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HomeMy WebLinkAbout0030 GLEN ROAD - Health 30.GLEN':ROAD, HYANNIS ° �'Vic, -- — — —� -- ----------------- — ---- — ° l o o Y ° 0 o it 0 ° 11 1 0 e °Il TOWN OF BARNSTABLE LOCATION 30 G len 0- SEWAGE# VIL&CI—E ASSESSOR'S MAP&LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY Iwo LEACHING FACILrTY:,(type) VIOWA-WeVt'S (size) 30L. NO.OF BEDROOMS BUILDER OR OWNER I PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility lb fe-14 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 fee=flehing acility) Feet Furnished by e ,���� hr n W n Go b uLAI-is�-- 6 �f a88- ai S Commonwealth of Massachusetts e Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 30 Property Address � O / �/�Owner lr'::71 �---- (/(J_ Owner's Name information is required for every page. City/Town State Zip Code Date of Inspfictiont Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the.end of the form. Important:When A. Inspector Information filling out forms P on the computer, use only the tab key to move your Name of Inspector cursor-do not use the return Company Name key. � Company Address L—rt �a 1 o VP fo W_ City/Town��4 o State 6701,0_9r7_ Zip Code tasoa Telephon Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above;the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.After conducting this inspection I have determined that the s tern: 1. Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fail Inspect is Signature Date The s stem 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 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 form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: 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. t5insp.doc•rev.V2612018 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for-Voluntary Assessments 110 Property Address Owner Owner's Name information is WW�0 required for every 14 r1s� page. City/Town State Zip Code Date of Infoectiil5n C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) Syst Passes: 71 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: 2) 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): t5insp.doc-rev.726/2018 Title 5 official Inspection Form:Subsurface Sewage oisposai System-Page 2 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address Owner Owner's Name , lit° information is required for every 14 4244 04('0 f 16 page. Cityrrown State Zip Code Date of 1 pec' n C. Inspec on Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ 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): 3) 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. a. 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: t5insp.doc•rev.726/2018 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 3v &1,*o Property Address c�br�e Owner Owners Name /b information is required for every page. City/Town State Zip Code Date o inspe ion C. Inspection Summary (cost.) ❑ 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 b. 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. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"-to each of the following for all inspections: Yes No ❑ r-,/ Backup of sewage into facility or system component due to overloaded or u 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 t5insp.doc•rev.726r2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 Commonwealth of Massachusetts ifTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address 3,o /J Owner Owner's Name information is � n required for every14"arle)1 d a-(o C) page. City/Town State Zip Code Date of I specti n C. Inspection Summary (coat.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ 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 ❑ 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. ❑ 010000- 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 water supply El well. El voo,— 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.] ❑ Vz he system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ 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. 5) 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 CA. 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 t5insp.doc•rev.7125=18 Title 5 Official Inspection Form:Subsurface Sevage Disposal system•Page 5 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form �� Subsurface Sewage Disposal System"Form -Not for Voluntary Assessments' r n Property Address Owner Owner's Name O bineo information is � 1�Ido required for every I Oa6ol 1 page. City/Town State Zip Code Date of In ectio C. Inspection Summary (cont.) If you have answered"yes"to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed.The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CM 15.304.The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes" r"no"for each of the following for all inspections: Yes No i ❑ mping information was provided by the owner,occupant, or Board of Health ❑ ere any of the system components pumped out in the previous two weeks? ❑ as the system received normal flows in the previous two week period? El this 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)] t5insp.doc•rev.7/26/2018 Title 5 official Inspection Forth:Subsurface Sewage Disposal system•Page 6 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form w Subsurface Sewage Disposal System Form -Not for Voluntary Assessments '319 _ 4-) Property Address Owner O wner's Name information is l required for every GiMIA- page. City[Town State Zip Code►— Date of Ins ection D. System nformation 3 1. Residential Flow Conditions: S G e, S Number of bedrooms (design): Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): Description: / loot) 3 �lo•�,i�i�s w" �- �-� r,�� . 