HomeMy WebLinkAbout0021 GUIMQUISSETT ROAD - Health �21 Gu:! uisse#t Road
Cotuit�P �
_ --- — - - LA = 019 058 .
ASSESSORS MAP NO: 01 7
Noll.-Ito -.. PARCEL NO: FEs...` ...............
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
....................... .....--.......O F..........................................................................................
Apli irFation for UhnVo i a1 Worko Towitrurtivat Frnnit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
i vv� �0. s
..... _...............A.... ............ 15 .
.._ anon Add or Lot No. •---
. ................................................. 1_ Y-�. `�� .--.._...._.._.. P
- Y............`wner.�.. ........... .. _�_ � �......�?C.t ss• 'l� •IlC4..S.�.:.. � `�.
Installer Address
Type of Building Size Lot............................Sq. feet
Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
Pa Other fixtures -------------------------------- -
W Design Flow..............................:.............gallons per person per day. Total daily flow............................................gallons.
f4 Septic Tank—Liquid capacity............gallons Length________________ Width................ Diameter---------------- Depth................
Disposal 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........----_----------------•---•----
Test Pit No. 1----------------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...................
--------- ----••---------•.............................•-•---•-------••-•...........................................................
Description of Soil..------••••• �
�
x
----------------- ---------------------------------------------------- -----------------------------------------------•--•-• ...............................- - -----
g -
V N, ure of Repairs or Alterations—Annsswer when applicable_ -�._ �,........I-D_S __'�__ �A_e- ------------------
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of'T'IE 5 of the State Sanit y C e—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance h s be issu by the boar of healj .
Signe . -----C ..` ---------•� Q!" —--------------- .................... .
Date
Application Approved By•-••••f Z �-- �...... -------•-•-•----------------------------
Date
Application Disapproved for the following reasons---------------------•-•----------------------•-•-------•---•-•-----------------------------------------......._
-------••-----------•------•------------••---•---------------------------------------•---••--•---•----•-----•---••---•••••-•••••-•••------•-•-•-•---------•-•-••--•---•••--•--•••----..................
Date
Permit No.,_. 7= �`° ........................... Issued---•------•-------
Date
or y
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
... . ..............OF.................................
, pphru#iou for %gpoii al Works Tnnitrurtiun Vrrutit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at: _
_ 0 cat on- Add r Lot No,
"�
a wrer ` 4J Address
O
9 _.:. `C~a ...... � + Y Cc
Installer Address
Type of Building Size Lot_________________• ........Sq. feet
U Dwelling No. of Bedrooms............................................Ex anion Attic
g— p ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
Otherfixtures ---------------------------------•-----------------...._...---------------------------------------•-.................................................
Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter---------------- Depth................
x Disposal Trench—NTo_ ____________________ 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........................................
a
Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water---__________•__•_-_-_-.
rs. Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
-- --------- _
DDescription of Soil -...........`` `*� =----•-•-•......... ....•----.........•-------------_....------•--.---------.--------•---------------
x
U
w _
U ure of rRepairs or Alterations.—Answer when applicable._ - _�_�._-......
�__(1S _4�._." ___ _ __________________
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of T LE 5 of the State Sani yD
de— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance s beSS by the board of hea h.
Signe _�:..-- .-----•-•-... ...#.V.L ------ -•-- ----•-------- •
Date
Application Approved By-------. - --------------------Da--..............
Application Disapproved for the following reasons----------------•-----------•----------------------------------•------------------------------------•-••-•-•-•---
---•----.......-•••-.....--••••---•-•.............••-•-----------••-•.....-•-----•--.......__-----....--••----•-----•--••-----•-•--•------------------•--•-----------•-----------------•------••-.._..--
Date
PermitNo--- .�_:... ? ' ............................ Issued-.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD
y� OF HEALTH -
LY( ..e!:1_...........OF......./.=r:rr::: r? rt*.k` "C.:......................................
C'rrtifiratr of
THIS IS TO��CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired
..............-----•--- ...........................................................
