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HomeMy WebLinkAbout0324 BRIDGE STREET - Health j 6t, usterville - oq3--0�8 - Ala T S d a { a c r 4 oa } ::. COMMONWEALTH OF MASSACHUSETTS' EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTALTROTECTION TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A x O CERTIFICATIN s - - Property Address:. 1 Ga© v t�StuiZ AOwner's Name: Owner's Address: f ?%d�xc , r `. �C. Date of Inspection:/ R ; N Name of Inspector: please print) -+ �--� . :tZr�` ' Company Name MAID s'001 Mailing Address: -0- /ram y 1y& /-/-- �° TOVV11,OF b Lvr i,45'lAdLE - HEALTH ADEPT. Telephone Number: l' . L4-- - 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 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 toSection 15.340 of Title 5(310 CMR 15.000).-The system: -I/Passes f Conditionally Passes ee urther Evaluation by the Local Approving Authority Fail's Signature' Date: 3— Inspector's � t 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. k Notes and Comments ' This report only descril3es conditions at the time of inspection and tinder 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.. + �. .. 1. F, ' - f, P ^"'. , �,sY r • r „ +` x . - a : : Title 5,InspectionForm+ 6/1..f/2000 ,; � " page I. Page 2 of l 1 OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: ? Owner: � _ Date of Inspe`ion: ��J Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. ystem Passes: I have not found any.information which indicates that any of the failure criteria described in 310 CMR ]5.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: i 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 theseptic 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 s'tatic.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: inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed - 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: 2 Page 3 of 1'1 OFFICIAL INSPECTION.FORM- NOT FOR VOLUNTARY'ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A , f CERTIFICATION(continued) Property Address: Owner: - - Date of Ins action: •3 ,11b/ 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 aseptic 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. Y The system has a septic tank and SAS and the SAS is,within a Zone I of a public water supply. _ The system has a septic tank and SAS and the SAS is within.50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than 100.feet but 50 feet or more from a private water supply well".Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform bacteria 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,provided that no other failure criteria are triggered.A,copy,of the analysis must be attached.to this form. Y 3. Other: 3 Page 4 of 11 OFFICIAL.INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTSM SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: (/ (21$P.i Dwz& yt. 74 Owners C LQ T Date of Insp tion: `? Q D. System Failure'Ceiteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes N Backup of sewage into facility or system component due to over or clogged SAS or cesspool 1 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 A clog0ged SAS or / cesspool Liquid depth in cesspool is less than 6"below invert or available volume is less than 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 groundwater elevation. Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. U1 Any portion of a cesspool or privy is within a Zone 1 of a public well. _ �/- Any portion of a cesspool or privy is within 50.feet of a private water supply well. 2 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 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,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems:. To be considered a large'system the system must serve a facility with a-design flow of 10,000 gpd to.15,000 gpd• You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) . 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—IW_ PA)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 " 1. 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. 4 Page 5 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: -1('A Owner: / Date of Insp ction: -�� �f!?l Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Ye�/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 breakout? _ V11 — 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 Syste r.