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HomeMy WebLinkAbout0356 BRIDGE STREET - Health 356 Bridge Street, Osterville ; A=093-004 o 0 • _ I TOWN OF BARNSTABLE LOCA i'[ON �o c�l`i�G�Sd�r�e SEWAGE # VILLAGE("his-CU,Ile- ASSESSOR'S MAP& OT62,?- R=MXMC $NAME&PHONE Nt�r7C'v>4/- 4Q-X - SEPTIC TANK CAPACITY /L�W Q5ZI LEACHING FACILITY: (type) QG a (size) x S' NO.OF BEDROO r BUILDER O OWNER S/JF-1 C al/2-,SrC1 PERMTTDATE: COMPLIANCE DATE:— Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching fac ) Feet Furnished by ba CJG7C1 >�LcG�%On. 77ilC ,�► lip O I 4 'DATE: 9/22/99---- PROPERTY ADDRESS: 3�6_Bridge-Street ____ a 9 Osterville ,Mass d® 02655 fCEIV�� ✓ 19919 b On the above date, I Inspected the septic system at the a'se�ve a OF sF e, This system consists of the following: A r 1 . 1-1000 gallon septic tank. 2 . 1—Distribution box. 3. 20'x30' leaching field Based on my inspection, I certify the following conditions: 4. This is a title FiveSeptic System ( 78 Code ) 5. The septic system is in proper working order; at the present time. 6 . Septic tank was pumped at time of inspection. 7 . No flow back from the leaching field . SIGNATURE: N a me:_,L, ,1M-a.94 m b_Q-]LJ r-------- Company: Jose.2k_P. Macomber-& Son , Inc . Address:_ Box-66__ Centerville , Ma . 02632-0066 Phone: 508_775_3338_______ THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARR ANTY • JOSEPH P. MACOMBER & SON, INC. Tan ks-Cesspools-Leachflelds Pumped & Installed Town Sewer Connections P.O. Box 66, Centerville, MA 02632-0066 775.3338 775-6412 • I COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFA RS DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET, BOSTON MA 02108 (617) 292.5500 TRVDY Sec ARCEO PAUL CELLUCCI DAvID B. S'f Co:t1.:J Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIRCATION PsopertyAdya4;356 Brideg Street NarrwofOwner James Wood Osterville , n r Q2655 Ad&sau of own«: te Da of Inspection: / 97 Nam. of Inspector:(Please Pr(rst) Joseph P.Macomber J r . I am a DEP approved system inspector purwarrt to Section 15.340 of Tlde 5 (310 CMR 16.000) Cornparty Name: J P Macomber & Son T n c . I.AaX,ng A ddr ass: Box 6 C:e n t p r v i 11_.e_s M a a s 02632 Telephone Number: CERTIFICATION STATEMENT I carvty that I hays person►lly Inspected the sewage disposal system at We address and that the Inlormadon reponed below is true, accuse and complete as of the tims of Inspecton. The Inspection wee performed based on my training and experience In the p(opst function and maintenance of on•slts sewage disposal systems. The system: Passes Conditionally Passes _ Needs Furthe)Ev luatlo By the Local pproving Authority _ Fails Inspector's Signauure Darts: 9 The System Inspec shall submit a copy of this Inspection report to the Approving Authority (Board of Health or DEP)whhin thiny f301 day completing this Inspection. If the system Is a shared system or has a design flow of 10,000 gpd or greeter, the inspector and the system o shall submit the rspon to the appropriate regional office of the Depenment oKnvironmemal Protection. The original should be sent to ate system ownst.and copies sent to the buyer, If applicable, and the approving authority. NOTES AND COMMENTS e j revised 9/2/98 Page I of 11 . " innit0 tin Recyc40lrptr SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(cond(wad) Prop.MAadr.&1:356 Bridge Street Osterville Mass . own«: James Wood oau of le-P-tion:9/2 2/9 9 INSPECTION SUMMARY: Check A. B, C, o/ D: A. SYSTEM PASSES: Y .7 1 have not found any Information which Indicates that any of the failure conditions described In 310 CMR 1-6.303 exist. Any failure crftsria not evaluated are Indicated below. COMMENTS: B. SYSTEM CONDITIONALLY PASSES: A& 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. Indicate yes,.no, or not determined(Y, N, or NO). Describe basis of determination In all Instances. If 'not determined', explain why not. The septic tank Is metal,unless the owner