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Home My WebLink About0025 WESTBURY WAY - Health �*25 WESTBURY WAY, COTUIT �L=,,026,032 f w TROY WILLIAMS SEPTIC INSPECTIONS Certified by MA Department of Environmental Protection (508) 760-1819 40 Old Bass River Road .. South Dennis,MA 02660 a t r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPEC ' ONS 1 S, Address of property 2 5 L•1 c s �- h r W 7 C`4u ' 199,5 c Owner's name& /�I r. S�- Q /? c, w u h Co Mailing address S � Date of Inspection g S o�� PART A 6 3„)— CHECKLIST Check if the following have been done: vPumping information was requested of the owner, occupant and Board of Health. _ None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. N ,1 As built plans have been obtained and examined. Note if they are not available with J N/A. wa N The facility or dwelling was inspected for signs of sewage b(2phe s�owm The site was inspected for signs of breakout. `' �c�T t T d]S/All system components, excluding the SAS, have been locati �3 -The septic tank manholes were uncovered, opened, and the the septictank was inspected for condition of baffles or tees, materialto dimensions, depth of liquid, depth of sludge, depth of scum. The size and location of the SAS on the site has been determined based on existing information or approximated by non-intrusive methods. The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of SSDS. Page 1 of 7 '4. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION FLOW CONDITIONS If residential 4/ number of bedrooms —,�?_number of current residents A,'Q garbage grinder,yes or no Ve laundry connected to system, yes or no N o seasonal use,yes or no If nonresidential, calculated flow: Water meter readings, if available: 141 ; Q (JOG i Y � 3 yy a Last date of occupancy GENERAL INFORMATION Pumping records and source of information: PJ PLI AV /;a y 19, S- 7/a?g Ap , 8 /I s ,wry ;"A -1Y'V cM t)6 At 1 h 4.11 a r. /�N✓ S i U.n r� /0 /A h�' A10 System pumped as part of inspection,yes or no If yes,volume pumped Reason for pumping: Type of system Septic tank/4isibt� soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no) (If yes, attach previous inspection records, if any) Other(explain) Approximate age of all components. Date installed, if known. Source of information: ,A/6 Sewage odors detected when arriving at the site,yes or no Page 2 of 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION continued SEPTIC TANK: V (locate on site plan) depth below grade: ► material of construction: _concrete metal FRP other(explain) dimensions: S ' X ' X l vow y 4//a h R" sludge depth ,2�2 distance from top of sludge to bottom of outlet tee or baffle NONE scum thickness -4distance from top of scum to top of outlet tee or baffle —distance from bottom of scum to bottom of outlet tee or baffle Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage,recommendations for repairs,etc.) a r J sy✓ . Ala /!a 3 a< 10�o h. DISTRIBUTION BOX: ✓ (locate on site plan) depth of liquid level above outlet invert Comments: (note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box, recommendation for repairs,etc) .Sh&.k—d Z ; h 'C- &'%) ;4- C-A So x 71�u a A PUMP CHAMBER (locate on site plan) pumps in working order,yes or no Comments: (note condition of pump chamber,condition of pumps and appurtenances, recommendations for maintenance or repairs,etc.) Page 3 of 7 S_ SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B " SYSTEM INFORMATION continued SOIL ABSORPTION SYSTEM(SAS)': (locate on site plan,if poss.;excavation not required,but may be approximated by non-intrusive methods) If not determined to be present,explain: Type: leaching pits and number o G ' X G L L, �H� leaching chambers and number leaching galleries and number leaching trenches,number,length leaching fields,number, dimensions overflow cesspool,number Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,recommendations for maintenance or repairs,etc.) - /) .S/ ci h / S 6 T �7 c. d�r.�✓ �- . I J✓G o t/ yJvs (� t ran ( / h 7 h ✓J to S 7 1 ✓�A c✓ L(J c CESSPOOLS (locate on site plan) : number and configuration depth-top of liquid to inlet invert depth of solids layer depth of scum layer dimensions of cesspool materials of construction indication of groundwater inflow (cesspool must be pumped as part of inspection) Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of . vegetation,recommendations for maintenance or repairs,etc.) PRIVY: /V//9 (locate on site plan) materials of construction dimensions depth of solids Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,recommendations for maintenance or repairs,etc.) Page 4 of 7 y 1 a SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION continued SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' ;25 35 '6 - i- w 3 �e- , DEPTH TO GROUNDWATER 54 