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HomeMy WebLinkAbout0070 SCHOOL STREET - Health 70 SCHOOL STREET, COTUIT� --�-- - - -- A= 035 022 - - - I ' Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ^M 70 School St. Property Address Carolyn Avery& Beth Hanley �_ ' Owner Owner's Name information is required for Cotuit Ma. 02635 6/19/2008 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. Important: A. General Information When filling out . forms on the computer,use 1. Inspector: only the tab key to move your Robert Paolini cursor-do not Name of Inspector use the return .: key. Ca ewide Enter rises,LLC Company Name. �. 6 P.O.Box 763s=" Company Address . Cn co Centerville Ma. 0263270 City/Town State Zip Code (508)428-4028 S14454 ' Telephone Number License Number cxr O t B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the C 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 15.340 of Title 5(310 CMR 15.000).The system: a _ ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority Insp or's Sign tur 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. 70 School St.•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 1 Gommonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 70 School St. Property Address Carolyn Avery& Beth Hanley Owner Owner's Name information is required for Cotuit Ma. 02635 6/19/2008 every 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: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The septic system is in proper working order at the present time. B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Answer yes, no or not determined (Y, N, ND) in the ❑for the following statements. If"not determined, please explain. ❑ The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND-Explain: ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ obstruction is removed 70 School St.•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2_of 2 Commonwealth of Massachusetts ti. W Title 5 Official Inspection Form ` Subsurface Sewage Disposal System Form -Not for Voluntary Assessments GSM 70 School St. Property Address Carolyn Avery& Beth Hanley Owner Owner's Name information is required for Cotuit Ma. 02635 6/19/2008 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ distribution box is leveled or replaced ND Explain: ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s).'The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ obstruction is removed ND Explain: C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 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. 70 School St.•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 3 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 70 School St. Property Address Carolyn Avery& Beth Hanley Owner Owner's Name information is required for Cotuit Ma. 02635 6/19/2008 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ :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 ❑ ® 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 Y2 day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the.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. 70 School St.•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 4 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 70 School St. Property Address Carolyn Avery& Beth Hanley Owner Owner's Name information is required for Cotuit Ma. 02635 6/19/2008 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. E] ® 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 1.5,000 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. 70 School St.•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 5 f Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for.Voluntary Assessments °M 70 School St. Property Address Carolyn Avery& Beth Hanley Owner Owner's Name information is required for Cotuit Ma. 02635 6/19/2008 . every page. City/Town 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? Y P 9 , ® ❑ 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.0 is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] 70 School St.•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 6 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 70 School St. Property Address Carolyn Avery& Beth Hanley Owner Owner's Name information is required for Cotuit Ma. 0263.5 6/19/2008 every page. City/Town State Zip Code Date of Inspection 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 Number of current residents: 2 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? 0 Yes ❑ No Seasonal use? ® Yes ❑ No Water meter readings, if available last 2 ears usage d unavailable 9 ( Y 9 (gp ))� Sump pump? ❑ Yes ® No Last date of occupancy: 6/19/2008 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: Last date of occupancy/use: Date Other(describe): 70 School St.