(SAS)on he site has been determined based one Yes no _ 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(3)(b)]. . ,i Y 5 Page 6 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION.FORM KART C SYSTEM INFORMATION Property Address: w �fi �e A ,4 Owner: , Date of Insp tion: J O/ FLOW CONDITIONS. RESIDENTIAL !/ Number of bedrooms(design): �}... Number of bedrooms(actual):. �. DESIGN flow based on 310 CMR 15.203(for example: 11.0 gpd x#of bedrooms): l� Number of current residents:7h' Does residence 1ave.a garbage.grinder(yes or no):, Is laundry on a separate sewage.system(yes or no):/2—&Iif yes separate inspection required] Laundry system inspected(yes or no):� j� Seasonal use: (yes or no): .. Water meter readings, if av,101able(last 2 years usage(gpd)): Sump pump(yes or no): �/ Last date of occupancy: ,n •p.�t.ih �-A 09k, COMMERCIAL/INDUSTRIAL/"X Type of establishment: Design flow_(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes.orno): Industrial waste holding tank present(yes or no):_ Non-sanitary waste discharged to the Title 5 system(yes or no):_ Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Was system pumped as':part of the i specti (yes or no): If yes, volume pumped: gallons--How was quantify 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) _Tight tank _Attach a copy of the DEP approval Other(describe): Approximate a-e of all components,date install(if known)and source of information: Were sewage odors detected when arriving at the site-(yes or no): -2t&— 6 f Page 7 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: ( ,4 r Owner:: Date of Ins ction: BUILDING SEWER(locate.on site plan) 11 /ter Depth.below grade: Materials of construction:_cast iron. 40 PVC other(explain):- Distance from private water supply well or suction liner Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: locate on site plan) Depth below grade:/a Material of construction: /concrete_metal_fiberglass _polyethylene —other(explain) If tank is metal list age:_ Is aoe confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) V Dimensions: 10,6'X &`x5 Sludge depth: " Distance from top of sludge to bottom of outlet tee or baffle: J �l Scum thickness: Aoxe- 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:,2Agv� <VA 1,- Comments(on pumping recommendations, inlet and outlet tee or baffle condition;structural integrity, liquid levels as related to outlet invert evidence of leakage, GREASE TRAP:i11,g_(Locate on.site plan). 4i a, {` Depth below gradee: 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: Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid,levels as.related to,outlet invert,evidence of leakage,etc.): 7 Page 8 of 11 OFFICIAL INSPECTION FORM.—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE:SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: r � Owner:�_ Date of Inspe tion: '3/,p 17'o TIGHT or HOLDING TANIS�(tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass_polyethylene other(explain): Dimensions- Capacity: gallons Design Flow: 'Eallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of fast pumping: Comments(condition of alarm and Tioat switches, etc.): DISTRIBUTION BOX: (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: ��tionto Comments(note if box is level and distriut 1 equal,any evidence of solids carryover,any evidence of ak 1_ ae into or out of box,etc.): _ o! r, PUMP CHAMBER, -(locate on site plan) Pumps in working order(yes or no): Alarms in working order_(yes or no):. Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): 8 Page 9 of 11 ' OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE,SEWAGE DISPOSAL SYSTEM INSPECTION FORM I PART. C SYSTEM INFORMATION(continued) Property Address: C Owner: Date of Insl6ection: ,3 f of D/ SOIL ABSORPTION SYSTEM (SAS): i/ (locate on site plan,excavation not required) If SAS not located explain why: Type < leaching.pits,number: ' eaching chambers,number: i/ 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 e /-)'' / ,to CESSPOOLSA/,"(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 or no): Comments(note condition of soil,signs ofhydraulic failure,.level of pondina,;condition.of vegetation;etc.): PRIVY-%CPJ—(iocate,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.): tq 9 Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: � Qy Owner: Date ofdnspe tion: U� SKETCH OF SEWAGE DISPOSAL.SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet.Locate