Installer . '
at {'1' -.. '1 't t.<s -----------------•=
has been installed in accordance with the provisions of T� L�, j of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No.... __ter'`ln_ ........... dated-----------------------___-.-_-__-_•_-_-------_
THE ISSUANCE OF THIS CERTIFICATE-SHALL NOT BE CONSTRUE® AS A dUARANTEE THAT YHE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE....................... r o ............................... Inspector Inspector---de------------- ---- .e V -----------•--•---
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
� ......•••G•`••' 't`'�-1...............O F...........!�.. ....rr.:�!...,, . ?::�''�
lYYO. ..�7._. ../ C� ............................... ;
'-
Disposal Works Tomitrwtion Vrrm
Permission is hereby granted--------car' ..........ff..P-?.-_��_
to Construct ( ) or Repair '(>4 an Individual Sewage Disposal System
Street
as shown on the application for Disposal Works Construction Permit Dated.......................................... ,
-c ll II 1 •
_______«
lth
DATE.................................................................................
Bo ar d of fI
FORM 1255 HOBBS & WARREN, INC., PUBLISHERS
TOWN OF BARNST LE
LOCATION"�1 U l S� SEW GE 497
cor
VII.I..AGE CZ� ASSESSOR'S MAP�&�LO
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY ,,0--\\®
LEACHING FACILITY: (type) LJU
NO.OF BEDROOMS
BUILDER OR OWNER
PERMITDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the 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
f
I� ��,►a . Alm
�� sy
B� 4®
�c 51
TOWN OF BAR STABLE
LOCATION �.tAl�� �01. - se 1'� �D. SEWAGE #
VILLAGE - ASSESSOR'S MAP & LOTn L aS
INSTALLER'S NAME & PHONE NO.
SEPTIC TANK CAPACITY 0 c)
LEACHING FACILITY:(type) lmr-eJk P, t (size)
NO. OF BEDROOMS 3A._PRIVATE WELL OR PUBLIC WATER
BUILDER OR OWNER
DATE PERMIT ISSUED:�n
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No
3®
COMMONWEALTH OF MASSACHUSETTS
' EXECUTIVE Q EICE OF ENVIRONMENTAL AFFAIRS
DEPARTMEN�OF90AW( N�MENTAL PROTECTION
T DEC 2 2 2003
TOWN OF BARNSTABLE
HEALTH DEPT.
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 2W (S'Q :ss
-Al,,`
Owner's I+tame: - id G MAP
Owners Address: ?I E4 d err!Wc,i
" 4 0,26<35` .. 0,500
- PARCEL
Date of Inspection: I=-1" 03 -� M
LOT
Name of Inspector:(please pelts_) <_h '10�11: "%?
Company Name: .41 ol.
Mailing Address: l : fWzi, W� ,
Telephone Number: � '-��i�
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is true,accurate and complete as of the time of the inspection The inspection was performed based on my
training and experience in the proper fimction and maintenance of on site sewage disposal systems.I am a DEP
approved system inspector pursuant to Section 15.340.of Title 5(310 CMR 15.000). The system:
Passes o r 1
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature:a `L Date- L2
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 I0,000
gpd or greater,the:inspector and the system owner shall submit the ivort 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.
,y
Notes and Comments:
This report only describes conditions at the time of inspection and under the conditions of use at that
time.t uis inspection dries not address how the system will perform in the future under the same or different
conditions of use.
Title.5 lnia e.inn Form All Vlffi I n�oa t
e
Page 2 of 11
OFFICIAL INSPEC14ON FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: -�/ &i r c' z4:�> fi,
Owner:
Date of inspection:
inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
have not found any'information which indicates that any of the failure criteria described itt 316 CMR
153 03 or in 310 CUR 15.304 exist Any failure criteria not evaluated are indicated below.
Comments:
B. System Conditionally Passes:
One or more system components as described in the"Conditional 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 statemertm.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 exfiitration 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.
N'D explain:
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 distfibution box.System will pass inspection if(with
approval of Board ofHealrh)_
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:
ry
Page 3 of 11
OFFICIAL INSPECTON FORM NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
'CERTIFICATION(continued)
Property Address:
Owner:
Date of Inspection: 1 Q.-6•-0_1
C. Further Evaluation is Required by the Board of Health: .
Conditions exist which require finther 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 Ci14R 15.303(1)(b)that the
system is not fuac inning in a manaei which wilt'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 inore from a
private water supply well**.Method used to determine distance i • - Y
f
_=i his 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. r
3. Other:
r .
