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HomeMy WebLinkAbout0053 SANTUIT ROAD - Health 53 Santuit R d, Cotuit _ A = 021-087 p. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 53 Santuit Rd. Property Address Shane Conroy Owner Owner's Name information is required for Cotuit Ma 02635 2/3/2011 every page. City/Town 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: A. General Information When filling out forms on the / computer,use 1. Inspector: (o only the tab key I ; to move your Scott Campbell cursor-do not . Name of Inspector use the return key. Cardinal Company Name 32 Ridgetop Rd. Company Address Cotuit Ma 02635 �IIBO" City/Town State Zip Code 508-420-1295 S1388 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that theCD --� information reported below is true, accurate and complete as of the time of the inspection. The inspe tion 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 15340.of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails I❑ Needs Fu er Evaluation by the Local Approving Authority -a t 2/3/2011 Inspector's Sig,ROLUIC 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. t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Dis sal System•P ge 1 of 7 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 53 Santuit Rd. Property Address Shane Conroy Owner Owner's Name information is required for Cotuit Ma 02635 2/3/2011 every page. Cityrrown 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: ® 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): t5ins•11/10 Title 5 Official Inspection forth:Subsurface Sewage Disposal System-Page 2 of 17 1 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 53 Santuit Rd. Property Address Shane Conroy Owner Owner's Name information is required for Cotuit Ma 02635 2/3/2011 every page. City/Town 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 t5ins-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M , 53 Santuit Rd. Property Address Shane Conroy Owner Owner's Name information is required for Cotuit Ma 02635 2/3/2011 every 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 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 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 ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ❑ Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 6V•,y 53 Santuit Rd. Property Address Shane Conroy Owner Owner's Name information is required for Cotuit Ma 02635 2/3/2011 every page. Cityrrown 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. ❑ ® 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- 10,000gpd. ❑ ® 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. t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ° 53 Santuit Rd. Property Address Shane Conroy Owner Owner's blame information is required for Cotuit Ma 02635 2/3/2011 every page. Cityrrown 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 E❑ ® 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 t5ins•11/10 Title 5 Official Inspection Farm:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments , 53 Santuit Rd. Property Address Shane Conroy Owner Ownel's Name information is required for Cotuit Ma 02635 2/3/2011 every page. City/Town State Zip Code Date of Inspection D. System Information Description: 1000 gallon septic tank. distribution box, 1000 gallon leach pit. Number of current residents: 0 Does residence have a garbage grinder? ❑ 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 2009=12,000 Gallons. 2010=13,000 Gallons Sump pump? ❑ Yes ® No Last date of occupancy: 2010 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 holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: bins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M , 53 Santuit Rd. Property Address Shane Conroy Owner Owner's Name information is required for Cotuit Ma 02635 2/3/2011 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: 2010 Date Other(describe below): General Information Pumping Records: Source of information: unavailable Wassystem pumped as art of the inspection? Yes No Y P p P P ❑ If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ 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): t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 53 Santuit Rd. Property Address Shane Conroy Owner Owner's Name information is required for Cotuit Ma 02635 2/3/2011 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: 12/1/1982 Date compliance issued from barnstable board of health. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 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: 1 feet Material of construction: ®concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain) 1000 gallon septic tank. If tank is metal, list age: years Is age confirmed by a.Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: Sludge depth: t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M , ' 53 Santuit Rd. Property Address Shane Conroy Owner Owner's Name information is required for Cotuit Ma 02635 2/3/2011 every page. CitylFown 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 3' Scum thickness 0 Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? visual inspection, tape measure Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Inlet and outlet tees in place at time of inspection. Liquid level at proper working height at time of inspection. No evidence of leakage into or out of tank at time of inspection. 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 Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form Not for Voluntary Assessments 53 Santuit Rd. Property Address Shane Conroy Owner Owner's Name information is required for Cotuit Ma 02635 2/3/2011 every page. CityfTown 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 t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ti 53 Santuit Rd. Property Address Shane Conroy Owner Owner's Name information is required for Cotuit Ma 02635 2/3/2011 every 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 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.): H-10 D-Box level. Single pipe out of box to one single leach pit. No evidence of solids carryover, no evidence of leakage into or out of box. 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.): Soil Absorption System(SAS) (locate on site plan,excavation not required): If SAS not located, explain why: 1000 gallon leach pit with less than 6"of water in pit at time of inspection. t5ins.11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M yVey�< 53 Santuit Rd. Property Address Shane Conroy Owner Owner's Name information is required for Cotuit Ma 02635 2/3/2011 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system T e/name of technology: 9Y: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Dry soil, no signs of hydraulic failure, no ponding, normal vegetation. 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 t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 53 Santuit Rd. Property Address Shane Conroy Owner Owner's Name information is required for Cotuit Ma 02635 2/3/2011 every page. Citylrown 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.): t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 117 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 53 Santuit Rd. Ili Property Address Shane Conroy Owner Owner's Name information is required or Cotuit Ma 02635 2/3/2011 f every page. Cityrrown 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..Locate where public water supply enters,the building. Check one of the boxes below: hand-sketch in the area below ❑ drawing attached separately i dd 3Z (D ox 37 3r7 ` 35 °Y7 ' t5ins•11/10 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Tithe 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 53 Santuit Rd. Property Address Shane Conroy Owner Owner's Name information is required for Cotuit Ma 02635 2/3/2011 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site.Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: feeetet feet 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 ❑ 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: Excavation at time of inspection. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 53 Santuit Rd. Property Address Shane Conroy Owner Owner's Name information is required for Cotuit Ma 02635 2/3/2011 every page. City/Town 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 t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 e Commonwealth of Massachusetts Executive Office of Environmental Affairs` 12 1 Department of Environmental Protection . William F.Weld AUG Governor r� 23 1996W Trudy Coxe ki SeuNe,Y.ECEA Davld B. Struhs g Commissioner Ap % SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PIAP# C t- 1 PART A PAR# a V / CERTIFICATION g 1.� £ 8 © J2)AV1J Property Address: S. nl� .r�� Address of O U �e �o Owner: Date of Inspection: r} -91s (If different) Name of Inspector: T M£.3 I) SSAR-S Company Name, Address and Telephone Number: A & B Canco 350 Main Street West Yarmouth, MA 02673 (508) 775-2800 CERTIFICATION STATEMENT I certify that I have personally Inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The Inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system. _Passes Conditionally Passes Needs Further Evaluation B� the Local Appro\Ing Authority Falls Inspector's Signature: gaod" Date: The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (30) days of completing this inspection If the system Is a shared system or has a design fluty 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 lu tiu- System ov.net anti cup.c� x:,i h' tIIV b,,�c:, ii ahpi-c.,b:t aru ll„ aI)i:!U,inh INSPECTION SUMMARY: Check A. B. C. or D Al SYSTEM PASSES: le 1 have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. 61 SYSTEM CONDITIONALLY PASSES: One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair, passes inspection. Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If "not determined", explain why not) The septic tank is metal, cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 8/15/95) 1 One Winter Street • Boston,Massachusetts 02108 • FAX(617)556-1049 • Telephone(617)292-5500 A " Printed on R"Ied Psper f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Owner: Date of Inspection: B] SYSTEM CONDITIO ALLY PASSES (continued) _ Sewag backup or breakout or high static water level observed in the distribution box ' due to broken or obstructed pipe(s) r due to a broken, settled or uneven distribution box. The system will pass ' spection if(with approval of the Board o Health): broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced The system quired pumping more than four times a year due to broken r obstructed pipe(s). The system will pass inspection if vith approval of the Board of Health): broken pipe(s) are replaced obstruction is removed Cl FURTHER EVALUATION IS REQ RED BY THE BOARD OF HEALTH: Conditions exist which require urther evaluation by the Board of He th in order to determine if the system is failing to protect the public health, safety and the en ronment. 1) SYSTEM WILL PASS UNLESS BOA D OF HEALTH DETERMINE THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUB C HEALTH AND SAFETY ND THE ENVIRONMENT: Cesspool or privy is within feet of a surface wa r Cesspool or privy is within 5 feet of a borderin vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOAR OF HEALT (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MA 'NER TH PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The sr}tem hd> a septic tanK anU SUI d u1poull ))'5Irin 'And b withlll 103 fcci to a SUrfacE kater supply or tr'l5utary to a surface water supply., The ss-sten) has a septic tank and s0i a sorption system and is within a Zone I of a public water supply well. The system has a septic tank and s 1 a orption system and is within 50 feet of a private water supply well. The system has a septic tank and oil abs rption system and is less than 100 feet but 50 feet or more from a private water supply well, unless a well water nalysis r coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that f ility and th presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. D] SYSTEM FAILS: I have determined that the syste violates one or more o he following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identifi below. The Board of H Ith should be contacted to determine what will be necessary to correct the failure. Backup of sewage i to facility or system component a to an overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS of cesspool. (revised 8/15/95) 2 f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Owner: Date of Inspection: D] SYSTEM FAILS (continued): Static liquid'leve in the distribution box above outlet invert due to an overloaded or clogg SAS or cesspool. Liquid depth in cess ool is less than 6" below invert or available volume is less than 1/2 ay now. Required pumping mo than 4 times in the last year NOT due to clogged or obstru d pipe(s). Number of times pumpe Any portion of the Soil Abs ption System, cesspool or privy is below the high gr undwater elevation. Any portion of a cesspool or p ivy is within 100 feet of a surface water supply r tributary to a surface water supply. Any portion of a cesspool or pri is within a Zone I of a public well. Any portion of a cesspool or privy is within 50 feet of a private water su ly well. Any portion of a cesspool or privy is le than 100 feet but greater tha 50 feet from a private water supply well with no acceptable water quality analysis. If the ell has been analyzed to b acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compo ds, ammonia nitrogen a d nitrate nitrogen. E] LARGE SYSTEM FAILS: The following criteria apply to large systems in addition to the criteria ove. The design flow of system is 10,000 gpd or greater (large Sy tem) a the system is a significant threat to public health and safety and the environment because one or more of the following c diti ns exist. the system is within 400 feet of a surface drinking wat supply the system ins within 200 feet of a tributary to a surfa d nking water supply the system is located in a nitrogen sensitive area (1 terim Ilhead Protection Area 0WPA) or a mapped Zone II of a public water supply well) The owner or operator of any such system shall bring the system d facility into II compliance with the groundwater treatment program requirements of 31'4 CMR 5.00 and 6.00. Please consult the to regional office the Department for further information. (revised 8/15/95) 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: P Y Owner: Date of Inspection: Check if the following have been done: Y�umping 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 Vuring that period. large volumes