HomeMy WebLinkAbout0590 MAIN STREET (COTUIT) - Health 590 MAIN STREET, COTUIT
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
,. 590 Main Street
Property Address
Ted Harrington
Owner Owner's Name
information is required for every Cotuit MA .02635 04/04/11
page. Cityrrown State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When filling out forms A. General Information
4, 6k
onthe computer, 1n,
use only the tab 1. Inspector: v
key to move your
cursor-do not Michael Kellett .
use the return Name of Inspector
key.
40---h Aardvark Environmental Inspections
Company Name
P.O. Box 896
Company Address
East Dennis MA 02641
Citylrown State Zip Code
508-385-7608 S13742
Telephone Number. License 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. I am a DEP approved system inspector pursuant to Section 16.340 of
Title 5(310 CMR 15.000).The system:
® Passes ❑ Conditionally Passes ❑ Fails,
❑ Needs Further Evaluation by the Local Approving Authority
_A
04/06/11 - .
Inspector's Signature Date
r�
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.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
590 Main Street
Property Address
Ted Harrington
Owner Owner's Name
information is required for every Cotuit MA 02635 04/04/11
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes: °
t ® 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:
❑ 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.
Check the box for"yes", "no"or"not determined" (Y, N, ND)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.
❑ Y ❑ N ❑ ND (Explain below):
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
590 Main Street
Property Address
Ted Harrington
Owner Owner's Name
information is required for every Cotuit MA 02635 04/04/11
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes (cont.): .
❑ 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 ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ 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 ❑ Y ❑ N ❑ ND (Explain below):
obstruction is removed '❑ Y ❑ N ❑ 'ND (Explain below):
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
Commonwealth of Massachusetts
NEW
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
590 Main Street
Property Address
Ted Harrington
Owner Owners Name
information is required for every Cotuit MA 02635 04/04/11
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
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 than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be
attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes"or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ Z 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 '/2 day flow
L
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
590 Main Street
Property Address
Ted Harrington
Owner Owners Name
information is required for every Cotuit MA 02635 04/04/11
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® 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 water elevation.
❑ Z 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 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® 'Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [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.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
1 0,000g pd.
❑ ® 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.
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.
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
590 Main Street
Property Address
Ted Harrington
Owner Owners Name
information is required for every Cotuit MA- 02635 04/04/11
page. Cityfrown State Zip Code Date of Inspection
C. Checklist
Check 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
❑ ® 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?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding 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?
® ❑ 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:
® ❑ Existing information. For example, a plan at the Board of Health.
® ❑ 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)]
D. System Information
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
Commonwealth of Massachusetts
Title 5 Official Inspection Form-
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
590 Main Street
Property Address
Ted Harrington
Owner Owner's Name
information is required for every Cotuit MA 02635 04/04/11
page. Cityrrown State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 1
Does residence have a garbage grinder? El Yes ® No
Is laundry on a separate sewage system?{if yes separate inspection required) ❑ Yes ® No
Laundry system inspected? Yes No
Seasonaluse? ® Yes ❑ No
Water meter readings, if available(last 2 years usage(gpd)):
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: current
Date
Commercial/industrial Flow Conditions:
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 holdingtank resent?, Yes No
P ❑ ❑
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter.readings, if available:
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
590 Main Street
Property Address
Ted Harrington
Owner Owner's Name
information is required for every Cotuit MA 02635 04/04/11
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information:
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
F ,
® 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)and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
590 Main Street
Property Address
Ted Harrington
Owner Owner's Name
information is required for every Cotuit MA 02635 04/04/11
page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components', date installed (if known)and source of information:
16 years
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 1.8
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: 4.0
feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑polyethylene ❑ 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:
1000 gal
-
Sludge depth: 3„
t .
Commonwealth of Massachusetts
,p Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
590 Main Street
Property Address
Ted Harrington
Owner Owner's Name
information is required for every Cotuit MA 02635 04/04/11
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle
2911
I
Scum thickness 3„
Distance from top of scum to top of outlet tee or baffle 611
Distance from bottom of scum to bottom of outlet tee or baffle
16"
How were dimensions determined? measured
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
The tank was sound and tight with tees in place and liquid at outlet invert.
Grease Trap(locate on site plan):
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
I .