Page 4 of i I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: -. l -. --A e,• 5,-�" l~d
Owner:
Date of inspection:
D. System Failure Criteria applicable to all systems:
You mu t indicate`yes"or"no"to each of the following for ail inspections:
Yes No i
ackup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
j/ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
esspuol
Riquid depth in cesspool is less than 6"below invert or available volume is less than'/z day flow
equired pumping more than 4 times in the Iast year NOT due to clogged or obstructed pipe(s).Number
f times pumped
Any portion of the SAS,cesspool or privy is below high ground water elevation.
! Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
Any portion of a cesspool or privy is within a Zone I of a public well_
t,-11,Xny portion of a cesspool or privy is within 50 feet of a private water supply well.
Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis.[This system passes if the well water analysis,
performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds
indieai,es ihat the well is free kom pollution from that faciiiiy and the presence of ammonia
Wix-open 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 aMched to this form.]
AL(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.
L 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 largersystems in addition to the criteria above)
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 Il 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 slwuld contact the appropriate regional office of the Department.
Page 5 of i 1
OFFICIAL INSPECTION FORM—NOT•FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
Property Address: --21
Owner:
Date of Inspection:
Cheek if the following have been done.You must indicate"yes"or"no"as to each of the following: .
Yes No
Pumping information was provided by the owner,occupant,or Board of Health r
•r:',;~
Were any of the system components pumped out in the previous two weeks?
Has the system received normal flows in the previous two week period? ,
Have large volumes of water been introduced to the system recently or as part of this inspection?
i.//Were as built plans of the system obtained and examined?(if they were not available note as NIA) ,
Was the facility or dwelling inspected for signs of sewage back up?
L/ _ Was the site inspected for signs of break out?
ti
_ Were all system components,excluding the SAS,located on site?+ -° t♦x,,, r • ,
'✓ 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? r"
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 f`
Existing information.For example,a plan at the Board of Health. - r
Determined in the field(if any of the failure criteria related to Put C is at issue approximation of distance
is unacceptable)[310 CMR 15.302(3)(b)j
Page 6 of 1 I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM LNTFORMATION
Property Address-
jr/ (.r}}1 �, s r �'�/
Owner:
Date of Inspection: 12--6 -_0 .;
PLOW CONDITIONS
-RESIIlENTIAL
Number of bedrooms(design): Number of bedrooms(actual):
DESIGN flow based on 310 Cv 15.203(for example: 110 gpd x#of bedrooms}:
Number of current residents.
Does residence have a garbage grinder(yes or no):
Is laundry on a separate sewage system Yes or no). [if yes separate inspection required]
Laundry system inspected(yes or no): /,;
Seasonal use:(yes or no): f,
Water meter readings,if available{last 2 years usage(gpd)):
Sump pump(yes or no):,/r,
Last date of occupancy: 12
COMMERCIAL(INDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): gpd
Basis of design flow(seats/persons/sgft'etc.):
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/use:
OTBER(describe):
GENERAL INFORMATION
Pumping Records �
Source of information: j�! : r F / G c•5 'q Q t:
Was system pumped as part of-the•inspection(yes or no):'/I)
If yes,volume pumped:/ gallons—How was quantity pumped determined?
Reason for pumping:
TY7E OF SYSTEM
J Septic tank,dis4%ufian-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�g age of ail components date installed(if known)and source of information:
yrt 1
. ��t .� � '��� �C'•La.$C' Yt'{rt� �y j"��rx .� �1 E'•-v'�.� r r1 /:��•
Were sewage odors detected when arriving at the site(yes or no): �`�
6
Page 7 of I 1
OFFICIAL INSPEC'H; ON FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: / &i._x'
Owner
Date of Inspection: l,2-tc -G 3
BUILDING SEWER(locate on site plan) ., i ?
Depth below grade:
Materials of construction:—cast iron k'• PVC_._other(explain): '
Distance from private water supply well or ruction Iine:
Comments(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK:✓(locate on site plan)
k
Depth below grade: ' `" r•=. ;*, ,
Material of construction:7zconcrete metal fiberglass_polyethylene
___.otber(explain)
If tank is metal list age:^ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of
certificate) r t
Dimensions:
Sludge depth:
Distance from•top of sI dge to bottom of outlet tee or baffle I '
Scum thickness: r r „ -, ,,i ;.; E ► , .� ;
Distance from top of scum to top of outlet tee or baffle: 16
- a
Distance from bottom of scum to botto of outlet tee or baffle: 16`r
How were dimensions determined: TY-&vC.I
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid Ievels
as related to outlet invert,evidence of leakage,etc.):
GREASE TRAP: (locate on site plan) +.a �., _
�,t fa
Depth below grade:
Material of construction:_concrete i—metal fiberglass polyethylene`otber
(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:
Cottunents(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc,):
Page 8 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 2j (IIj f)1v^12
Owner.