0 Number of current residents: Does residence have a garbage grinder? ❑ Yes No 7 Does residence have a water treatment unit? ❑ Yes No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes 'Co information in this report.) Laundry system inspected? ❑ Yes No Seasonaluse? ❑ Yes LkNo t Water meter readings, if available(last 2 years usage(gpd)): Detail: Sump pump? ❑ Y4 No Last Gate or occupancy: Date t5insp.doc-rev.U26=18 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 7 of 18 Commonwealth of Massachusetts P Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 3 ,o 6/4-0 Property Address bl7,e in Owner Owner's Name information is g4 required for every page. CityfTown &01State Zip Code Date of Irlspectfon D. System Information (cont.) 2. ComrriercialfIndustrial 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 Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: I Last date of occupancy/use: Date Other(describe below): i 3. . Pumping Records: �V 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: i t5msp.doe•rev.7/26=18 Title 5 Official Inspection Forth.Subsurface sewage Disposal System•Page 8 of 18 r Commonwealth of Massachusetts p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 30 C44 V I Property Address Owner Owner's Name 060'e' information is required for every lS page. City/Town State Zip Code Date ofinspe&ion D. SystemZInfor 'o (cost.) 4. Type of S 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/Altemative 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 com onents, date installed(if know )an source of information: Were sewage odors detected when arriving at the site? ❑ Yes �No 5. Building Sewer(locate on site plan): Depth below grade: feec Material of structi;40 �Stn PVC ❑ other(explain): 1/0 Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): t5insp.doc-rev.7/261=18 Title 5 Official Inspection Forth:Subsurface Sewage Disposal system-Page 9 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments go Property Address Owner Owner's Name information is C,NN�1 (!� daGO required for every page. CitylTown State Zip Code Date of Inspe on D. System Information (cost.) 6. Septic Tank(locate on site plan): d Depth below grade: feet Material of nstruction: oncrete ❑ 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: " Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle /W 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 How were dimensions determined? Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 0.0 L4 et►�h/ G✓�� f 6Sinsp.00c•rev.7/28f2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address Owner Owners Name - ] information is li►,1���1 /� Od co required for every �""s / page. City/Town State Zip Code Date of Inspe tion D. System Information (cont.) 7. 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.): 8. 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): r Dimensions: Capacity: gallons Design Flow: gallons per day onsp.doc-rev.R26=18 Tide 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 11 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments So G-/.�N RC Property Address Owner Owner's Name -,} ! )• information is required for every 1/�� V��O / /b o�d A���f _ page. City/Town State Zip Code Date of lofspecti6n D. System Information (cont.) 8. Tight or Holding Tank(cont.) 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 9. Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): vx t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments leo Property Address Owner Owner's Name information is � required for every a j4 11 Jjr page, City/Town State Zip Code Date of lnspecti 1 D. System"'Information (cont.) 10. 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.): * If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS)(locate on site plan, excavation not required): If SAS not located, explain why: Type / r f)1.✓J -�`I �( ` �� G_ f ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: -------- f5insp.doc•rev.7/26=18 Tide 5 official Inspection Form:Subsurface sewage Disposal System•Page 13 of 18 t Commonwealth of Massachusetts P Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments _ �✓_ _ �! Property Address 20 Owner Owner's Name information is / i� iI required for every Q � / yo�(7 page. City/Town State Zip Code Date of InspeLtion D. System Information (cont.) 11. Soil Absorption System (SAS)(cont.) Comments (note condition of soil,signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): V [n�►K &4,e �9/ a✓I Q✓td 01�//11 12. 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.): Sinsp.doc•rev.7/26/2018 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 I Commonwealth of Massachusetts �s P Title 5 Official Inspection Form Subsurface Sewage Disposal System F rm -Not for Voluntary Assessments .� Gee,,,, Property Address Owner Owners Name information is aNv1� ` /1�/] 0DC4/ V-C o-required for every page. City/Town State Zip Code Date ofIn D. System Information (cont.) 13. 