l/i9 r�vy rar' r11 i�Ze 1J S6 -r Try T/yt AIC I 4 7r�� 3sS' '-$.3-r-- I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C FAILURE CRITERIA Indicate yes, no, or not determined (Y, N, or ND) . Describe basis of determination in all instances. If "not, determined" , explain why not) Backup of sewage into facility? Discharge or ponding of effluent to ' the surface of the ground or surface waters? /10 . Static liquid level in the distribution box above outlet invert? Liquid depth in cesspool <6" below invert or available volume< .1/2 day flow? Required pumping 4 times or more in the last year? number of times pumped No Septic tank is metal? cracked? structurally unsound? substantial infiltration? substantial exfiltration? tank failure imminent? Is any portion of the SAS, cesspool or privy: below the high groundwater elevation? within 50 feet of a surface water? . within. 100 feet of a surface water supply or tributary to a surface water supply? ,b within a Zone I of a public well?. within 50 feet of a bordering vegetated wetland or salt marsh (cesspools and privies only, not the SAS) ? ' V within 50 feet 'of. a- private water supply well? /V 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 analysi for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. l TOWN OF 9rQl , i�SzFr BOARD OF HEALTH SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART D - CERTIFICATION -•--------------------.-------�------•---`-TYPE OR PRINT CLEARLY- PROPERTY INSPECTED STREET ADDRESS 7? ASSESSORS MAP, BLOCK AND PARCEL OWNER' s NAME PART D - CERTIFICATION NAME OF INSPECTOR COMPANY NAME COMPANY ADDRESS Street Town or City State ZIP COMPANY TELEPHONE �y7,_ FAX CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported is true , accurate ,, and complete as of the time of inspection . The inspection was performed and any recommendations regarding upgrade , maintenance , and repair are consistent with my training and experience in the proper function and maintenance of on- site sewage disposal systems . Check one : L/System PASSED The inspection which I have conducted has- not found any information which indicates that the system fails to adequately protect public health or the environment as defined in 310 CMR 15 . 303 . Any failure , criteria not evaluated are as stated in the FAILURE CRITERIA section of this form. System FAILED* The inspection which I have conducted has found that the system fails to protect �rhe public health and the environment in 'accordance with Title 5 , 310 CMR 15 . 303 , and as specifically noted on PART C - FAILURE CRITERIA of this inspection form. Inspector Signature Date 7 io 95 One copy of this certification must be provided to the OWNER, the BUYER (where applicable ) and the BOARD OF HEALTH. * If the inspection FAILED, the owner or operator shall upgrade the system within one year of the date of the inspection, unless allowed or required otherwise as provided in 310 CMR 15 . 305 . partd.doc TOWN OF BARNSTABLE LOCATION 77 LAlt.z-�C SEWAGE # ��_&67� VILLAGE ASSESSOR'S MAP & LOT ! o' �l [vr 2 INSTALLER'S NAME&PHONE NO. C.9Rt Tvy /i'�,�oiZ•�/rs y77- �,�3� SEPTIC TANK CAPACITY /:S� C�t LEACHING FACILITY: (type) (size) NO. OF BEDROOMS 3 BUILDER OR OWNER f�F�i T f G lcv2� —�STAT� PERMITDATE: /afia Te COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted,Groundwater Table and Bottom of Leaching Facility S,G 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 facilili Feet Furnished by 6A 7//0 If, � � �� s,�- 4 \� a „ Mems- rVu THE COMMONWEALTH OF MASSACHUSETTS �_7 BOARD OF HEALTH /_2 s� L.V�fi(/1 ...................OF..... ............... Appliration for Dhoprioat Works Triastrurti n rrrmit Application is hereby made for a Permit to Construct (� or Repair ( ) an Individual Sewage Disposal System at: ?�...7......006.W-0p.0....L#4Qct._....... --------------- -•----....