of water have not been introduced into the system recently or as part of this inspection. s built tans have been obtained and examined. Note if theY are not available with N/A. P "'The facility or dwelling was inspected for signs of sewage back-up. JThe system does not receive non-sanitary or industrial waste flow The site was inspected for signs of breakout. Y�Al system components, 4xcluding the Soil Absorption System, have been located on the site. The septic tank manholes were uncovered opened, and the interior of the septic tank was inspected for condition f baffles r p p p p c o o ba es o tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. w The size and location of the Soil Absorption System on the site has been determined based on existing information or a proximated by non-intrusive methods. The iacrlrit u%\r.L: %d:.0 u(cup.:,t,, rr d,ficrcn; it r. ;"..;w:, '„r;c provided v.0) information on the proper maintenance o(Sub- Surface Disposal System. a (revised 8/15/95) 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: Owner: Date of Inspection: FLOW CONDITIONS RESIDENTIAL: Design flow: gallons Number of bedrooms: `3 Number of current residents: Garbage grinder (yes or no): Laundry connected to system (yes or no):2 Seasonal use (yes or no):—IJO Water meter readings, if available: Last date of occupancy: COMMERCIAUINDUSTRIAL: Type of establishment: Design flow: stallons/day Grease trap present: (yes or no)_ Industrial Waste Holding Tank present: (yes or no)_ Non-sanitary waste discharged to the Title 5 system: (yes or no)_ Water meter readings, if available. Last date of occupancy: OTHER: (Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: 9 i System pumped as pan of inspection: (yes or no)_Ad'® If yes, volume pumned gallons Reason for pumping. TYPE O_ SYSTEM V 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) and source of information: / 9 Sewage odors detected when arriving at the site: (yes or no) Al (revised 8/15/95) 5 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: Date of Inspection: SEPTIC TANK:_ (locate on site plan) Depth below grade: Material of construction: concrete _metal _FRP —other(explain) Dimensions: i S1' 7/3, Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Comments: (recommendation for pumping, condition of inle and outlet tees or baffles, depth of liquid level in relatio to outlet invert, structural integrity, evidence of leakage, etc.) /A/WJr /),r jt,,o) A-1A, < ��T Tf vv'i J-f T- + C'ovt/' S i6 L3z< aw Ch'A.� £ GREASE TRAP:_ (locate on site plan) Depth below grade: Material of construction: _concrete _metal _FRP —other(explain) Dimensions Scum thickness. Distance from top of scum to ton of outlet tee or baffle: Dista-ce from hotto- t,, hntlnm p' outlet tee Or hahle Comments: (recommendation for pumping. condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integri,y, evidence of leakage, et(.) (revised 8/15/95) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: Date of Inspection: TIGHT OR HOLDING TANK:_ (locate on site plan) Depth below grade: Material of construction: _concrete _metal _FRP —other(explain) Dimensions: Capacity: gallons Design flow: gallons/day Alarm level: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX: (locate on site plan) Depth of liquid level above outlet invert: Comments: (no:e ii level and d:s;ribu:ic• c:;,.::'. r%idc^ce c( s hd- ca•- r� , evidence of leakage into or out of box, etc 1 £ atv PUMP CHAMBER:_ (locate on site plan) Pumps in working order.(yes or no) Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) (revised 6/15/95) 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: Date of Inspection: V J SOIL ABSORPTION SYSTEM (SAS): V (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: Type: leaching pits, number: ' leaching chambers, number:_ leaching galleries, number: leaching trenches, number,length: leaching fields, number, dimensions: overflow cesspool, number: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vggetation,etc.) /G oo 6 �- Zoe£ Cd ST r�.T z % �- 6j i"j :-, Cle/1 U � 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, sign: of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY:_ (locate on site plan, Materials of construction: Dimensions: Depth of solids: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) (revised 8/15/95) 8 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' �. . O 4 q O DEPTH TO GROUNDWATER Depth to groundwater: feet method of determination or approximation; A✓!d SS'_'_W rst t° ry P lM/ gesi A�,�• ik 0 7' / ,0 1'aP v!�l f W T�/ 2.r./1 t,•=A�L (revised 8/15/95) 9 -- — - THE COMMONWEALTH OF MASSACHUSETTS BOARD? ..................OF......................................................... ApplirFation for Dispoti al Works Toulitrnrti>orn Vamit Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal System at: / �kl (' ( ® �� ������yyyy .I LoFatigf>f� s��P0 t/L//' V�/ jW AAAJ- ------------- --I - ---------....._........................... Owner dress... n .