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.): Oinsp.doc•rev.7262018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal Systemr�44' t'j -Not for Voluntary Assessments _ Property Address Owner Owner's Name /vJ� information is d 6D required for every r1tfS /T page. Cityrrown State Zip Code Date of In pectiofi D. System Information (cont.) 14. Sketch Of Sewage Disposal System: M of the s wage disposal system, including ties to at least two permanent reference c marks. Locate all wells within 100 feet. Locate where public water supply enters eck one of the boxes below: h in the area below ched separately )v - cd- 6 / L , i t.5insp.doc•rev.7262018 Tide 5 official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments '?0 C/ yA Property Address /n Owner Owner's Name information is required for every � ✓� tate /� page. C,tyfTown S Zip Code Date of Inspe lion D. System nformation (cont.) 15. Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells 01 Estimated depth to high ground water: 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 des how you est lihec�l�e high ground water ele7)7 n: -740 f —. COI.rL,4dA,� C� �. - -ro t1491 . S !sfdo y� ` �o�tavr Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.726/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 Commonwealth'of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal Syste Form -Not for Volunt Assessments 3/0 64le` Property Address Owner Owner's Name ` information is / required for every D�tO //Ao� page. Cityrrown State Zip Code Date of nspe tion E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: [v�A. Inspector Information: Complete all fields in this section. I ertification: Signed& Dated and 1, 2, 3, or 4 checked C. Inspection Summary: 1, 2, 3 r 5 completed as appropriate 4 ailure Criteria)and 6(Checklist)completed D. System Information: For 8:Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc•rev.7/26/2018 9 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 18 of 18 11/18/2020 Assessing As-Built Cards TOWN OF BARNSTABLE LOCATION 30 9 Ien 0. SEWAGE N VILLAGE �Vhm;S ASSESSOR'S MAP&LOT INSTALLER'S NAME dl PHONE NO. SEPTIC TANK CAPACITY LEACHING PAC=:(type) Vlo,44,5,43 (size)_10(_ to 4 NO.OF BEDROOMS BUILDEROROWNER �jrou�nS PERMrrDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility 10f"4 YQ Feet Private Water Supply Welland Leaching Facility (If any wens exist on site or within 20D feet of leaching facility) Feet Edge of Wedand and Leaching Facility(If any wetlands exist within 300 f ffhing aedity), Feet Furnished by a �r K N' 0o p • 14A'� �c 44 b' I https://www.townofbamstable.us/Departments/Assessing/Property_VaIues/HMdisplay.asp?mappar-288018&seq=1 1/2 T L0 AT oN4x SEWAGE PERMIT NO.,, VILLAGE Ain bo is m IN.STA LLER'S NAME & ADDRESS C � o� `S ee -ft � i B U It D E R OR OWNER DATE PERMIT. ISSUED 'DATE " CO-MPLIANCE ISSUED C1 =k N Y7 &2rAfz" S1 ; � i' . • �' r44 # 1 t a a C b cc C�+ n �r d f• ..............3.-/0 FES............................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...........................................OF..........................................---....----•------.................._........... Appliration for 13iopasal Workii Tonotrnr#ion "rrmi# Application is hereby made for a Permit to Construct ( ) or Repair (Do an Individual Sewage Disposal System at: n n ............................................. .....................................•---.........................-•----........-----••---•----... (� Location-Address or Lot No. �? ................................ ................................................... Owner Address t aY�Y Y�.S....:... .................... t...^........ Installer Address QType of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms....... --............................Expansion Attic ( ) Garbage Grinder ( ) A4 Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) a' Other fixtures ..----•.............•-•---•••• .... W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacityAQP9.galIons Length................ Width.................Diameter................ Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No.... 'a............ Diameter...e-(.Y_18.... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ✓r . Dosing tank ( ) . aPercolation Test Results Performed by..........•............................................................... Date........................................ Test Pit No. .1................minutes per inch Depth of Test Pit.................... Depth to ground water......................... Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ •-•••-•-••-•••••••--•---•---••-•••••-•................••••..........................._............_............................._..........._................ 0 Description of Soil........................................................................................................................................................................ U -••••••........•---••-•-••-••••••••••••••-••-•-••-•••••••-•••••••••................•••••......•••--•••-----•••••-----.......---•••••••••••-•••-•••...•••-••••••••••••••••--•...................._...... �1 .................................................................................................................................................................. K .. Re V ature of airs or Alter tions—Answer wheq applicable•.15—enm).---- i .�QA..- • ..........Sal. • l F1- Agreement: The undersigned agrees to install the aforedescribed. Individual Se a Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Code— h ndersi ed urther agrees not to place the system in operation until a Certificate of Compliance has been ' e of ealth. igned•.;•• •.............. ............ /..................................... .... ..._.... Application Approved By... ......... ..................••-•..._......................................•... ll .�o • ------•----....-•---•-- Date Application Disapproved r e following reasons-------------------------------------------------•-----...._..--------------...-----•-•-•--------------........ ............................................•------....._.....---••------------.............-----..........----•--•------•-•--......................------------•--- --....Date----........-- PermitNo......................................................... Issued........................................................ Date FEB............................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................0 F......................................................................................... Appliration for Uhipoiial Workii TomitrurtiAn Vamit Application is,hgeby made for a Permit to Construct ( ) or Repair (V,) an Individual Sewage Disposal System at: �L'.�[n. o.�z. ,: ..................................•____ ......_.._..___--•-...._._....___.._............................................................. (~ n ocation-A`�ess or Lot No. �'?�.o �,hr..... :C]:�.16.:t'-! ._...... ..-•-•--•••......_..: ..........................................:....:..__ Owner �' Address sa.,c�cif,._..... Sc�_acrl ..n__S_r.__.. .2...:`Lfl2.mm.. •--••-• Installer Address Q Type of Building' Size Lot............................Sq. feet U Dwelling— No. of Bedrooms........ -__............................Expansion Attic ( ) Garbage.Grinder ( ) Other—Type T e of Building ____________________________ No. of persons............ Showers p., yp g p ( ) — Cafeteria ( ) Q" Other fixtures ......_____-•••--•-•--••_....... - -•-•-•-.... ---------------- W Design Flow............................................gallons per person per day. Total daily flow..._.____.__._.____._.._.....___._...__.____gallons. WSeptic Tank—Liquid'capacity..kQO-Q_gallons Length................ Width................ Diameter................ Depth..............:. WDisposal Trench No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No...... ........... Diameter.... :?t_a---- Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ✓f Dosing tank ( ) . aPercolation Test Results Performed by........................................................................... -Date........................................ Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water......................... G14 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ -------•---------------------------------------------------------.......... -............................................................._ .......--_....•. 0 Description of Soil....•-------•-•••-••--••--•-••---•...........................••-••--•••••-•-•--•-•-•---•••-•-•------•-•-----•--•-----•-••-•-•-•------•-••-•••-_._.__.___.........._.._.. x VW •--••-•..................•-•---•---•----•••-••••-•-••-••••••---••---••--•--••---•-•••-•-•-----•••••----••-••-••=•••••-•••-•-----•-••--•--•--••-•••••--•--•••- ature of Repairs or Alter ions— nswer -when,applicable._eC�_YY!!J. =4.. _,� .__._�.�.S_a_ .�. . 2�^4.�._3'�ao:vS.i _�n _. t : can_.' A_s�t .... -•-r.lc�......................... '......................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Code— h ndersi d further agrees not to place the system in '! operation until a Certificate of Compliance has been t e of 14ealth. ined. -:_:' ...... .. . - ------=-------•-______.._.._..._ /�'V. g t . AppliApplication Approved By--- cation ..... ••--:-•••::............•••-•---•-•••-••--•••-•••-..........•-•••••-- '�.( . Date Application Disapproved r t e following reasons:-----•------•---------•--•-•--••-•-•-•••--•-•-•-•----•-•---__-••••••---•..............•• ________--•-•-_... ••-------•-----------••---••---•-•-•-------•----•--••••-•-••----•--•-•--•____________________________••..••---••--•--••....--•••--••-----•--•---•-•-•-••-----•--•-•---••-.............................. Date PermitNo......................................................... Issued-........................................................ Date O� THE COMMONWEALTH OF MASSACHUSETTS BOARDt OF HEALTH ..........................................OF.:........`.:.....': ............................................._......__•__....... Trrtifiratr of 'fin tpiiaurr TJII S TO CERTIFY, That the Individual Sewage Disposal,�4System constructed (, ) or Repaired b .:_ ______________y..:. .. . ......... ._______ •-•••...............•-•-•---•--..............--•--••••--- �" � t� , Installer - .... ..... at. =_-- ------•-------•-•••------••-•-.....--•------•-•-•--•---•-•..................... ..... has',been installed in accordance with the provisions of TI LE 5 of Tlie tate Sanitary Coe as a ibed in the 'application—for Disposal Works Construction Permit No..__ __`". ._. ______ dated_f.,__l'o ...:_:. ...THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRU AS GUARANTEE THAT THE SYSTEM WILY FU CTION SATISFACTORY. DATE....`Z_- ,O10.._..------•________________________________________ Inspector ... •-'- ......._. P THE COMMONWEALTH MASSACHUSETTS BOARD OF HEALTH ............OF.......................... �� No... ... .'.�3 FEE.:._-_-:................ �i��� �rk� �ua��t��rti�n rrmit • Permission is reby granted_.. 4 '' ^-__.....--.--.....