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: date
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
590 Main Street
Property Address
Ted Harrington
Owner Owner's Name
information is required for every Cotuit MA 02635 04104M 1
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
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):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
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 copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
Commonwealth of Massachusetts ,
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
590 Main Street
Property Address
Ted Harrington
Owner Owner's Name
information is required for every Cotuit MA 02635 04/04/11
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert Even
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.):
The box was level and tight with no sign of carryover.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): r
Soil Absorption System (SAS) (locate on site plan, excavation not required):
f
b
If SAS not located, explain why:
r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
590 Main Street
Property Address
Ted Harrington
Owner Owner's Name
information is required for every Cotuit MA 02635 04/04/11
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type. I
® leaching pits number: 1
❑ 'leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length-,
El -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.):
This system has 6'x6' precast pit surrounded by two feet of stone. There was two feet of liquid with no
sign of ponding or failure.
5
Cesspools (cesspool must be pumped as part of inspection) (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 ❑ Yes ❑ No
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
590 Main Street
Property Address
Ted Harrington
Owner Owner's Name
information is required for every Cotuit MA 02635 04/04/11
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
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.):
Commonwealth of Massachusetts
Tale 5 Off Inspection ection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
590 Main Street
Property Address I
Ted Harrington f
Owner Owner's Name
information is Cotuit MA 02635 04/04/11
required for every
page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or.benchmarks. Locate all wells within 100 feet.j Locate
where public water supply enters the building. Check one of the boxes below:
s
® hand-sketch in the area below 1
❑ drawing attached separately f
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
590 Main Street
Property Address
Ted Harrington
Owner Owner's Name
information is Cotuit MA 02635 04/04/11
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope rt
❑ Surface water
® Check cellar
❑ Shallow wells
Estimated depth to high ground water: 20.0feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked,date ofdesign plan reviewed: pate
❑ 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)
® AC ssed USGS database-explain:
You must describe how you established the high ground water elevation:
USGS maps show an elevation of over 20.0 feet.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
Commonwealth of Massachusetts
Title 5 Official Inspection- Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
590 Main Street
Property Address
Ted Harrington
Owner Owner's Name
information is required for every Cotuit MA 02635 04/04/11
page. Cityfrown State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed
® System Information—Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
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BORTOLOTTI CONSTRUCTION, INC. `
a Yt 765 WAKEBY ROAD,MARSTONS MILLS, MA,v02G48
508-7714399 ,N508-428-8926- -FAX: 508-428-9399`
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION'FO'RM �r�� `9d
PART A °� e
CERTIFICATION .
Property Address: d _
Date of Inspection: Inspecto ' Name:
Qmmcr's Name and Address:
CERTIFICATION STATEMENT!.,
I certify that I have personally inspected the sewage disposal system at this address and that the informa-
tion reported below is true,accurate and complete as of the time of inspection.The inspection was per-
formed based on my training and experience in the proper function and maintenance of on-site sewage
disposal sy tems. The System:
Passes
Conditionally Passes .
Needs Further Ev 1 tion 13 li ocal Aproviiig Authority
Fails
Inspector's Signature: `Date
m Inspector shall submit acco of this ins ect�on re rt to the Approving authority within thir-
The System pee copy p po
Y
ty(30)days of completing this inspection. If the system is a shared system or has a design flow of 10,000
gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional
office of the Department of Environmental Protection. The original should be%sent to the system owner
and copies sent to the buyer,if applicable and the approving authority.
INSPECTION SLI MARY:
A)SYSTVI PASSES:
�// I have not found,any information which indicates that the system violates any of the failure
criteria as defered in 310 CMR 15.303. Any.failure criteria not evaluated are indicated
below.
B)SYSTEM CONDITIONALLY PASSES;
One or more system components need to be replaced or repaired. The system,upon comple-
tion of the replacement or repair,passes inspection.
Indicate yes,'nor,or not determined(Y,N,OR ND). Describe basis of determination in all instances. If
"not determined",explain why not.
The septic tank is metal,cracked,structurally unsound,shows substantial infiltration or
exfiltration,or tank failure is imminent. The system will pass inspection if the existing sep-
tic tank is replaced with a conforming septic tank as approved by The Board of Health.