------- Installer Address Type of Building Size Lot____2j.M.D_..Sq. feet Dwelling—No. of Bedrooms____.________________________________Expansion Attic ( ) Garbage Grinder ( Q '4 Other—T e of Building ............................ No. of persons____________________________ Showers — Cafeteria d Other - - - - ---- •-•-•-------------•-----•------------- -- --- - - --------------------------- allons per person per day. Total daily flow_______- _ Ions. W Design Flow g P P P Y Y - � WSeptic Tank—Liquid capac� __gallons Length----- Width....,...... Diameter________________ De?thn _ _______- Disposal Trench—No..................... Width_____.._.___..._._._ Total Length____________....____ Total leaching area. __._sq. ft. 3 Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) ~' Percolation Test Results Performed by_________________________________________________________________________ Date........................................ aTest Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water------------------------ 0-4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground �+ / water_______________-�__,_,_�____ ----_----- VDescription of Soil...... _ -•• ...........-- .................................................... UNature of Repair2 Or Alterations—Answer when applicable................................................................................................ .i Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with -'A the provisions of TITLE 5 of the State Sanitary de , The un;qrsigneA further agrees not to place the system in operation until a Certificate of Compliance has be i u d by b and ealth. gned. •-----=--..... ..............................S...(.: .................. . ..A Application Approved By________ _______......�_.:' ....._.__.______-- - �BZ Date -•••..._._._ Application Disapproved f the ollowing reasons_________________________________________________________________________________•__..._.__...____________-._.___ -------------------•--------•-----------••-•--------------...._..--------•----------........---------------...._.._..-•-----•••----••••------•----•------------------•---••-••-•..-------•--------_..._ Date PermitNo......................................................... Issued....................................................... Date ..............YmB....y............ THE COMMONWEALTH OF MASSACHUSETTS BOARD6�X -1H'JIT ................OF............................_........... Appliration for Dhipaaal Workii Tomitrurtion run fit Application is hereby made for a Permit to Construct LT_o_r*"Repair an Individual Sewage Disposal System at: ......................... .. ................... .. r..................4f 41� ?)�.......... �111` _.i.... -------- ... o aij341an�41^... ......... . ............... .... . ........................... ............ ................. . .... ..... .................... .......................................................... installer Address Type of Building Size Lot......AA. ----Sq. feet U Dwelling—' No. of Bedrooms......... --Expansion Attic Garbage Grinder ............... Other Type of-Building ............................... No. of persons__._.__........._..._._.__.. Showers Cafeteria Other fixtures .................I........................................................ ?. . ................. -------------------------------------------------------------- Design Flow i:............................:..............gallons per person per day. Total-daily flow....................._ I , ... ....................gallons. 1:4 Septic Tank—Liquid capacity............gallons Length................ Width..._...___:__... Diameter._........._.....Depth.............._. W ial Disposal Trench—No..................... Width_....__......_...... Total Length.................... Total leaching area-------­-­------Sq. f t. Seepage Pit No..................... Diameter....._....__.__..... Depth below inlet..............::.... Total leaching area..................sq. f t. Z Other Distribution box Dosing tank Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. I................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......._,_:-_:_----__-_----------- ft.... ....... igtion o -e.4 0 Descr* f Soil....... 7.tj ......................... .................... ....... ...... .. . ........... ......... ........ ...... ...... ....... ....................... ....... .. U .......... I ----- ----------- .... .......I . ............ .................................................. U Nature of Repair or Alterations.