-•-•-•-•----•----•----•••.........................•-••---•._...._.._.................... to Construct (4' o r r r ( as Individual Sewage Disposal System at No. (�� �/!'f' •-•__ -•................................... -------------------------- Street as shown on the applica 'on for Disposal Works Construction Permit No.............. ated.......................................... ______________________ •--:..-------•----------•--......---____._._...___•--•-___...._ oard of Health r DATE... /. _/4 FORM 1255 A. M. SULKIN, INC., BOSTON - _ John Grad D.E.P. Title V Septic Inspector 564-6813 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Address of. property 3d -Glen Owner's name Date.-of --Inspection PART A - - CHECKLIST Check if the following have been done: - - �f Pumping iif_ormation ,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. ✓ As built plans have been obtained and examined. Note if they are not available .with N/A. / The facility or dwelling was inspected for signs of sewage back-up. The site was inspected for signs of breakout. All system components, excluding the SAS, 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 tees, material of construction, 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. I SUBSURFACE SEWAGE DISPOSAL-.SYSTEM INSPECTION FORM PART B . . - _ SYSTEM INFORMATION : FLOW CONDITIONS - _. If residential -- : number of bedrooms _ _ number of current residents tgarbage grinder, yes. or no eS laundry connected_to 'system., yes -or no seasonal use, yes or no If nonresidential, calculated flow: - - Water meter -readings, if available: ec'r/1 � Last date of occupancy GENERAL INFORMATION Pumping records and source of information: System pumped as part of inspection, yes or no if yes, volume pumped Reason for pumping: Ty 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) Other (explain) Approximate age of all components. Date installed, if known. Source of information: Nei. /63 410 Sewage odors detected when arriving at the site, yes or no -, . _ ; �,,,•,ki,b�,�i•.#;..'��,icr�' .. '"p;s,.:�::�` ..... "� . - .'t"tee -' '_..._ 1'f ,�. �. •_----------- 7�..,ls...._.. 1 9 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION continued SEPTIC TANK: - (locate on site plan) -- depth below grade: - material- of construction: concrete metal FRP other(explain) dimensions: L sludge depth _ ---_ 114 distance from top of sludge to bottom of outlet- tee or baffle 0 scum thickness T - to distance from top of scum to top of outlet tee or baffle 0 '. distance from bottom of scum to bottom ofoutlet 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. ) 5o11 5�ovlj he PvnPe6 ever] t ro 4 -64rs tO KeIeO .vS f-ZN ;A tiZd y..ock-'ng o..-&g DISTRIBUTION BOX: (locate on site plan) Lie Mo ; e 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. ) PUMP CHAMBER:. .2 (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. ) s I r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION continued SOIL; ABSORPTION SYSTEM. (SAS) : - (locate' on site plan, if possible; excavation- not required, but may be approximated by non-intrusive methods)- If not determined to be present,. explain: Type - leaching pits and number leaching chambers and number _ F'l�w S w: h �� o, S ec ar©��.! }t�74, 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 o vegetationq recommendations for maintenance or repairs, etc. ) s _ S V S �► t5 �`� �cx9d ems►-K�%� or��r CESSPOOLS (locate on site plan) : I 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: (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. ) • 11 i� SUBSURFACE.' SEWAGE DISPOSAL SYSTEM ZNBPECTION FORM _ - PART B _ - SYSTEM. INFORMATION continued - 1 SKETCH OF ..SEWAGE DISPOSAL SYSTEM: i_n.clude tit s_ to at least .two permanent references landmarks or benchmarks. ' locate :al.l wells. within 100 ' - - - C ; �A 'b' C' �B 3� L u1q , �° DEPTH TO GROUNDWATER fU . 0 depth to groundwater "method of determination or approximation: i -SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C FAILURE CRITERIA ---- --Indica-te--,yes--- -no, or not determined (Y., N, or ND) . Describe basis of determination in all instances. -If "not determined", e;-.plain why not) Backup'. of sewage into facility? - _ .Discharge or ponding of effluent to the surface of the-ground or surface waters. .- - Static liquid level in the distribution box above out-l-et- invert? - Liquid depth in cesspool <6" below invert oravailable lable volume< 1/2 day I. Required pumping 4 times or more in the last ear? number of times pumped y 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? N 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) ? within 50 feet of a private water supply well? Al 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 analy: for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. r s 13 . . _ SUBSURFACE SEWAGE DISPOSAL SYSTEM -INSPECTION. FORM _ PART D - ;'- - CERTIFICATION - Name of Inspector _ JOHN GRACI _- Company Name TitleTlInspector. P.O.Box 2119 Company,Address Teaticket, MA 02536 -. 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 manitenance of on-site sewage disposal systems. Ch k 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 environment as defined in 310 CMR 15. 303 . The basis for this determination is provided in the FAILURE CRITERIA section of this forma Inspector' s Signature a - Date Original to system owner Copies to: Buyer (if applicable) Approving authority 1 ;i