Date of Inspection:
TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:
Material of construction: concrete metal fiberglass---polyethylene other(explain):
Dimensions:
Capacity: QalIons
Design FIow: aallonsiday
Alarm present(yes or no):
Alarm level: Alarm in working order(yes or no):
Date of last pumping:
Comments(condition of alarm and float switches,etc.):
t
DISTRIBUTION BOX:1 (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert:
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.):'
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.).
Page 9 of I I
f
OFFICIAL INSPECTION FORM--NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C -
SYSTEM INFORMATION(continued).
Property Address: ,�21 Gk f-41 e f4 a 3!ie f A ,
Owner:
Date of Inspection: l
SOIL ABSORPTION SYSTEM(SAS}:_ (locate on site plan,excavation not required) _ Y
If SAS not located explain why:
Type
,teaching pits,number._ r,j
7 leaching c�l�s,number- o— cl A,
Ieaching galleries,number:-
leaching trenches,number,length:
_leaching fields,number,dimensions:
overflow cesspool,number.
_innovative/alternative system Type/name of technology w
Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,
etc.)-
'C/
CESSPOOLS: (cesspool must be pumped as part of inspection)(Iocate on site plan)
Number and configuration: Y
Depth—top of liquid to inlet invert:
Depth of solids layer.
Depth of scum layer
Dimensions of cesspool: t
Materials of construction: r
Indication of groundwater inflow(yes or no). --
Comments(note condition of soil,signs of hydraulic failure,4evel 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.):
Page 10 of I 1
OFFICIAL INSPECTIO
N FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM[INSPECTION FORMM
PART C
SYSTEM INFORMATION(continued)
Property Address: �R
Owner:_
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.
FrID A G
Page Ilofll
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: .ct; .�
Owner:
Date of Inspection:
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water_J feet
Please indicate(check)all methods used to determine the high ground water elevation:
brained ftvm system design plans on record-If checked,date of design plan reviewed:
=observed site(abutting property/observation hole within 150 feet of SAS)
--_.Checked with lo
cal Board of Health-explain:
O- Accessed
ecked with local excavators,installers-(attach documentation)
USGS database lain:
You must-descnie how you establis)ted the high groun water elevation: f
yt L'c•a T"�:- '�KLL✓r f ./
Title 5 Inspection Form 6/15/2000 11
............................
..... .. .....
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAI AFFAIRS John Grad
DEPARTMENT OF ENVIRONMENTAL PROTECTION DEP Title V Septic Inspector
ONE WINTER STREET BOSTON MA 02108(617)292-3500 P.O.Box 2119
TeaTicket,Ma.
(508)564-6813
TRUDY COXE
Secretary
ARGEO PAUL CELLUCCI DAVID B.STRUHS
Governor Commissioner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION c ,p
Property Address: 21 GUIMQUISSETT RD. COTUIT OS 5'<
r
Name of Owner MR.GIESSLER c
Address of Owner: 9-2 DRAKER CIRCLE WALPOLE MA.02081 t�i
Date of Inspection: 8/30/99 \\
Name of Inspector:(Please Print)JOHN GRACI
1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000) S�A r /pFD
Company Name: n/a to TO D
Mailing Address: n/a KNOP �9�q,9
Telephone Number: n/a ® fc�'09T
� tla
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate
and complete as of the time of inspection.The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems.The system:
X Passes The inpection is based on criteria defined In Title V
Conditionally Passes code 310 CMR 15.303.My findings are of how the system is
Needs Further Evouayon By the Local Approving Authority performing at the time of the Inspection.My inspection does
Fails not imply any warranty or guarantee of the longgevity of the
septic system and any of its components useful life.