where public water supply enters the building. ' S s O G'- i d9 �I o 10 Page I I of I 1 ♦P . - OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C . SYSTEM INFORMATION(continued) I � h ' Property Address: 9 AgIZ ,.1r11 Otis r?ia�T�• cq Owner: Date of Inspe ion: O% SITE EXAM. Slope Surface water Check cellar. Shallow wells Estimated depth to groundwater feet Please indicate(check).all methods used to determine the high groundwater elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) , Checked-with local Board of Health-explain: �hecked with local excavators,installers-(attach documentation) /Accessed USGS database-explain: You must describe how you established the high ground water elevation: '0006� COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS `t DEPARTMENT OF ENVIRONMENTAL PROTECTIO' �j ONE WINTER STREET. BOSTON, r,tA 02108 617-29'•"00 T;-D`. uILLI.\>t F HELD Go%cmor ti � - ,RGEO PALL CELII'CCI �� '` D.-\ 10 5 S, Li Govcmor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSP ON ►"" '�OJOJ C, .-. PART A tL�J CERTIFICATION OG� �E00�1� Pro a Address: Osterville Address of O 1o�'NV P m 3?��/ 5�dge Street (If different) Date of Inspection: 97 Name of Inspector: Jc)qp h 'P_MAC O MBER Jr. 6' `► I am a DEP a proved system inspector pursuant to Section 15.340 of Title 5 (310 C 15 00 Company Name: Y•P•Macomber & Son Inc.. Mailing Address: BOX 66 Centerville,Mass . 02632 Telephone Number: rnF3_77S_���$ CERTIFICATION STATEMENT I cen,fy that I have personally inspecned the sewage disposal system at this address and that the information reponed Delow is ut,e. acc_ and complete as of the time of inspection. The inspection was performed based on my training and experience in the proDer fvncl-on if maintenance of on-site sewage disposal systems. The system: L/ Passes Conditionally Passes Needs Funher Evaluation By the local Approving Authority Fails Inspector's Signature: Date: ��'� 7�7 The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (30) days of completing In:, inspecl-on If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system ov.T,er snj!i s,D, the repon to the appropriate regional office of the Department of Environmental Protection The original should ce sent to :r,e s.veT• o, and copies sent to the buyer, if applicable, and the approving authority. INSPECTION SUMMARY: Check A, B, C, or D: AI SYSTEM PASSES: I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 C�• > ? Any failure criteria not evaluated are indicated below. COMMENTS: BJ SYSTEM CONDITIONALLY PASSES: One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. 'ne s,s:e— . completion of the replacement or repair, as approved by the Board of Health, will pass. Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If "not determined-, exp a n _n, no: ' The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Cen-:,c2ie o Compliance (artached) indicating that the tank was installed within twenty (20) years prior to the date of the ns -c on the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or ex'iltralion p• t. failure is imminent. The. system will pass inspection if the existing septic tank is replaced with a conform.ng as approved by the Board of Health. (r•vis.d 04/1s/97) Fag• 1 of 10 DEP on the Wono Woe Weo nnp rrwww magnet state ma uvaep Pnnleo on Recycjw Paper 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Propeny Address:324 Bridge Street Osterville Ma O.ner: Robert Stout Date of Inspection: 1 0/1 5/97 B) SYSTEM CONDITIONALLY PASSES (continued) Sewage backup or breakout or high static water level observed in the distribution box is due to oro'.en o oos: pipets) or due to a broken, senled or uneven distribution box The system will pass inspe(i,on ,i tw,!n aD ro•d _ Board of Health). Describe observations: broken pipets) are replaced obstruction is removed distribution box is levelled or replaced AZQ The system required pumping more than four times a year due to broken or obsirucied pipe(s) The system ass ,nspect,on ,f(with approval of the Board of Health) broken pipe(s) are replaced obsuuct,on ,s removed C) FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: t)1]_ Conditions exist which require funher evaluation by the Board of Health in order to determine if the system ,s iadl ng 10 :-•e public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: AM Cesspool or privy ,s within 50 feet of a surface water Cesspool or privy ,s within 50 feet of a bordering vegetated wetland or a salt marsh 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERmuN;S T-ta1 THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet to a suriacc waters oo• (ribuiary to a surface water supply. The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supat; »eu The system has a septic tank and soil absorption system and the SAS is within 50 fee( of a pr,va(e water s oo -•e,. ,J The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 fe-et c, more L, -n a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compocncs nc•ca:e+ the well ,s free from pollution from that facility and the presence of ammonia nitrogen and nitrate n,,rogen s E---_a :D o less than 5 ppm. Method used to determine distance .V"k (approximation not valid) 3) OTHER dCiT 2 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOR.m PART A CERTIFICATION (continued) Property Address:324 Bridge Street Osterville eta Owner: Robert Stout Date of Inspection: 1 0/1 5/97 DI SYSTEM FAILS you must indicate e.. er "Yes' or "No' as to each of the following I have determined that the system violates one or more of the following failure criteria as deflnec ,n 310 C'• c t i :^= e c=' for this determination Is Identified below. The Board of Health should be contacted to determine what will b? the failure Yes No Backup of sewage Into facility or system component due to an overloaded or clogged SAS cr cessoeo; 1/ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaeec or rogge­ cesspool. Static liquid level In the distribution box above outle Invent due to an overloaded or clogged SAS o cess.co Liquid depth in less than 6" below Inven or available volume is less than 1:2 da: 8 mpin Pired Required u more than 4 times in the last year NOT due to clogged or obstrvcteo Number of times pumped Any ponlon of the Soil Absorption System, cesspool or privy is below the high groundwater ele\a.i Any ponlon of a cesspool or privy Is within 100 feet of a surface water supply or ulbulan :o a s.1a_e -ate! &/ Any ponron of a cesspool or privy is within a Zone I of a public well. Any ponron of a cesspool or privy Is within 50 feet of a private water supply well. Any ponlon of a cesspool or privy Is less than 100 feet but greater than 50 feet from a private -a:er suo:l. -e I . acceptable water quality analysis if the well has been analyzed to be acceptable, anach cosy of wen wa;e, ar•a vs,s :c collform baeieria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen E) LARCE SYSTEM FAILS: You most Indicate either "Yes" or "No" as to each of the following. The following criteria apply to large systems In addition to the criteria above The system serves a facillry with a design flow of 10,000 gpd or greater (Large System) and the system is a s,xrn, rc-­ public health and safety and the environment because one or more of the following conditions exist Yes No eV4 the system Is within 400 feet of a surface drinking water supply �(1A the system Is within 100 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area (Interim Wellhead Proteeiion Area • IWPA) or a r^acDrc Zo^.e c a public water supply well) The owner or operator of any such system shall bring the system and facility into full compliance with the groundha:el !rea me c =3 �— requlrements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Depanment for further i'nior•ma:ic Ic•v�•.d 0�/7!/971 D•q• J of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 324 Bridge Street Osterville Ma Owner: Robert Stout Date of Inspection: 1 0/1 5/9 7 Check if the following have been done. You must indicate either "Yes" or "No" as to each of the following Yes No � Pumping information was provided by the owner, occupant, or Board of Health. lZ/' None of the system components have been pumped for at least two weeks and the system has been receiving rc,mai now rates during that period. large volumes of water have not been introduced into the system recen:l as pan 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 system does not receive non-sanitary or industrial waste flow. 4 _ The site was inspected for signs of breakout. All system components, WIuding 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 o7 baffles or tees, 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. The facilrry owner land occupants, if different from owner) were provided with information on (he Groper mamten nce