b,J L. depth to groundwater — adjusted high groundwater level method of determination or approximation: Q 1 - ,/* Le Q L L H G Li Page 5 of 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM r PART C FAILURE CRITERIA Indicate yes, no or not determined(Y,N, or ND). Describe basis of determination in all instances. If"not determined",explain why not) Backup of sewage into facility? /y Discharge or ponding of effluent to the surface of the ground or surface waters? Static liquid level in the distribution box above outlet invert? /y//1 Liquid depth in cesspool<6"below invert or available volume< 1/2 day flow? _\/ Required pumping 4 tunes or more in the last year? Number of times pumped M Septic tank is metal?cracked?structurally unsound? substantial infiltration? substantial exfiltration?tank failure imminent? Is any portion of the SAS, cesspool or privy: below the high groundwater elevation? within 50 feet of a surface water? Al within 100 feet of a surface water supply or tributary to a surface water supply? N within a Zone I of a public well? within 50 feet of a bordering vegetated wetland or salt marsh(cesspools and privies only,not the SAS)? N within 50 feet of a private water supply well? 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. Page 6 of 7 '4 Y X SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM4x � y PART Dti CERTIFICATION zits Name of Inspector: Troy Williams Company Name: TROY WILLIAMS SEPTIC INSPECTIONS Company Address: 40 Old Bass River Road,South Dennis, MA 02660 Certification Statement I certify that I have personally inspected the sewage disposal system at this address and that the information reported is true, accurate and complete as of the time of inspection. the inspection was performed and any recommendations regarding upgrade,maintenance and repair are consistent with my training and experience in the proper function and maintenance of on-site sewage disposal systems. Check one: I have not found any information which indicates that the system fails to adequately protect public health or the environment as defined in 310 CMR 15.303. Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form., I have determined that the system fails to protect public health and the.emnronwent as defined in 310 CMR 15.303. The basis for this determination is provided in FAILURE CRITERIA section of this form. ` Inspector's Signature Date Original to system owner Copies to Buyer(if applicable) Approving authority PROPERTY ADDRESS: T��1✓( Gw . Page 7 of 7 TOWN OF BARNSTABLE LOCATION Q S I 424 Ljly SEWAGE # VILLAGE C%y �-v. 4- ASSESSOR'S MAP &LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) / (size) NO.OF BEDROOMS L BUILDER OR OWNER PERMIT DATE: 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 ...-'....................._ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF JHE LT AP.Pfiration for Dispos t Works Tonstrurtion Urrmit Application is hereby made for a Permit to Construct or Repair ( ) an Individual Sewage Disposal Sys em at: .. . �e � ... ilo �d SS ��' F� J IAt rra. ...---...---•-.....-.....--- - ................ s. -----..... W Owner s Installer Address Q Type of Buildin �' Size Lot____________________________Sq. feet U Dwelling No. of Bedrooms.___.. Expansion Attic ( ) Garbage Grinder ( ) �-+ ------.•...._ aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Q' Other fixtures ...................................................... Design Flow...___.. ®................................gallons per person per day. Total daily flow........ . ®....______________gallons. WSeptic Tank—Liquid capacity:/ ____f,I Ions Length................ Width---------------- Diameter-------.-------- Depth_-_--__----_---- x Disposal Trench—No._.....•.. .._ Width_ _ _____ ___ To 1 Length.................... Total leaching area....................sq. ft. Seepage Pit No.. � t°. �t�luelow inlet.................... Total leaching area------------------sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by..................... ..................................... •-•--• Date.................................... Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water.._-______-____-_-..---. 44 Test Pit No. 2................minutes er inch Depth of Test Pit.................... Depth to ground water------------------------ - ..... _ Description of Soil------- -15— x w x ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- U Nature of Repairs or Alterations—Answer when applicable------------------------------------------------------------------------------------------------ .................................................................................... ---•----•---••-•-- Agreement: The undersigned agrees to install the aforedescribed I ividual Sewa Disposal System in accordance with the provisions of Article NI of the State Sanitary Code— e undersigne ur her agrees not to place the system in operation until a Certificate of Compliance has b iss y the board he th. t� Q Sied.... ...... ---------- --�-• • . ......