----------------...............: Location- ess or Lot No. ......--- �..:.............. 4, a� ............... ----------------------- -----•-•...............................•.......•. n Address ....... w.� -�-P_YY .-------•.. .................................................................................................. I Installer Address Dwelling Building of Bedrooms..............J..........................Expansion Attic ( ) Garbage Grin Grinder fee Type of Buildin I Size Lot. ....._... Showers Garbage Grinder ( ) p, 'Other—Type Type of Building ............................ No. of persons.•...•...........•. ( ) — Cafeteria ( ) W Other fixtures .................................. W Design Flow.............S..5......................gallons per person per day. Total daily flow__.........4_-- .....................gallons. WSeptic Tank—Liquid,ca.pacity/J`00.gallons Length./-f-70.... Width&.�.-... Diameter................. xDisposal, Trench—No..................... Width F..._..4............ Total Length...........-...... Total leaching area....................sq. ft: Seepage Pit No..___._._f .._.. . Diameter./Z.0....... Depth below inlet.&..-10....... Total leaching area.6 26....:..ff Z Other Distribution box ( ) Dosing t ,� �/ R LD, '-' Percolation Test Results Performed by....... A ke .._�.fV..�. ....... Date........ a Test Pit No. 1.. ........minutes per inch Depth of Test Pit.....1!44._..... Depth to ground water........................ G4 Test Pit No. 2...............minutes per inch Depth of Test Pit.................... Depth to ground water........................ R+' y a D � � . Z _/� ....G. & :.O p x Q._.. . w UNature of Repairs or Alterations—Answer when applicable............................•..._.............................................................. ..-----••-•---------•---••-•---•........................•--•-•------•-------•------............................-----------------...----....------------••--------.....................................•. Agreement: The undersigned: agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. . _T—.......... .Signed..... Yt . - - _ ......JA pationApproved�13y . ate Application Disapproved for the following asons:.............................:...........•------•--•--•-•••---•-------------------•----.................-••----- ..................•-------••-------..._......---............................•-•---....---...........••-•---•------------•-•-•-••-•-••-•......--•-----•-•-........................••---••---•-....------. Permit No......1:............ C .--...._..�..... ...__ Issued.. Date Date ► �- 1. r Fic ".....1.. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .....TNT/._.................OF..... L /, . ,I� T.A..t .�F....---••.................••--- Applirtttion for Dispnottl Works Cnnm #rnrtiun Vrruli# Application is hereby made for a Permit to Construct ( Y) or Repair ( ) an Individual Sewage Disposal System at: __ Location• dres or Lot No. .._....!_ �—�_ E,.L T-- _-:�1 '-_ ° ............... ..................................................••----•------......_.......----.......---••--- ....- wne Address Installer Address Type of Building Size Lot_. ,_��a_ q. feed U Dwelling—No. of Bedrooms............... ....._...___.. _Expansion Attic ( ) Garbage Grinder ( 04 Other—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( ) a Other fixtures ____________________________ Design Flow.............J`�..__.__.................gallons per person per day. Total daily flow............4_96.....................gallons. Septic Tank—Liquid*capacityJ5Q0_gallons Length.11`0__._ Width�,.`-6. :_ Diameter________________ Deptht .J'...- Disposal Trench—No_____________________ Width.................... Total Length_..__.____.._..................... Total leaching area....................sq. ft. �- Seepage Pit No.........1...... Diameter.lt?.