Inspector's Signature: Date:912199
The System Inspector sh#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
THE SYSTEM PASSES TITLE V INSPECTION.RECOMMEND PUMPING EVERY TWO YEARS.RECOMMEND MOVING SPRINKLER LINE OVER
SEPTIC TANK COVER.
revised 9/2/98 Page 1 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 21 GUIMQUISSETT RD.COTUIT
Owner: MR.GIESSLER
Date of Inspection:8/30/99
INSPECTION SUMMARY: Check A, B, C, or D:
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:
System passes Title V inspection
B. SYSTEM CONDITIONALLY PASSES:
nta 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 ND).Describe basis of determination in all instances.If"not determined",explain why not.
nLa 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.
nta Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s)
or due to a broken,settled or uneven distribution box.The system will pass inspection if(with approval of the Board of Health).
_ broken pipe(s)are replaced
r _ obstruction is removed
distribution box is levelled or replaced .
Wa 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
t
revised 9/2/98 Page 2 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 21 GUIMQUISSETT RD.COTUIT
Owner: MR.GIESSLER `
Date of Inspection:8/30/99
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 nla_(approximation not valid).
3) OTHER
nLa
revised 9/2198 Page 3 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 21 GUIMQUISSETT RD.COTUIT
Owner: MR.GIESSLER
Date of Inspection:8/30/99
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
X Backup of sewage into facility or system component due to an 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 1/2 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 n1a.
X Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation.
X Any portion of a 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.If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic ompounds,
ammonia nitrogen and nitrate nitrogen.
X The liquid level in the SAS is over the invert-pipe,is in Hydraulic Failure.
E. LARGE SYSTEM FAILS:
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:
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
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)
The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.30412).Please consult the local regional office of the
Department for further information.
revised 9/2/98 Page 4 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 21 GUIMQUISSETT RD.COTUIT
Owner: MR.GIESSLER
Date of Inspection:8/30/99
Check if the following have been done:You must indicate either"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 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.
X As built plans have been obtained and examined.Note if they are not available with N/A,
X The facility or dwelling was inspected for signs of sewage back-up.
X The system does not receive non-sanitary or industrial waste flow.
X 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.The size and location of the Soil Absorption
System on the site has been determined based on:
X Existing information,For example,Plan at B4O,H,
X Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable)
[1 5.302(3)(b)]
X 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 Page 5 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 21 GUIMQUISSETT RD.COTUIT
Owner: MR.GIESSLER
Date of Inspection:8/30/99
FLOW CONDITIONS
RESIDENTIAL:
Design flow:-M g.p.d./bedroom
Number of bedrooms(design): 2 Number of bedrooms(actual):2
Total DESIGN flow: 221
Number of current residents:Q
Garbage grinder(yes or no):MQ
Laundry(separate system)(yes or no): NO If yes,separate inspection required
Laundry system inspected(yes or no):_LQ
Seasonal use(yes or no): YES
Water meter readings,if available(last two year's usage(gpd): n&
Sump Pump(yes or no): NQ
Last date of occupancy: nLa
COMMERCIAL/INDUSTRIAL
Type of establishment: n&
Design flow: n&gpd(Based on 15.203)
Basis of design flow: Wit
Grease trap present:(yes or no):M
Industrial Waste Holding Tank present:(yes or no): NQ
Non-sanitary waste discharged to the Title 5 system:(yes or no):NQ
Water meter readings.if available:Wit
Last date of occupancy: n&
OTHER: (Describe)
nta
Last date of occupancy: nLa
GENERAL INFORMATION
PUMPING RECORDS and source of information:
nLa
System pumped as part of inspection:(yes or no):NQ
If yes,volume pumped nLa_ gallons
Reason for pumping: nLa
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)
I/A Technology etc.Attach copy of up to date operation and maintenance contract
Tight Tank Copy of DEP Approval
Other: Wit
APPROXIMATE AGE of all components,date installed(if known)and source of information:
1986
Sewage odors detected when arriving at the site:(yes or no): NQ
revised 9/2198 Page 6 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 21 GUIMQUISSETT RD.COTUIT
Owner: MR.GIESSLER
Date of Inspection:8/30/99
BUILDING SEWER:
(Locate on site plan)
Depth below grade: '
Material of construction:_ cast iron X 40 PVC _ other(explain)
Distance from private water supply well or suction line: TOWN ,
Diameter: n1a
Comments: (condition of joints,venting,evidence of leakage,etc.)