c, Sub-Surface Disposal System _ Existing information. Ex. Plan at B.O.H. _ Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unaccep(able) (I5.302(3)(b)) (r.vl..d 01/)5/97) .Yap. 4 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Properly Address:324 Bridge Street Osterville Ma owner: Robert Stout Date of Inspection: 1 O/1 5/97 FLOW CONDITIONS RESIDENTIAL:', Design now :VAO > p.d./bedroom for S.A.S. Number of bedrooms: Number of current residents:D Garbage grinder (yes or no):_y%_'1 Laundry connected to system (yes or no): S _a6y 000 06-:GP'I Seasonal use (yes or no): 4r p Water meter readings, if�vailable (last two (2) year usage (gpd): /�- qt, &- •5� 'D ` Sump Pump (yes or no): Last date of occupancy AA"O't4e I'so-wr COMMERCIAUINDUSTRIAL: Type of establishment V9 Design ilow: Al>f_gallons/day Grease trap present: (yes or no)& Industrial Waste Holding Tank present: (yes or no)-& Non-sanitary waste discharged to the Title 5 system: (yes or no)" _ Water meter readings. if available. A/A Last date of occupancy. OTHER: (Describe) Aze Last date of occupancy _� GENERAL INFORMATION PUMPING RECORDS and urce of information: ,1)A'IL- System pumped as pan of inspection: (yes or no)X0 If yes, volume pumped: t-,V gallons Reason for pumping ltJr TYPE Of,,5,YSTEM Septic lank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy X)N Shared system (yes or no) (if yes, anach previous inspection records, if any) 410 I/A Technology etc. Copy of up to date contract? Other JV'4 APPR XIMATE AGE of all components, date installed (if known) and source of information: 7,7 , ,. �- •� Sewage odors detected when arriving at the site: (yes or no) lull (r.yl..d 04/25/97) _ P.9. 5 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Addreis:324 Bridge Street Osterville Ma owner: Robert Stout Date of Inspection: 10/1 5/97 BUILDING SEWER: ;Locate on site plan) i/ Depth below grade j�1 Material of construCllon Cast If0r) C PVC _ other (explain) D.stance from private water supply well or suction line D,ameter 1 Comments tcond,tron of lornts, ve (mg, evidence of leakage, etc.) s t f SEPTIC TANK:z ;locate on site plan! ♦r II Depth below grade � %,%alet.al of construction. concrete _metal _Fiberglass _Polyethylene _other(explaln) It tank is metal, list age /)_, Is age confirmed by Cenificate of Compliance (Yes/No) D,mens.ons f/ hY�G// 111z'0 C � ` °� ' wde, Stooge depth _ 11 D,stance from top of sludge to bonom of outlet tee or baffle: _ Scorn thickness Distance Irom top of scum to top of outlet tee or baffle. D,stance from bonom of scum to bonom of outlet''tee o,fJJbaffle riow dimens,ons were determined. Comments Irecommendaocin for pumping, cond,t,oJf of Inlet and outlet tees or baffles, depth of liquid level in relation to outlet nve.,i. slr�c._:3- nteggn evidence of le kage, etc ) ♦6i Tlol� i'"i� iD,(i�'/ �/. cL.r�.�,�T D� /lsf 5'Zl r r� S a-C / ` GREASE TRAP:�f� [locate on site plan) Depth below grade'VII Mater al of constructlo>4AconcretagJ,�metaVlAFiberglass,r/APolyethylene4!Ather(explain) x4d D'menslons: zle Scum thickness., Distance from top of scum to top of outlet tee or baffler D,stance from bonom of scum to bonom of outlet tee or baffle. A!2 gate of last pumping .e- C omments vecommendatlon for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet ,name^ ntegnry. evidence of leakage, etc.) I` Ir•vi••d 0�/75/9)1 P•q• 6 0� 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C .SYSTEM INFORMATION (continued) Property Address: 324 Bridge Street Osterville Ma Owner: Robert Stout Date of Inspection: 1 0/1 5/97 TIGHT OR HOLDING TANK: ONCJank must be pumped prior to, or at time, of inspection) (locate on site plan) Depth below grade Material of con struction*Aconcrete444metal/Y,¢FiberglassV,-9PolyethyleneK�other(explain) Dimensions: V4 Capacity: A14 gallons Design flow. _ gallons/day Alarm level: Alarm in working ordet4/4 Yeses No Date_of previous pumping: tw Comments (condition of nlet tee, condition of alarm and float switches, etc ) DISTRIBUTION BOX: (locate on site plan) Depth o: liquid level above outlet inven:1'e__ Comments (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) le file C� !