Sewage backkup or breakout or high static water level observed in the distribution box is due
to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. The
system will pass inspection if(with approval of The Board of Health): ;
- 1 -
SUBSURFACE SEWAGE DISPOSAL SYSTEM.INSPECTION FORM
PART A _
CERTIFICATION (continued)
Broken pipe(s)replaced
Obstruction is removed
Distribution Box is levelled or replaced
The System required pumping more than four times a year due to broken or obstructed pipe(s).
The system will pass inspection if(with approval of The Board of Health):
Broken pipe(s)are replaced
Obstruction is removed
C)FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
Conditions exist which require further evaluation by The Board of Health in order to determine if
the system is failing to protect the public health, safety and the environment. x
1)SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE
SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE
PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
Cesspool or privy is within 50 Feet of a surface water
Cesspool or privy is within 50 Feet of a bordering vegetated wetland or a salt marsh.
2)SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER
SUPPLIER,IF APPROPRIATE)DETERMINES THAT THE SYSTEM IS FUNCTION-
ING IN A MANNER THAT PROTECT THE PUBLIC IIEALTH AND SAFETY AND;THE
ENVIRONMENT:
The system has a septic'tank and soil absorption systerwand•is within 100 Feet to a surface
water supply or tributary to'a surface water supply;
The system has a septic tank and soil absorption system and is with'a Zone I of a public
water supply well. "
The system has a septic tank and soil absorption system and is within 50 Feet of a private
water supply well. '
The system has a septic tank and soil absorption system and is less than 100 Feet but 50
Feet or more from a private water supply well,unless a well water analysis for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from
the facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less
than 5 ppm.
D)SYSTEM FAILS:
I have determined that the system violates one or more of the following failure griteria as defined
in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health
should be contacted to determine what will be necessary to correct the failure.
Backup of sewage into facility or system component due to an overloaded or clogged SAS
or cesspool.
Discharge or ponding of efluent to the surface of the ground or surface waters due to an
overloaded or clogged SAS or cesspool.
Static liquid level in the disiributiori boz above outlet frivert due'to an,overloaded or.clog-
ged SAS or cesspool. ?
Liquid depth in cesspool is less thaii'ti" below invert or available volume is less than 1/2
day now:
Required pumping more than 4 times iri the last year'h )Z due to clogged or obstructed
pipe(s). Number of times pumped
-2- ,
SUBSURFACE SEWAGE'DISPOSAL SYSTEM;INSPECTION FORM
1: PART A
CERTIFICATION (continued)
Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater
elevation.
Any portion of a cesspool or privy is within 100 Feet of a surface water supply or tributary to
a surface water supply.
Any portion of a cesspool or privy is within a Zone I of a public well.
Any portion of a cesspool or privy is within 50 Feet of a private water supply well. !
Any portion of a cesspool or privy is less than 100 Feet.but greater than 50 Feet from a private _^ a
water supply well with no acceptable water quality analysis. If the well has been analyzed
to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic
compounds,ammonia nitrogen and nitrate nitrogen.
-E)LARGE SYSTEM FAILS:
The following criteria apply to a large system in addition to the criteria above:
The design now of a system is 10,000 gpd or greater(Large System)and the system is a significant
threat to public health and safety and the environment because one or more of the following
conditions exist:
The system is within 400:Feet of,a surface,drinking water supply �.
x ' - The:system is,within 200 Feetof a tributary to a tsurface drinking water supply
The system is located in a nitrogen sensitive area Interim Wellhead Protection Area,
(IWPA):or a mapped Zone 11 of a,public water supply well
The owner or operator of any such system.shall bring,the system and`facility into fill compliance with the
groundwater treatment program requirementi of.314'CMR 5:00 andd6.00.' Please consult the local
VE
regional office of the Department for further information.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
a
Check if the following have been done:
✓Pumping information was requested of the owner,occupant,and'Board of Health.
None of the system components have been pumped for atleast two weeks and the system has
been receiving normal flow rates during that period. Large volumes of water have not been
introduced into the system recently or as part of this inspection.
✓As-built plans have been obtained and examined. Note if they are not available with N/A.
�w-"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,excluding the Soil Absorption System, have been located on site.
_ The septic tank mariholes were uncovered,opened,and the interior of the septic tank was in-
c 5 ;; _ ,spected.for.condition of baffles,depth
construction,dimensions,depth of liquid,
depth of sludge,depth of scum.