•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 7 iL Commonwealth of Massachusetts W Title-5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ^M 70 School St. Property Address Carolyn Avery& Beth Hanley Owner Owner's Name information is required for Cotuit Ma. 02635 6/19/2008 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 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: ® 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): Approximate age of all components, date installed (if known)and source of information: System installed in 1994 Were sewage odors detected when arriving at the site? ❑ Yes ® No 70 School St.•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 8 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 70 School St. Property Address Carolyn Avery& Beth Hanley Owner Owner's Name information is required for Cotuit Ma. 02635 6/19/2008 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): 4' Depth below grade: feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line. 10+ feet Comments (on condition of joints, venting, evidence of leakage, etc.): Joints appear tight.No evidence of Ieakage.System vented through the house vents. Septic Tank(locate on site plan): 3' Depth below grade: 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 gallon 4" Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle 28" 1„ Scum thickness Distance from top of scum to top of outlet tee or baffle 7 Distance from bottom of scum to bottom of outlet tee or baffle 13" How were dimensions determined? Measured 70 School St.•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 9 ' Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 70 School St. Property Address Carolyn Ave & Beth Hanle Y Avery Y Owner Owner's Name information is required for Cotuit Ma. 02635 6/19/2008 every 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.): Pump septic tank every 2 years.lnlet and outlet tees are in place.No evidence of Ieakage.Tank .appears to be structurally sound. 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 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): 70 School St.•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 10 r Commonwealth of Massachusetts L W Title .5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;M 70 School St. Property Address Carolyn Avery& Beth Hanley Owner Owner's Name information is required for Cotuit Ma. 02635 6/19/2008 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) - Tight or Holding Tank(cont.) 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 Distribution Box(if present must be opened) (locate on site plan): Depth of liquid.level above outlet invert No 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.): Box is Ievel.Box has one outlet Iateral.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 70 School St.•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 11 t -Common wealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ° 70 School St. M Property Address Carolyn Avery& Beth Hanley Owner Owner's Name information is required for Cotuit Ma. 02635 6/19/2008 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS)(locate on site plan, excavation not required): If SAS not located, explain why: Type: 1-1000 gallon ® leaching pits number: w/2' stone ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Sandy dry soil.No signs of hydraulic failure.Leaching pit was dry at time of inspection with stain line 51" below invert pipe.ln§talled 2' riser on leaching pit. 70 School St.•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 12 7-7 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ^M 70 School St. Property Address Carolyn Avery& Beth Hanley Owner Owner's Name information is Cotuit Ma. 02635 6/19/2008 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 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 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.): 70 School St.•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 13 Map Page 1 of 2 Town of Barnstable Geographic Information System Parcel Viewer Custom Map Abutters Map Size Zoom Out J µ J 0 M J.J In. "y r R 1i: y, l f `5 f_ \ I �\ \ \ \Y I, \ Y1___ 1 � bk I 1 1 °T^ , I � a I IN 1 , ` 1 II , 1 I Y , I 0 20 Feld t I I 1 `I Set Scale 1" = 20 I Aerial Photos ( MAP DISCLAIMER (nnvrinht')00r-9(V1R Tnum of Rarnetnhlo RAD All rinhtc r—r- htti)://www.town.bamstable.ma.us/arcims/ap p eoapp/map.aspx?propertyID=035022&map... 6/21/2008 Commonwealth of Massachusetts W Title 5 Official ' Inspection. Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 70 School St. Property Address Carolyn Avery& Beth Hanley Owner Owner's Name information is required for Cotuit Ma. 02635 6/19/2008 every page. City/Town 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: Bottom of LP 25'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: USED:USGS Observation Well Data.USED:Technical Bulletin 92-000-01 Plate#2 Annual ranges of groundwater elevations. 70 School St.