—Answer when applicable............................................................................................... ........................................................7............................................................................................7...... ................................. Agreement: The undersigned. agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of T 1T!L- 5 of the State Sanitary C de he un signe .urther agrees not to place the system 'n operation until a Certificate of Compliance has bee is by and health. ....... .......... ned. ........... ............................ . ................ .... D e ... . ................ Application Approved By....... ...... ............................................... . ................. Dace...::......._ Application Disapproved fm1th ollowing reasons:...................................I............................................................. ................ ......................................................................................................................................................................................................... Date PermitNo.......................................................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS 4-001-0010 BOARD (,>Y HEAkTo ./I .........................................OF........ ..................I......................................... T-Urrtifiratr laf Toutpliancr - THIS IS TO CERTIFYffhat the I ividual, wage posal System constructed ®repaired ... .......... ................................................ . ........e by--------------- ..................... ....................... ------ ------------ _7............... 4 14) t........ _Q .....3.... ..........10 at................. ....... ..... ............................................................................................ has been instilled in accordance with the provisions of TITLE 5 of The State Sanitary _Z Co ribed in the , 5;Ky.. application for Disposal Works Construction Permit ............... dated_...,.# ;S e ................. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONS RUE® AS GUARANTEE THAT THE SYSTEM WI L fUNCTION SATISFACTORY. DATE...!ZZLZ�-- .....I.................................................. Inspect .. ... ..................(........................................................ THE COMMONWEALTH OF M SSACHUSETTS BOARD 0 HEAL-16 ........... .......................... ...........I....................................................................... No..?'9.-.V.3.. FEE........................ .unfit Permissionis ......................... ....... . ............... ............................................. - ��c. jereby granted ------- to an a ewa osal Sys Cons Repair at No.. S.. ........... .................................... ........ ........................................... __>rucl__#1 __1`0r__ :'Street' as shown on the application for Disposal Works Construction Per' 01'---------------- ated..V.-.P.....73 - - . ....................... .................. ... ................................................................. A B rd of Health DATE.... A�:1&1.................................................. FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS Si►�Gt.C: FVAMtLY - �b gEORoOM jp uo •C,AQ�A�E GwND�2 oA►�Y FLOW 110 A 3 = 3306.Pp SEPTIC, TAWK = a30x150% 31495&.P US1= ►000 GAL. ot5Po5At_ PIT v,SE I000 SAL.. 'Zo,ovo 5 t D4WALu AtZGI+ s 150 5.F x 0 3?5 G.R� RAP Exr BOTTOM AREA: .. f0 SiF._ Pir A2. i Sa S.F X. 1• o At I•o G.P o' 0 'ToTA L_ pEIIGN * 444 G.P D PaOP 39 'TOTAL DA t t_Y FLOW 33o G?0 31 o rA�1� o PE2Go►_ATIow RATE+ 1''IN VAIN ot~I_IE$5 —' TL6T yALTEV. R oI.D AAM ?,Z0�• 145C SA of> �`�� or A,,� I Cr`p FdCNAHO ���, o� ALAN BAXTER ti 10N Nu. No.24048 c � O � o I �1STEP{pQ' T Pj'�E #� SV�V� f ONAI ENC q1i �I+N 1 v I� �D q44 � q9 *T o Fwov%oo•o T6�T ►��18�$0 ?���9�T • Not_ • q-�a �` ' ITT . LOAM t I o o� ►wv. SUBhoIL. 9�K INS. SrPTIPTI- G I I2,' I000 INY, 90•L •TANK . . i •B¢ow� 1.EAG11 4� INV. INV. �jAQD W N 9G L 44 d- I 1 3/g•I�z � , WASN6D II 6TaN6 I GERTIFIGD P%-c,"r PI-A.W . SA alb P�ZUFOL� Loc4T10N CDT ' IZ NO SCALE �jGp.LE ILL dp V_ATE IOS' >32 �o k14T przoPoS►�t� P 1..A N Rr 1= EBEN GE 1 GE aT IFY THAT THE you s a 5NoWN I Nr,.RGo►J GOMPL."(5 WITH'TH6. SIo6t_1NE L o"r A W P -56TQe►GK R.66QVIR•EMSN'T' �Dr F'TN — 'tow of $A2417ra3 v Le AN IS Oc AN TED •WIT NI T •6 Ft.o Pl. IN 1� ;• DA'r>r b1. .0Z' t_ BA-KTEV-IL AI YE I NC• EG I'S'T�i�6'D'LAu o s u Q.Y isYoi�S L_. h 'Tuts PL&W 1�; NOT BnSEp o►d AN R. osTEe.VILI.Fz o MASS• IN5-�R,uME�N'1' SU2vt=Y �-TNE oFvSET5 -$wl?U0 rn'Coft rlr- rr_c� MIl.1r L-C�T ►.IpaG�� APPL•IIAN'r 'v4.lLl TOWN OF BARNSTABLE It LOCATION _ � AP(i t-r eQ j SEWAGE# VELLAGE COT,1 t ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY I o ��� �i9N� '�-,BoX /o0o MI. Pt7— LEACHING FACMrrY: (type) (size) I NO.OF BEDROOMS 3 BUILDER OR OWNER L"I PERMTTDATE: 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 I s 1? EAT O O LO CATION Lvf 3 S C E PE Ii1AIT NO. VILLAGE Cl/4, IMSTA LLED'S NAME�- ADDRESS 6 uILOE o OR owaEla -tea 0ATE PERMIT ISSpfD ��,T� 4 0 A T E C0M ►LIANCE ISSUED l e � f i I