. ,. The size and location of the SoiLAbsorpti s been etermined based on
on System on the site ha d
existing information or approximated by non-intrusive methods.
°a " . -3-
i
SUBSURFACE SEWAGE DISPOSAL SYSTEM;IN FORM ,
E PART B
.CHECKLIST(continued)
V The facility owner(and occupants, if different from owner)were provided with information on
the proper maintenance of Subsurface Disposal System
i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
FLOW CONDITIONS
' ' ✓ Y,
Design Flow v allons Number of Bedrooms: Number of Current Residents:
Garbage Grinder: Laundry Connected'1•o System: Seasonal Use:
Water Meter Readin s, if ailable:
Last Date of Occupancy:
CO MERCLAIJINDIJSTRi_AI,:• /l,c)
Type of Establishment: y
Design Flow: Qailons/day Grease Trap Present:(yes or no)
Industrial Waste Holding Tank Present:
Non-Sanitary Waste Discharged To The Title V System:
Water Meter Readings,If Available: Last Date of Occupancy:
OTHER: Describe)
Last Date of Occupancy:
GENERAL INFORMATION
9�
PUMPING RECORDS and source of infonna.on:
System Pumped as part of inspection: PU If yes,volume pumped: gallons
Reason for pumping:
TYPE SYSTEM:
Septic Tank/Distribution Box/Soil Absorption System
Single Cesspool
Overflow Cesspool
Privy
Shared System(If yes,attach previous inspection records,if any)
Other(explain):
AP RO TE AGE of all components,date installed if known)and so ce'of i ormation:°
_... - — ,
- Sewage odor detected w6en'arriving'at the site: /t,
1
-'; SUBSURFACE SEWAGE DISPOSAL'SYS'I'EM•INSPECTION FORM
PART C
GENERAL INFORMATION (continued)`
SEPTIC TANK: ✓
Depth below grade: Material of Construction: concrete metal FRP_Other
(explain)
Dimisions: 'X Sludge Depth: 72 Scum Thickness:
Distance from top of sludge to bottom of outlet tee or baffle: 3/
Distance from bottom of scum to bottom of outlet tee or baffle: d '
Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid
1 el in Mationto tlet invert, structural integrity,evi ence of leakage,qtc.)�� 149 /
-
GREASE TRAP:_
Depth Below Grade: Material of Construction:_concrete metal_FRP—
Other
(explain) —
Dimensions: Scum Thickness:
Distance from top of scum to top of outlet tee or baffle:
_ Comments: (recommendation for pumping,condition of inlet and outlet tees or bafBes,depthtof liquid
level in relation to outlet mverl,structural integrity,e �dence:of leakage,^etc.) e=
TIGHT OR HOLDING TANK:
Depth Below Grade: Material of Construction: concrete metal FRP_Other(explain)
Dimensions: Capacity: gallons Design Flow: gallonstday
Alarm Level:
Comments: (condition of inlet tee,condition of alarm and float switches,etc.)
DISTRIBUTION BOX: Ll -
Depth of liquid level above outlet invert:
Comments: (note if l el and distribution i�a uaI evidence of solids carryover,evidence of eakage into
or out of box,etc.) t �1 gB �X ,/lr � tf/2r�Pirt�
ZZ A
zz%-F ..
PUMP--CHAMBER— L�
Pump ii to worldng order: 4
+ Comments (note conditwn of pump chambei condition oC punips an :appurtenancesw
o
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
SOIL ABSORPTION SYSTEM(SAS):
(Locate on site plan, if possible;excavation not required,but may be approximated by non-intrusive
methods) If not determined to be present,explain:
Type:
Leaching pits, number: Leaching chambers, number: Leaching galleries,number:
Leaching trenches,number,length:
Leaching fields, number,dimensions:
Overflow cesspool, number:
Comme ts: (note condition of soil,signs of hydra failur eve l of po ing,condition of vegetation,
etc) /000
/j
CESSPOOLS:
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 soilk, signs of hydraulic failure, level of ponding~condition of vegetation,
etc.)
PRIVY:_
Materials of construction: Dimensions:
Depth of Solids:
Comments: (note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,
etc.)