•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15 c Regulatory Services >3nxNsreat.e. « Thomas F. Geiler, Director 9 MAC' �a 039 a`� P� rFnMr•� 1 ublic Health Division Thomas McKean, Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 REGARDING SEPTIC INSPECTIONS BY PRIVATE CONTRACTORS DISCLAIMER This septic system inspection report was completed by a private inspector who is certified by the State of Massachusetts, Department of Environmental Protection. Although the Town of Barnstable Health Division received the original or copy of the report; this Division does not warranty the functionality of the septic system in the future nor does this Division agree with any technical observations and interpretations contained within this report. In addition, by receiving this report the Town of Barnstable Health Division does' not automatically approve the number of bedrooms listed within this report. The actual number of bedrooms approved at a particular property would be listed on the "Disposal Works Construction Permit". If you should have any questions regarding this report, please contact the certified Septic System Inspector who conducted the inspection. Q.•ISEPTICTisclaimer Private Septic Inspections.DOC q� f No.•--9-1 940 FIzs........3 0........ ns leConseroa Depe THE COMMONWEALTH OF MASSACHUSETTS ,�, BOARD OF HEALTH ipned Date I OWN OF BARNSTABLE Alip iratiun fur Di-wipuitt1 Vlarkii Tvastrnrtiun ramit Application is hereby made for a Permit to Construct ( ) or Repair (- ) an Individual Sewage Disposal Sya . ../ ........................................... ------------------------------•-•------•-•-- ------•---------•--------•---•......------ ..-...... �......oy e, dress..�i(-�......•.......... ............ or Lot No. ..---•- - I 'elf" CJ ---------------- In 1 -- - -- l/ .. W '. ;O�yper Addr j�f j^Q Installer Address / d Type of Building Size Lot............................Sq. fget,� U Dwelling—No. of Bedrooms____.__._.3 Expansion Attic ( ) Garbage Grinder (M ►.• ----•------------------ — aOther—Type of Building ............................ No. of persons---------------------------- Showers ( ) Cafeteria ( ) Q' Other��ufes •-------------- ------------- W Design Flow............................................gallons per person per day. Total daily flow.___- _._ gallons. WSeptic Tank—Liquid capacity------------gallons Length................ Width---------------- Diameter_..-.._.-_-__-_- Depth................ x Disposal Trench—No. .................... Width-------------------- Total Length.................... Total leaching area....................sq. ft. Seepage Pit No..................... Diameter-------------------- Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box �__) Dosing tank ( ) Percolation Test Results Performed by-------------------------------------------------------------=............ Date........................................ aTest Pit No. I----------------minutes per inch Depth of Test Pit.................... Depth to ground water........................ (i Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water...-_--..-_-___-._-----. P4 .....---•-----•------------------------•-•-----------------•----•---------------------------......--......................................................... 0 Description of Soil........................................................................................................................................................................ x U --------------------------------------------- -------------------------------------------------------------------------------------------------------------------------------------------•-.._..-------- x ----••-------------------- ------------------------------------------------------------------------------- --- boo--- �+Ir,�------ -Answer - U Nature o aI s or Alterations when applicable.._ '-------------------- ----------- ----- +_.(.(!X4X.......... - -'-v""`.....--------------------------------------•-----------------------------------------------------...------------------------------•-----------................. 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 undersi ned further agrees not to place the system in operation until a Certificate of Compliance has beeA issued the b a ealth. [� Signe 14f'q -/................ Date Application Approved By ..-----------------�e—."'------ -------------------- ----- Application Disapproved for the following reasons- --------------------------------------------------------------------------------------------------------------------------------- ............. ..... ................. ................ ... ........_......__................ .. .................... ... -- ........................................ D PermitNo. .... .. - 1. �............................. Issued -------------------------------------------------------- ate Date s q - No. .. �6 � FFB.....-3.0........ �+ THE COMMONWEALTH OF MASSACHUSETTS (/ BOARD OF HEALTH TOWN OF BARNSTABLE Alipliratiuit for Di-tipmial W,arltu Tomitrurtiun ramit Application is hereby made for a Permit to Construct ( ) or Repair an Individual Sewage Disposal System at: ((-,mi 'n tb- es-J, ........--•-•••-•---•••-------- ------------------------------- ............................................................. h rlo -----� --Hdress � - or Lot No. ......................