/0 T 0�= PUMP CHAN/BER: e —P (loc.atc on site plan) Pumps in working order: (Yes or No) g Alarms in working order (Yes or NO) � Comments: In condition pf pump hambe r condition of pumps s and appunenances, etc eJ� tr.vi..d 04/2s/97) P.g. 7 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address:324 Bridge Street Osterville Ma Owner: Robert Stout Date of Inspection: 10/1 5/97 SOIL ABSORPTION SYSTEM (SAS):z ;locate on site plan, if possible: excavation not required, but may be approximated by non intrusive methods) If not determined to be present, explain: Type leaching pits, number: � I�1 leaching chambers, numberAj�L7rr��ors leaching galleries, number: leaching trenches, number,length:�-- leaching fields, number, dimensions: (y overflow cesspool, number:Q Alternative system A.,74 Name of Technology 't Comments (note condition of soil, sign of hydr ulic failure, eve l of ponding, 4ondition o vegetat on, etc A L- y�1 f—rst CESSPOOLS:abWC- (Iocate on site plan) Number and configuration: 4/4 Depth-top of liquid to inlet rnven: 4�,d Depth of solids layer: A44 Depth of scum layer: xiv Dimensions of cesspool. Materials of construction: Indication of groundwater: 720-9 inflow (cesspool must be pumped as pan of inspection) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc,) PRIVY: / '(de— (locate on site plan) Materials of construction: Dimensions Depth of solids:6W Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) ✓ tr•v1a.d 04/35/27) P•9• B of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C 'r SYSTEM INFORMATION (continued) Propeny Address: 324 Bridge Street Osterville Ma Owner: Robert Stout Date oltnspeclio^ 1 0/1 5/9 7 SKEZCH OF SEWAGE DISPOSAL SYSTEM: �ncivde t,es to at least two permanent references landmarks or benchmarks locate all wells within 100' (locate where public water supply comes into house) I 01 1 j 1 � 1 s Cr , 0 t I VU� 0 I I I (9-1—d Or/75/57) P.g. 9 of 10 J SUBSURFACE SEWAGE DISP SYSTEM INSPECTION FORM I C SYSTEM INFOI. . :ION (continued) Proper,y Address:324 Bridge Street Osterville Ma O..ner: Robert Stout Date of Inspection:1 O/1 S/9 / r Depth to Croundwalet// r !Feet Please indicate all the methods used to determine High CroundwaiV HV a!ion: _ Oota.ned from Design Plans on record Oblervat.on of Site (Abuning prope(Ty. observat,on hole. basement•sjmp etc.) Determine it from local conditions Check with local Board of health Check FEM^~saps �eck pumping records Check local excavators. installers _ Use USGS Data Desc,oe n your own cords how you established the High GrouncK xcr-E evation. (Must be completed) Installed system in July of 93 Infiltraors 4 ' 4" off the water table. (r•rl•.e 01/75/f71 P•S• of 10 �.•+-n+rr-Tt-•.rn-m.•n*s-rrr,+n rrr.rrR:•.�r+e+a.r:++r+•+mn nenmy ns�mar.rn mvn+-�a-.rr-srn-rr+-r-+-. _ _ Barnstable '1'UHN OF BOARD OF HEALTH SUIISURFACF SEHAGE DISPOSAL SYSTEM INSI'FCTION FORM - PART D - CF11TIFICATI0t1 �- �•..s.- r .--.ir.-. „n-.-n•n:.nr,.rnm+r.rT,-,r-•.,•• mr-�mnvr'�-n+r�vw�rmvn.+'s-tw••rsrt mnn�mr�.r.rr-rrr.,-.r._-.-r.-.r _. _. , -TYPL OR PRINT CI,EARLY•- PROPERTY INSPECTED STREET ADDRESS 3 44 Bridge Street Osterville,Mass. ASSESSORS MAP , DLOCK AND PARCEL # OWNER' s NAME Stout PART D - CERTIFICATION NAME OF INSPECTOR Joseph P. Macomber Jr . COMPANY NAME Joseph P. Macomber & 'Son, Inc . COMPANY ADDRESS Box 66 Centerville , Ma. 02632-0066 S tr9Pt Town or City Stat• I I P COMPANY TELEPHONE (508 775 -3338 FAX ( 508 ) 790 -1 578 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system nt 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 ne : System PASSED The inspection which I have conducted has 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 failtile criteria not evaluated are as stated in the FAILURE CRITERIA section of this form , System FAILED* The inspection which I have con�ilcted has found that the system fails to protect the 'Public health and the environment in accordance with Title 5 , 310 CMR 15 . 303 , and as specifically noted on PART C - FAILURE CRITERIA of this inspection form . e Inspector Signature Date One copy of this certification must be provided to the OWNER, the BUYER ( where app11cable ) and the BOARD OF HEAL111. • If the inspection FAILED, the owner or oporator shall upgrade within one year of the date of the inspection , unless allowed ortrequiredm otherwise as provided in 3.10 CMR 16 . 305 . partd . doc � r lJ � Z7 7 I'7 THE COMMONWEALTH OF MA.SSACHUSET'T'S DEPARTT\! ENT OF ENVJRONMMA NTAL PROTECTION DE IT KNOWN THAT Joseph P. Macomber, Jr. Has satisfied the De arnnent's ualificati ns as required - P q 4 q d and is hereby authorized to use the title CER i D TITLE S SYSTEM STEM INSPECTOR as provided M 310 CMR 15 .340 and Section 13 of Chapter 21 A of the General Laws_ Issued by Tile Department of Environmental Protection. Jur.