nta
SEPTIC TANK: X T
(locate on site plan) r
Depth below grade: Z'&"
Material of construction:X concrete_ metal_ Fiberglass _ Polyethylene _ other(explain)
Wa
If tank is metal,list age Is age confirmed by Certificate of Compliance(Yes/No): NQ
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: 3E
Scum thickness: 11"
Distance from top of scum to top of outlet tee or baffle: § `"
Distance from bottom of scum to bottom of outlet tee or baffle: 17"
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 EVERY TWO YEARS
GREASE TRAP:
(locate on site plan)
Depth below grade:
Polyethylene other(explain)' I f constructi n. concrete metal Fiberglass Matena o o _ _ _ _ s ,
Wa
Dimensions: n(a
Scum thickness: nLa
Distance from top of scum to top of outlet tee or baffle:_n&
Distance from bottom of scum to bottom of outlet tee or baffle nLa
Date of last pumping: nla
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.)
itta
revised 9/2/98; Page 7 of 11 •-
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 21 GUIMQUISSETT RD.COTUIT
Owner: MR.GIESSLER
Date of Inspection:8/30/99
TIGHT OR HOLDING TANK: NO (Tank must be pumped prior to,or at time of,inspection)
(locate on site plan)
Depth below grade: n&
Material of construction:_ concrete_ metal_ Fiberglass _Polyethylene_ other(explain)
nLa
Dimensions: nLa
Capacity: nLa gallons
Design flow: nLa gallonsiday
Alarm present: MO
Alarm level: n/a Alarm in working order:Yes_No_: MO
Date of previous pumping: nLa
Comments:
(condition of inlet tee,condition of alarm and float switches,etc.)
nLa
DISTRIBUTION BOX: _
(locate on site plan)
Depth of liquid level above outlet invert:nLa
Comments:
(note if level and distribution is equal,evidence of solids carryover;evidence of leakage into or out of box,etc.)
nLa
PUMP CHAMBER: NQ
(locate on site plan)
Pumps in working order:(Yes or No): NQ
Alarms in working order(Yes or No):.MQ
Comments:
(note condition of pump chamber,condition of pumps and appurtenances.etc.)
nLa
revised 9/2/98 Page 8 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 21 GUIMQUISSETT RD.COTUIT
Owner: MR.GIESSLER
Date of Inspection:8/30/99
SOIL ABSORPTION SYSTEM(SAS): X
(locate on site plan,if possible;excavation not required,location may be approximated by non-intrusive methods)
If not located,explain:
nLa
Type:
leaching pits,number: nLa
leaching chambers,number: FLOW DIFFUSERS .
leaching galleries,number: _nLa
leaching trenches,number,length: nLa
leaching fields,number,dimensions: nLa
overflow cesspool,number: n(a
Alternative system: nLa
Name of Technology: -n&
Comments:
(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.)
THE FLOW DIFFUSERS ARE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY
CESSPOOLS: _
(locate on site plan)
Number and configuration: nLa
Depth-top of liquid to inlet invert: n/A
Depth of solids layer: n&
Depth of scum layer. nLa
Dimensions of cesspool: nLa
Materials of construction: nLa
Indication of groundwater: nta inflow(cesspool must be pumped as part of inspection)nLa
Comments:
(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.)
WA
PRIVY: _
(locate on site plan)
Materials of construction:nLa Dimensions:nta
Depth of solids: Wa
Comments:
(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.)
Wa
revised 9/2198. Page 9 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION continued)
Property Address: 21 GUIMQUISSETT RD.COTUIT �`� `�•
Owner: MR.GIESSLER
Date of Inspection:8/30199
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)
n/a
o � -
4C aj
6c 51
revised 9/2/98 Page 10 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 21 GUIMQUISSETT RD.COTUIT
Owner: MR.GIESSLER
Date of Inspection:8/30/99
NRCS Report name: nta
Soil Type: n&
Typical depth to groundwater: n&
USGS Date website visited: n&
Observation Wells checked: NQ
Groundwater depth:Shallow _ Moderate _ Deep _
SITE EXAM _ Slope
_ Surface water
_ Check Cellar
Shallow wells
Estimated Depth to Groundwater 10 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
X Used USGS Data
Describe how you established the High Groundwater Elevation.(Must be completed)
USGS MAPS AND CHARTS
revised 9/2/98 Page 11 of 11