_____-.f.......F-.LJ--^-__'__..-^"--•-------•----•--•---'---•-----^._----- •__---•__... ........... .._._...•._--- Owner Addres F f 9 - - --- ------•-----•-----•. ---•---- -- -•...•---•-. Installer Address d Type of Building _ Size Lot............................Sq. feet U Dwelling—No. of Bedrooms___________ ____ Expansion Attic ( ` ) Garbage Grinder aOther—Type of Building ---------------------------- No. of persons-_-_________-_____-_--..---- Showers ( ) — Cafeteria ( ) Other fixtures -------------------------------- -------------- •.................... W Design Flow...................... ........................gallons per person per day. Total daily flow.........��.__._........._._...__...gallons. WSeptic Tank—Liquid capacity__--_-_---.gallons Length---------------- Width-.-----_-_-.-_ Diameter---.------------ Depth................ x Disposal Trench—No. .................... Width.................... Total Length-------------------- Total leaching area....................sq. ft. Seepage Pit No--------------------- Diameter-------------------- Depth below inlet.................... Total leaching area..................sq. ft. z Other Distribution box K) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date...................................... a ,.a Test Pit No. 1----------------minutes per inch Depth of Test Pit.................... Depth to ground water........................ 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water..-____-----.__-----_--. P4 .....•-•---------------------------•----••--------...-----...--•-••-•-----•-----•-••----•-----------......................................................... 0 Description of Soil------------------------------------------------------••---•--------------------------------=----------------------------------------------------------••-----•-•------ x U ---••• W --------------------------------------------------------------------------------------------------------------------=------ UNature of Repairs or Alterations—Answer when applicable _�tn_t1_...__«�'--------------------------------------- t_._..f.. ..�1 ........................ 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 has been, issued by the bard-of-health. ` N Signed � . `- -�� J --------------------- ---- +.�---- �— Date Application A ....� '.'...... PP Approved B Y ................._. ate Application Disapproved for the following reasons: ............................................................................................................................. ............. ................................................. ...... . .... ............... . . .................................... ------------------------------------- �y Date PermitNo. ......./.. ---r---]--7&. ........ .. . ...... Issued ------------------------------------------------------------------- Due ----------------------------- ----------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS '- BOARD OF HEALTH TOWN OF BARNSTABLE Gertifirate of C ontplianre THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (� ) b ---- - ....r iZ it �'} _... ..------- -----------------.----.-------------------------- ..--------- C� �7oor�lc I-�-i,� " at --........ .............._........_.._...... .. ---... - ------------ has ...... r - -- - been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in the application for Disposal Works Construction Permit No. -_ .... ..�.-.../.h -------__. dated .........-------------------------------------- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT E OIVSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE .. ..... _ �<----- Inspector --- -l5e..._ .i.... --------------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE No....2.4-Y.,..- _7l° FEE..__fir�•_l- Dispusnl Workii Tongtrurion f rrutit Permission is hereby granted................... �� � �--� tt / ----------•-----•---------------------••-----..........._..... r -- - -- -- ;- to Construct ( ) or Repair (-')�an In ividual. Sewage Disposal/S stem at No. ol -_----_---.-ia.. ...--�-.- -------- C�. Street qq q as shown on the application for Disposal Works Construction Permit No---l. ___..__Z4Dated------- .1� ....... r+ ^�� Board of Health `� 7 L DATE..............--.---•---•---•--------..