< H, 1995 - ----._-- --- -------IJ - ncimp, Uircctor of the I c ion of wi(cr ['011u(101) control a i TOWN OF BARNSTABLE I.00AiION,32 y I�/-/c15 SST _SEWAGE # Q e' VILLAGE ASSESSOR'S MAP & LOT INSTALLER'S NAME & PHONE NO. J_,/7 wG�z•�,j r,� ZI SEPTIC TANK CAPACITY G a -LEACHING FACILITY:(type) 7L n P,"!1 r��%Gr,s (size) NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER DATE PERMIT ISSUED: 4,_ 3 DATE COMPLIANCE ISSUED: :2- VARIANCE GRANTED: Yes No ` } - _ .� .^ _ _ �..�- -ti �t �` �-� [.� . � i ♦ } 1 � �q��Cr � ,� �• ���� "b � � � 3 � 2 5� �1, •�u -� - - �- o , - C LI) " Q Fps.....�....�.......r....r�.. THE COMMONWEALTH OF MASSACHUSETTS APPROVED BOARD OF HEALTH ftrn8Wb10 CMMfVMWn OcXMn9nt TOWN OF B A R N ST A B L E ZA —/—F,3 ,� lffio� �i►���1��! �uxlt,� C�>agt��r�r�tnn leruti� Application is hereby made for a Permit to Construct ( ) or Repair �X) an Individual Sewage Disposal System at: 324 Bridge Street Osterville ...........................................................••--------------•••••.................. ••-••-•--------•--••••--••-•-•-•••-•----••.....•-•----•-..........•--•••..........-•-•............ Stout Location-Address or Lot No. .................................................................................................. -•--•------•------••--•-------•-•-•............................................................... O,cncr Address W J.P.Macomber Jr. Installer Address Type of Building Size Lot............................Sq. feet Dwelling x No. of Bedrooms----------------------------_ . _ .Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building ............................ No. of persons.-.---.---------------..---- Showers ( ) - Cafeteria ( ) WDesign Flow.Other fixtures-----------------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 b .................................................... Date........................................ Test Pit No. I................minutes per inch Depth of Test Pit....--.............. Depth to ground water....-------...-......... LZo Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ R+ s ............................ ......................................................... ODescrMfondof�c o ................•---.....------......--..............------••----------....-------------------------•---------------------------•--...................... x ravel ......................................................... W ----•--•------------------- --------------------------------- .............................................. ----.........:.-------------------------------------------------•-----•------......... x -1500 -,allon tanl£- um •--- - U Nature of Repairs or Alterat�ns—Answer when applicable................... p . .�2 ch�.ml�.er-. 1-pump-light-alrm infiltrators . 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 isslaed b the bond of health. ��/ 5/2�+/93 Signed .... .. ... ..................... ./.....���. `..`.�...�..�..............-........... .......................... • ..:- - Dare Q Application Approved By . sr�5� ...... .....*- �.."1..3... .............--- ---.... .. .......�.� \..--------..............-............................................. � Dare Application Disapproved for the following reasons: ........................ . ............................... ............................-- ..-- . .............................................................................................................................. ................Date.................. Permit No. .. .L..,,,,t..-.....�®-...C�....................... Issued ............ -._f...�..1.-3 Dace Fps.........�.rJ..•.rJ.. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Appliration for Diripinial Works C owitrurtion 'rutit Application is hereby madeFior a Permit to Construct ( ) or Repair ZLX ) an Individual Sewage Disposal System at: 324 Dridge Street Osterville • ............................. --------... --.... Stout Location-Address or Lot No. .................................................................................................. ............•______........................._......_............_.._............................_. W J.P.Macomber Jr. Owner Address a •----------- --••---••------------------•---------•-------------------------------•------...... ---••---------------•----------•--..........