•- ------------- . Daf ApplicationApproved BY --------� ----------------------------- ........................................ Date Application Disapproved for the following reasons:.._.--••-•------• --------------------•--------...•--••--------------------•------------------------•---......- ......................................................-.................................................. Date PermitNo......................................................... Issued........................................................ Date No.. _ __-------- Fimim............... ...�... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF H A TH 91 Apphratiuu for Biipuutt1 Vviko Tonotrurtiuu Prrmit Application is hereby.made for a Permit to Construct ( dK6r Repair ( ) an Individual Sewage Disposal Sy teem{ at: )) 3sE_ ........................................ ._ o n dd�est N , S` - # (J ' �`' ° . Owner '� � "......................................... ......................... ••--------&- r-=...--..------------•----------------------- 14� Installer Address d Type of Buildi Size Lot----------------------------Sq. feet U Dwellin No. of Bedrooms..................................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ___________________________ No. of persons---------------------------- Showers ( ) — Cafeteria ( ) P., Other fixtures ------------------------------------------------- - --- - - - -------------------- ----------------------- wDesign Flow------- ..................... allons per person per day. Total daily flow____._:--...______..._.__.._.........__..-_gallons. WSeptic "Tank—Liquid capacityjj__-. allons Length................ Width................. Diameter-___-____-__.__ Depth----._-__---.--- x Disposal Trench—No. ----------- Width ____-•_____�__r- Tal Length.................... Total leaching area__---..-___-___-___-sq. ft. /See a e Pit No._ � I VIA.nf' ?`5 6low inlet.................... Total leaching area------------------sq. ft. z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by------------------------•---•--------•-=-------•-•-•--•--•---••---------- Date---------------------------------------- ,� Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water-_.___________--___-_--. f1 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water----_................... 0 Description of Soil------ _ ._____ " x w U Nature of Repairs or Alterations—Answer when applicable.--____________________________________________________________________________________________- ------------------------------------------------------------------------------••----------------------------------------------------------------------------------------------------------------------- Agreement: The undersigned agrees to install the aforedescribed �idividual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code— le undersigne further agrees not to place the system in operation until a.Certificate of Compliance has b n ss� y the board he lth. N fDate Application Approved By_., _ ��•x' --------------------- -- Date Application Disapproved for the following reasons:................ -----------------------------------.................................................. Date PermitNo......................................................... Issued........................................................ Date THE COMMONWEALTH OF MASSACHUSETTS — '? BOARD OF HEALTH 7 .........OF... '' ........................ &rfif tratr of Tuutlif aurr THIS IS TO CERTIFY, That the(Lildividual -Sewage Disposal System constructed ( or Repaired ( ) by.............. •••------------------------------------•--•-•-_-- =Y- --------------------------------------------------•------------•------- / Installer 9 f f at- g ---a� ------------------- --,-- fit: _ ......................... _ has been installed in accordance with the provisions/of Article T XI of e State Sanitary Code as described in the application for Disposal Works Construction Permit No------- c ._ -:_________________ , . dated_.____: _.- :_. _ • - _ ------------ - THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE S-��- Inspector.. THE COMMONWEALTH OF MASSACHUSETTS . . BOARD OF HEALTH No. ✓ FEE - =-•------- DiiiVvii al Norkli Chu tit-rurfiuu Vrrmit ; Permission is hereby granted---- ---- . -- ^' ,,. to Construct o pr RepairN ) an Individual Sewage Disposal System rn ---`- f --- at No.--------- •} ---- z is r. f y.I a* -r as shown on the application for Disposal Works Construction Permit Nox� _.. '�" Dated_._. : ..._.._. g Board of Health DATE.......... ----"- FORM 1255 HOBBS & WARREN. INC., PUBLISHERS