=,!_'__...__ Depth below inlet/a___,...... Total leaching area. Zt 5__.._sg.,,,fL Z Other Distribution box O Dosing tank 4 ;s �. �. Percolation Test Results Performed b ..__..__ ?-x �E iV l �� aY r :--•....:.................... Date--••---•�' -__._.._.. a w Test Pit No. 1.. `2_.__:_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........................ --... t O Description of Soil..: l_ t !��_.. tUILlf -�� / ( a..............• .............................................................. -•-•••-•--- -- ------- -.._.. V Nature of Repairs or Alterations—Answer when applicable...........................................................:................................... ••-•----•-•.................:.......•..:....._...._...---....._.._._.._..._.........--•••--•-----...-----•----••••-•••---•--•-••--•--••----•._...._..--•••-•-•-••------•--••-••••-••--•.._._._......:._. Agreement: " The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. A Signed........ ._.... ...........................••••-••-•--..._._.. - Pv_ A lication Approved BY............ ............... . ---•-_-••- .. Date Application Disapproved for the following �asons............... ... ::.._:...._.:...... :.:.. --••••••-•••-•-•....•••.......-•-••••.:...._..--•-•-••--••---•••••••••....••••....................••-•••-•••--•-•---------••--•------_._._._.......•-•-•---•--••••-•--•.....-•-_....-.---•-••--______--- Date ' PermitNo....:.... ....... ..) Issued........................................................ Date , THE COMMONWEALTH,OF MASSACHUSETTS BOARD OF HEALTH ' 1K)I OF........` 5 ... ................... . _....................._.............. C9rdifiratr of Tnmplitturr THIS IS TO C KTIFY, Th t the Individual Sewage Disposal System constructed or Repaired ( ) by...............(I��� �.•••••••.�%� �/L •-•••----•••••••--•--•... .................••••••••••-••--•--••-••••••---- U7 Installer at. )........... rieprovisions ................._._....__-. "._�..•--••--•___--•__....__..._.....•-•--•-.._.._...__......_••-••--•---•-- has been,installed in accordance with of T .TIE 5 0 The State Sanitary o _ escribed in the application for Disposal Works Construction Permit No.. 'p_ ___ __________________. dated....... ___ .................... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FU CTI N SATISFACTORY. - (5- DATE.............................�1....................___.........__._-•-•----•••-• Inspector....:......C�-....---•-•--..._..............__...._......_____............_ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH PP - S .........`S .:..........OF.. �1S 1� tL................. P No.-_6............... FEE........ .......... 11tov lial nr inn rnr#' rrnti# Permission Is hereby granted........... !.._. .......•-•................. •-•••••- ....-•-••-•-••-....................................._---_-___ to Construct V), or Repair ,(� ) an Individual Se gag Disposal System at No..___....Ld-.,: ....2•••.._....1: `(. ZjU1�..... C C�i_7J ? r Street _ -- as shown o7thlication for Disposal Works Construction rmit No. � '� �ated..........�. -__�.`.. . ...... ......... 4. . _.___ _:�r...................................- 'Z t9 h Board of Health DATE........ ..._... FORM 12$5 HOBBS a WARREN. INC., PUBLISHERS ,yam i 46 3Ytj 1 �- Z.o r . 41x_ ? 14 a' . 1x� qz 461 3 ; 31)e A, s f K-Poo. AL s 5 '♦ ' 4 ZZz. Ot 1 '• r/° 711 ��� ��• 01,�' Q,�X3. � IZr; s �eo--MEMENT 'e CAR. Ior 7 l f _ 44 z t 44 7. a DER 00 40 I-OT 6 r 1-07' 9 x`y i R C APPL/CA/V T : 0Z. : RWOPQSEl;p DG ln-L IA16 L orA 7 laAl ®k�G�C1.SE0 .Srk..IA 6 c .s Y- T�'Ad L oeA rl o,4j * or poc? MVO" Op Z A/F".. J. JACOd . y C O T U I T MA.53. SCAL E: ! = 4 0 OA rE: 9 181& AC.QWIA16 NA. :sT ���Q�Q DR,4WAI9Y CAIRIC&ED RY cJD N©. 40466 ALL CAPE -32I 2 VEY i OA1-5Z.1L TA1VT CH 72 E4.3 r )CAL M 0 L T-/ I N/«QUA Y .. ; EA5 7 oALMOZ1 T1-1, IM4.