-6 -
. . , ;1 SUBSURFACE,SEWAGF.UISPQSAL SYS'I EM INSPECTION FORM
:a. aap ; Twy4('ti -Ailx Mgr c fa
I'A I'C
SYSTEM,INFOItM,ATION (conlinncd)
SKETCH OF SEWAGE DISPOSAL SYSTEM:
Include ties to adeast two permanent references, landmarks or benchmarks.
Locate all wells within 100 Feet.
^--•,� ~•- Ya ".i• .�I�:r Lf1. S1,iStii/. 'P �� C:� t c„fS• s .t„' w -
w
DEPTH TO GROUNDWATER: I
Depth to groundwater: 3 Feet
Methodd' of Determination or A pprom nation: /�l i <I T/4�1 �' 5. d� ✓
- 7-
i
TOWN OF BARNSTABLE
LOCATION 1�Q&12 � �� SEWAGE
VILLAGE ASSESSOR'S MAP & LOTg
INSTALLER'S NAME & PHONE NO�('p /(>
SEPTIC TANK CAPACITY_Ze&V
LEACHING FACILITY:(type) gL Cr% (size) 'x,,&
NO. OF BEDROOMS PRIVATE WELL R PUBLIC WATER
BUILDER O OWNERR? eC��
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes - No
r � r
r ? ,
h
� p
4 n
A
A
� �
r
No. .... . _..._ FEB................. ..
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
TOWN OF BARNSTABLE
Apphratiuu for Diupuutti Work.6 Towitrurtion Prrmit
Application is hereby made for a Permit to Construct ( ) or Repair (54 an Individual Sewage Disposal
System at:
a.........................................' .................................... .....................;z�-�- .....................................--=
o lion-:\ddass or Lot No
��,�_�A/ �_ O •ncr
W C�� U 9/ C�/i��� �/1^tWV ��a �// dress
.. _._..-•-••-•. •-.---••-----•--•-•--•-•-•-•-•----•---•--••--•-------••-----• .................. j..----- _. . .............................
a Installer _�__
� Address
Type of Building Size Lot............................Sq. feet
Dwelling— No. of Bedrooms----------------—---___-_______-__-__Expansion Attic ( ) Garbage Grinder_(_--}-ftJC)
aOther—Type of Building ____________________________ No. of persons---------------------.------ Showers ( ) — Cafeteria ( )
Q' Other fixtures _____--------------------_---------------
W Design Flow.............. ---------------gallons per person per day. Total daily flow............ V..................gallons.
WSeptic Tank—Liquid capacity,/QUO__gallons Length---------------- Width................ Diameter------.......... Depth................
x Disposal Trench— No_ ____________________ Width______-_--_-______ Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No............ _.. Diameter--------lU..... 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_-____-__________..__-_.
fi, Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water........................
a -•--•-•--••-----------------••----•••••-••-••-••--•--•-•-•-•---••---•-••--------•-•---•---•-._...•--.........................................................
Descriptionof Soil........................................................................................................................................................................
x
V .; e --------------/s. /r
-- ---/-------
�_
U Nature of Repairs or Alterations—Answer when applicable._-_ .A/S_J__ '!'�--_. -.....
�$�J�7�
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Compliance s been issu b e board of health.
Signed ..
� �
-_. .......`-"''...`�......� ....... ...... � ----
- .�
Application,Approve
y .... :.. .,
Dare
Application Disapproved for the following rear on - ----- ------------------------- ---------- ----------------- ----------------------....................................
.............................._.............._.......... .. ..........._.................. ... ................................-------- ----------------------------------- -------------- --------------
Date
Permit No. .....���.. .... ��..................... Issued " e 'e-
Dace�
• a
v
No..l..... ............ �................
yf
... - THE COMMONWEALTH OF MASSACHUSETTS
- BOARD- OF HEALTH
TOWN OF BARNSTABLE
Apphrat" it f or Dir oml 19nr1w Towitrnrtinn rnmit
Application is hereby made for a Permit to Construct ( ) or Repair (x) an Individual Sewage Disposal
System at:
O
I
��! Loc tion-Address or Lot No.
Owner A /{4 dress
a �o�� /! l L_t^j S"T/l�C.� <G� ��, ....... 1i.•_'` .� (sr L ..