or operator has provided the system Inspector with a copy of a Certificate of Compliance (attached)Indicating that the tank was installed within twenty (20) years prior to the date of the Inspection; or the septic tank, whether or not metal,Is cracked,structurally unsound, shows substantial Infiltration or sxfiltration, or tank failure Is Imminent. The system will pass Inspection if the existing septic tank Is replaced with a complying septic tank as approved by the Board of Health. �99�� Sewage backup or breakout or high static water level observed In the distribution box Is due to broken or obstructed pipets) /1L1/ and of or due to a broken, settled or uneven distribution box. The system will pass Inspection If(with approval of the Bo Health). broken pipe(s) are replaced obstruction Is removed distribution box Is levelled or replaced Nl) - The system required pumphig-Tnom than•four-dmes wyeardue to broken or obstructed pipe(si. The rystem wiltyesr Inspection If(with approval of the Board of Health): broken pips(s) are*replaced obstruction Is removed " revised 9/2/98 Page 2of11 ' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 356 Bridge Street Osterville ,Mass . Owner: James Wood Data of Inspection:9/2 2/9 9 C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: A Conditions exist which require further evaluation by the Board of Health in order to determine if the system,is failing to protect the public health,safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 15.303(1)(b)THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WWCI1 M-L.PRQTECT THE PUBLIC HEALTH AND SAFETY AND.THE EN.VIBONMEHT. &;4 Cesspool or privy is within 50 feet-of 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 AND SAFETY AND THE ENVIRONMENT: 40 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 soil absorption system and the SAS is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. 416 The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well,unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine distance (approximation not valid).- 31 OTHER �R N revised 9/2/98 Page 3of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(contirxred) Property Address: 356 Bridge Street Osterville,Mass , Owner: James Wood Date of Inspection: 9/2 2/9 9 D. SYSTEM FAILS: You must Indlcate either "Yes" or"No" to each of the following: _) 1 have determined that one or more of the following failure conditions exist as described In 310 CMR 15.303. The basis for this determination is Identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No ' Backup of•sewage i►rtofeciBty"or-rfetem component-due tto an overloaded or-cIeggsd•S,AS•or•csaspod. 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 dtutioP box�b�}�e ut t�v�rt du n oyerl'oraded or clogged SAS or cesspool. Liquid depth in �' -b Ie or available volume Iss less than 112 day flow. Required pumping more the 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped .� Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. 41 Any portion of a cesspool or privy is-within a Zone I of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for »coliform bacteria, volatile organio•compounds, ammonia nitrogen and nitrate nitrogen. - E. LARGE SYSTEM FAILS: 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: /yU The system serves a facility with a design flow of 10,000 gpd or greater(Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No / the system is within 400 feet of a surface drinking water supply _v the system•is-witWn 200 teetofairi ►tar toasurtaoedririicir+gwat+r+upply•••• _ - -- - - 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) The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional office of the Department for further Infognation. i revised 9/2/98 Page 4orn I i ` SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM i PART B CHECKLIST PrportyAddr..s: 356 Bridge. Street •'Osterville ,Mass . owner: James Wood Date of