�--------------•-------------._..... FORM 36508 HOBBS 6 WARREN.INC..PUBLISHERS �. , / r ,/ 1 Commonwealth of Massachusetts Executive Office of Environmental Affairs ;�.RECEIV D Department of 'UN 19- Environmental Protection 96 o Lr►,Q�P,. William F.Weld BARNS SABLE Governor Trudy Coxe / Secretary,EOEA /r� David B. Struhs V Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: �TD SGvWO�— S-T GO—tV�7 Address of Owner: NY �4—L90IQ Date of Inspection: (0—ko-ci(P (If different) Name of Inspector'® �,� Company Name, Address and �lephone Number: 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/Passes sewage disposal systems. The system: i _ Conditionally Passes _ Needs Further Evaluation By the Local Approving Authority _ Fails Inspector's S' re: t 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 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 tc• the system owner and copies sent to the buyer, if applicable and the appro%ing authority: INSPECTION SUMMARY: Check A, B, C, or D: A) SYSTEM PASSES: y I 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. B) SYSTEM CONDITIONALLY PASSES: One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair,i 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) One Winter Street • Boston,Massachusetts 02108 • FAX(617)556-1049 • Telephone(617)292-5500 A i,Printed on Recycled Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) -.•- Property Address: "70 Owner: U.W-`V Date of Inspection:&AO B]SYSTEM CONDITIONALLY PASSES (continued) Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The.system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced 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 CJ FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: !� Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES 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 EBOARD ANONER HEALTH ERMINES THAT THE SYSTEM IS FUNCTIONINGTHAT PROTECT THE PUBLIC HEALTH AND SAFETY AND HE ENVIRONMENT: _ the svctem has a septic tank and soil absorpoun system and is within 10, fcci to a Sulia�c Yv'uici SUppl) or tributary t0 a surface water supply. _ The system has a septic tank and soil absorption system and is within 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 that 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 criteria as defined in 310 CMR 15.303. The basis f Health should be contacted to determine what will be necessary to correct for this determination is identified below. The Board o the failure. _ Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. (revised 8/15/95) 2 1 . IV SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A 4 CERTIFICATION (continued) Property Address: -70 SC--V p p <p l y Owner: We b Date of Inspection: _ci(_ D]SYSTEM FAILS (continued): Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. L4 Liquid depth in cesspool is less than 6" below invert or available volume is less than 112 day flow. { Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Q' 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. i `ll Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from.a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach Copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. EJ LARGE SYSTEM FAILS: The following criteria apply to large systems in addition to the criteria above: t S The design flow of 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 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? t. The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program -•= requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. 1 F t (revised 6/15/95) 3 t ., e c: lY SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B , f CHECKLIST Property Address: -7 0 S(�d Owner: W SST Date of Inspection: 6_ -cty Check if the following have been done: ✓fPumping information was requested of the owner, occupant, and Board of Health. one of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates ! during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. '/ =As built plans have been obtained and examined. Note if they are not available with N/A. � it VThe facility or dwelling was inspected for signs of sewage back-up. 1/he system does not receive non-sanitary or industrial waste flow _V'fhe site was inspected for signs of breakout. f � t V All system components, excluding 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 of baffles or es, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. _The size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods. _ she facility o..r,c ;a:,:,' occupants, if differe^! from owner) were provided with information on the proper maintenance of Sub- Surface Disposal System. ,pp I i F. (revised 8/15/95) 4 ! ) �SYY; 1 k SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C c' ` SYSTEM INFORMATION operty Address: �Qpc)� `vr �lJ l wner: U.l eS 1 ate of Inspection: FLOW CONDITIONS l SIDENTIAL: esign flow: allons umber of bedrooms: i umber of current residents:_D arbage grinder(yes or no):_L-j i undry connected to system (yes or no): i asonal use (yes or no): f ater meter readings, if available: i st date of occupancy: MMERCIAUINDUSTRIAL: pe of establishment: sign flow: gallons/day ease trap present: (yes or no)_ ustrial Waste Holding Tank present: (yes or no)_ n-sanitary waste discharged to the Title 5 system: (yes or no)_ ater meter readings, if available: i ist date of occupancy: HER: (Describe) st date of occupancy: GENERAL INFORMATION JMPING RECORDS and source of information: "ou-e. System pumped as part of inspection: (yes or no)_ If yes, volume pomned: gallons f; Reason for pumping: i PE OF SYSTEM i Septic tank/distribution box/soil absorption system Single cesspool i Overflow