.............. ............ --- •----
Installer Address
UType of Building Size Lot.................... Sq. feet
Dwelling— No. of Bedrooms-----------------7--__.--_-____.-..-..-Expansion Attic- ( ) Garbage Grinders-,*Jv
aOther—Type of Building ---------------------------- No. of persons---------------------------- Showers ( ) — Cafeteria
Other fixtures ------------------------- ----------------------------
Desi n Flow.............. .�_.............._.gallons per person per day. Total daily flow_.___---___ 3 V___.........._..._
W g g P P P Y• Y --- gallons.
WSeptic Tank—Liquid capacitv/4�4_-gallons Length---------------- Width.-____-_.-...._- Diameter._..-_.-.-__--- Depth................
x Disposal Trench—No. .................... Width---------------_.... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No----------- ... Diameter........ Depth below inlet..... .-r......... Total leaching area..................sq. ft.
Z Othir-NDistribution box ( ) Dosing tank ( )
~' Percolation Test Results Performed by............................................................................ Date........................................
a
Test Pit No. 1----------------minutes per inch Depth of Test Pit-_-___---_-_--...___ Depth to ground water........................
r14 Test Pit No. 2................minutes per inch Depth of Test Pit--------------------- Depth to ground water........................
a •-••---••••---•--------•...--•-----•--••••••---------------••--••--•----••---••-••--••.......................................................................
0 Description of Soil........................................................................................................................................................................
x
U --•--------------------•----.....---------------------------....--------------•--•-•••••............•--•- ... -----•-----• . •-------.
W ---- ------- �'� ,[ G��S�pGD/S L`''ll �e /l�o�',
x / ----- ••• ---- ------
U Nature of Repairs or Alterations—Answer when applicable.-_:Ct4LS_./._.A"�r 1¢-.....�UUU _.._ sf(J�4....
......
_..� 7�_*I.......r-'�1�.�r-�GGU .... _ :� SZ-J�
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Compliance hlas been issu • b e board of health.
Signed -------------- ............ --------,-- ------ ..................----- -�6 ---
Application.Approve y .
- ....- . .. ::. _..... - - ..... - ._... ............ -
Dare
Application Disapproved for the following reasons- --------------------_------------.._...-------- ---------------------------------------------------------------.......-----
_.................... - - .._...._...._.......... ...._.._..... .._
................ ..................
Dare
Permit No. 4,1
_/-------....---.. ... . y----------------- Issued ---- ..:..... j '" ..................
Dace
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Certifirate of (111ompiiance
THIS IS TO CERTI�,_That the Individual Sewage Disposal System constructed ( ) or Repaired
Y -- -
Inst:dler
at .----------------------------------__-------- 0 )AJ S i 7L c i- G C�j 7�t
t--------------------- ----- .._..._...----------------- ------ -----------..---------------------
has been installed in accordance with the provisions of TIT 5 0�The Stat E vironmental Code as d scribed in
the application for Disposal Works Construction Permit No �,T' �-..��..� ............ dated `. .. .
THE ISSUANCE F H CERTIFICATE HALL NOT BE CONSTRU D A A T E O THIS CERTI C S S GUARANTEE TH�
SYSTEM WILL FUNCTION SATISFACTORY.
DATE . �` ..� ... - Inspecto -ram r '
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
No..,%-1:✓...... FEE•--•-•---...--•---......
Ropno tt Workii Tnmitrurtinn rrntit
Permission is hereby granted-_-_---__-__-0�6VC; 7 �...... .. ................
to Construct ( ) or Repair ( xf an Individual Sewage^Disposal System
at No.
S ....................
ce
as shown on the application for Disposal Works Construction Per '�_��Dated____ ._._�__._ `�C�..._..
Board of Health
-ff...................................
DATE......�... {{{
FORM 36508 HOBBS 6 WARREN,INC..PUBLISHERS
�3 TOWN OF BARNSTABLE
I OCATION ��--qn 1/Ji SEWAGE #
`VE.LAGE ASSESSOR'S MAP & LOT 0,3(
SNS;P&r-702S NAME&PHONE NO. ',n o2
SEPTIC TANK CAPACITY /00o 0,1J�.c%�s�.(/.C.� x, , P
LEACHING FACILITY: �%�
(type) (size) /0 DPI
NO.OF BEDROO
BUILDER 0 OWNER'
PERMITDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
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