------•--...•--•-••-•---------...---•-------•----.:... Installer Address d Type of Building Size Lot............................Sq. feet ►U, Dwelling Y No. of Bedrooms.-------------------------------------------Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons---------------------------- Showers'(, ) - Cafeteria ( ) QOther fixtures -------------------------------------------------------------------------•----•-----•--.. . W .g g P P P y y � --------- Design Flow............................................ allots per person per day. Total Bail flow_._____..__.._.._.._.._..____.._...___....__ lons. ; WSeptic Tank—Liquid capacity------------gallons Length________________ Width................ Diameter__.-- .......... Depth................ x Disposal Trench--No. .................... Width.................... •rotal Length.................... Total leaching area....................sq. ft. Seepage Pit No..................... Diameter-------------------- Depth below inlet.................... Total leaching area..................sq. ft. 'i Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by---•----------------------•-------------- .._._........--•--------- Date........................................ Test Pit No. I................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........................ M --------------------- ....-•-------------------------•--...-•-------------............._..._........-----•-------------------••--•..._...----•-........ DDescri.tion of Soil-- -- -•--------••--------•-----------------------•------------------------------------------------...----•-----)'------------------------- •-----........-•------ x Wand & Grave � l --------•----•--------------------•-•---....---...--------••-----•-•--•------ W x L-�1500 r-allon tanlc,-_-T)utTijJ...sahia ber_. U Nature of Repairs or Alterations—Answer when applicable______ _______________.__.._..._..._.__._._ 1-pump-light-ali-m-8, infiltrators. 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 r system in operation until a Certificate of Compliance has bee/is ed b the boa d of health. 5/2-4/93Signed ..... / .................. -......... Dare I' Application Approved By ................ .. - -- ------ �. � ..r.. .�. .�J... I' Dare Application Disapproved for the following reasons: .. ........................ . ..... .......................................................... .................................. ....... . ............................................. .... ... . . ..................................... ........ .. ........................................ Permit No. ...... - U...f . ................... Issued ............ ..-... ..."../..��.................. + llare THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE CZer#tfirate of C�oxnplianre I TT''HH11 S IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (XX ) J.B.Macomber Jr. by................................................................................................................ ............... ......... ......... ... ...................... ----- --.... ........... 1-tak, at ....324Bridpre Street0stervill ................................................... .. .. .... . . . .... - has been installed in accordance with the provisions of TITLE 5 f The State Environmental Code as described in the application for Disposal Works Construction Permit No. .... '3..�}--------- dated ..._................._.................... ` THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE....._............ .- ....... ....._....... Inspector ----------- .._....:.................................................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE $ 30,00 FEE........................ is las�tl arks Tomitrudinn Wtufit r Permission is hereby granted-----J-.-P.Macomber... r-e------------------------------•---------......--------•-----------------••-----•--........ at Co.J ct ( )- or RepairX(X ) an Individual Sewage Disposal System 3 � bridge %Street Os-ter, ille----------------------------------------- at No. •• -----•--•-- --- ---•------ ..... . Street GG as shown on the application for Disposal Works Construction Permit No._.___'_.354�Dated..........7._-..�. ..1....��...... - r // ........--------------------------•--•--- Board of Health DATE-----•-------------l---•-----�-- FORM 36508 HOBBS&WARREN.INC.,PUBLISHERS