cesspool Privy Shared system (yes or no) (if yes, attach previous inspection records, if any) Other(explain) {I 'PROXIMATE AGE of all components, date installed (if known) and source of information: �Y✓S i wage odors detected when arriving at the site: (yes or no) evised 8/15/95) 5 t { n SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 70 Sc��c�v1v S r Co'T V1 l Owner: 619,L?t7r Date of Inspection: `O Zito SEPTIC TANK:_ (locate on site plan) �r Depth below grade: / Material of construction: 1(concrete _metal _FRP—other(explain) Dimensions: Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: I Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle:_ Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, �epth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) a r''ewT (SV I GREASE TRAP: (locate on site plan) i Depth below grade: ' Material of construction: _concrete _metal _FRP—other(explain) i i Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance fro.^n bottom ro <rpr" to hotlflm 01 otlt!el tee or battle' i i Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) (revised 8/:5195) 6 f ' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION.FORM r" PART C SYSTEM INFORMATION (continued) Property Address: 70 SONoc&- S f' CC1TV C— Owner: UYeST^ Date of Inspection: (p_ko'ci�p TIGHT OR HOLDING TANK:_N (locate on site plan) Depth below grade: Material of construction: _concrete_metal_FRP—other(explain) Dimensions: Capacip,: gallons Design flow: gallons/day Alarm level: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX:_Y . (Locate on site plan) Depth of liquid level above outlet invert: Comments: (note n levei and distributlui. ,> eyuai, e�.dence of sulid: ca:r�o�er, evidence of leakage into or out of box, etc.) 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 8115195) 7 1 i i a i i i r I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C i SYSTEM INFORMATION (continued) Property Address: �70 8 YAW L -- 1517 CO'%U o Owner: Date of Inspection: SOIL.ABSORPTION SYSTEM (SAS): (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) I If not determined to be present, explain: Type: I leaching pits, number: leaching chambers, number:_ leaching galleries, number: i leaching trenches, number,length: leaching fields, number, dimensions: I; overflow cesspool, number: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,etc.) t._ t i I jI j CESSPOOLS: 461 (locate on site plan) II ' Number and configuration: ,I Depth-top of liquid to inlet.invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of ground%%ate.-. inflow (cesspool must be pumped as part of inspection) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY: (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) (revised 6/25/95) 8 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: V iSUV,pJL- Owner: o vtQc,� (we ST 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� 40 1. t 'TH TO GROUNDWATER th to groundwater: feet iod of determination or approximation: d�v W� pug ised 8/15/95) 9 s 1 r i s r TOWN O/F' BARNSTABLE // LOCATION '®� S�hao� C®t SEWAGE # IN /7 VILLAGE 67- ASSESSOR'S MAP 6 LOT INSTALLER'S NAME & PHONE NO.&er ���� —7,���� SEPTIC TANK CAPACITY A06 LEACHING FACILITY:(type) /7' (size) �V6 NO. OF.'BEDROOMS PRIVATE WELL OR PUBLICWATER 'BUILDER OR OWNER &4�e- DATE PERMIT ISSUED: ` DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes—,- No s I <; 000 l-eac k, fv- `L TOWN OF BARNSTABLE LOCATION 170 SEWAGE # �y n� VILLAGE b/ ASSESSOR'S MAP & LOT INSTALLER'S NAME & PHONE NO. 4 -7 SEPTIC TANK CAPACITY LEACHING FACILITY:(type) / (sue) V� NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER . 0 DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes---- No •u v - (0o ' H R-CMov6 vE,JrVOV:e� 2evs-c- 710x�y tJ7 C,oW FAgC.A -. - - NEN Eu/ _ Go O. $°8► So B► PA55 ) '60n1G. IWOA L/j '� -r PA,I,'? ,a NCNoe_ SOt T' P R i,- 6 PnA>E,-Co hPDG KET E-A6 AR% �. ,yEw4 I -7-7//a"c.t , M/rsr r�ArArTE2rore TRr. /RT a x/o._G��Tj -� -- BA - G s s.,fi, n•,A�eF► „�� - " " ►: 5- " � AXW J (jpT_ FCU51-1, - a"pOGCETS W/uDOto rY/Ld 5 KJS��I-E5 N�W_DBL.VAN1t� HI rZEnAOJr 2y,ST••.' O O 3�a" GONG- GUGUM Nl r . PQ�� rS °� G AP,zz . p Y/L L 157►7 w V 3UPP�Yf eNc 5y�t v -roP 'n ` i.. ]j� LI GoNC. 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G/ 7" N LD 1 T i a A-LL P-All f.v65 - `j C&-fLNT �/ Gs1Pf - - E _OcJ V/A/A TTIG 6 L - , t• a r �LDO��/�-N �,GA-G� Sin•-- r '� ,r �OUNt7�9TJDt3 1't-AAL These d—I+!gs were;Pr4Parbtl by Ca plat Harris TU G K E� a 9y U at Imp employees subcontractors. e use ac ors.A Home Improvement AvvnovEo er: owAwra er r employees and subcontractors.Anyoreusing these s<ALE:'y";/ drawings shou)d held verity ril existing conditions, pEvrsEo wTE y-y ©S dimens,cns, b,:at 1-,c state building modes and Ine,degt:zCy ci thes_draxgngs.Cap,zzi Home Imp,ovarnent disclaims any responsibility lo,any and all DRAy �€ac3�3 4 - problems which arise from the use o1 these drawings by l/ Anyone other than employees&subcontractors oj- V Cepial Home Improvemant. _