Inspection:9/2 2/9 9 Check If the following have been done:You must Indicate either "Yes" or "No" as to each of the following: Yes N Pumping information was provided by the owner, occupant, or Board of Health. _ None of the systemsompawtts.hauaiman puPMwd4=stJeast two-aw9Ww and-t wsystem hasJ;"aa*csiaiag+osUai 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. `�°—, ^e �� s The facility or dwelling was inspected for signs of sewage back-up. The system does not receive non-sanitary or industrial waste flow. _ The site was inspected for signs of breakout. _ All system components,alluding the Soil Absorption System,'have been located on the site. _ The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or 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:- _ Existing information. For example, Plan at B.O.H. / _ Determined in the field(if any of the failure criteria related to Part C is at issue,approximation f distance is unacceptable) / 115.302(3)(b)] The facility owner.(and.ocrupants-if differ&at fram ommer).wara prouidedawith lafar,„". on�►,o Proper jmalntaaaaca rf SubSurface Disposal Systems. I i i i revised 9/2/98 Page 5of11 LO CAT ION SEWAGE PERMIT NO. ,3s � � 0 VILLAGE INS A LLER'S NAME i ADDRESS OWNER /J DATE PERMIT ISSUED /.e DATE COMPLIANCE ISSUED i SUBSURFACE SEWAGE DISPOSAL SYSTEM WSPECTiO[t FORM PART C , SYSTEM INFORMATION Property Address: 356 Bridge Street Osterville ,Mass . Owner: James Wood Dab of Inspection:9/2 2/9 9 FLOW CONDITIONS RESIDENTIAL: Design flow: 1Jd g.p.d./bedroom. Number of bedrooms(design Number of bedrooms(actual): Total DESIGN flow Number of current residents: Garbage grinder(yes or no):_�& Laundry(separate system) s 00 :_, If yes, sepamtoImpection.required --. Laundry system InspectedVyo or no) Seasonal use(yes or no): _ �l f Q� Water meter readings,If available(last two year's usage(gpd): Sump Pump(yes or no):� iy,+ l -A�&V 9 = �T Last date of occupancy: ''7777 �.A�„ /„� 4—R� `Jlfe COMMERCIAL/INDUSTRIAL: p Mom' �j� / Type of establishment: Design flow:,_A� �Udd ( Based on 15.203) Basis of design flow A h Grease trap present: (yes or no) Industrial Waste Holding Tank present: (yes or no)A114 Non-sanitary waste discharged to the Title 5 system: as or no)N4k Water meter readings,if available: A11� Last date of occupancy:�� OTHER:(Describe) AIX Last date of occupancy: GENERAL INFORMATION PUMPING RE,Cr 21*fapu 1 information: ,41oSystem pumped as part of inspection:(yes or no)z If yes,volume pumped. A gallons R Reason for pumping:ti�•�►�.Aoir irr t/ iid�i/Gf �l TYPE OF SYSTEM _iLzSeptic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no) (if yes, attach previous inspection records,If any) AW I/A Technology etc.Attach copy of up to date operation and maintenance contract �Q Tight Tank _Copy of DEP Approval Other OXIMATE AGE of all components, data instaNed{if known)-and Bourse of 40formation: 0� VIr Sewage odors detected when arriving at the site: (yes or no) revised 9/2/98 Page 6of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) PropertyAddre": 356 Bridge Street Osterville ,Mass . Owner: James Wood Date of Inspecdm:9/2 2/9 9 BUILDING SEWER: (Locate on site plan) Il Depth below grade: Material of cons c cas - on 40 P C other(explain) ,4sT16 Distance fro •ASiI ate water supply well or suction line Diameter Comments:(condition of joints,venting, evidence of(aakage,-etc.) Joints appear tight No evidence of 1pakagp . StPTIC TANK: (locate on site plan) r( Depth below grade: Material of construction: ncrete��meta4/Fiberglass.tPolyethyleneother(explain) If tank Is Fnetal,list age 1s.age.confirmsdby Certificate ofComplianceA/ (Yes/No) �Dimensions: " y4�1� lJ"'of Sludge depth: Distance from top of sludge to bottom of outlet tee ortaffle .Scum thickness:_ 9 Distance from top of scum to top of outlet tee or baffle: ? Distance from bottom of scum to bott9m of out] t tee or baffle. How dimensions were determined: Comments: (recommendation for pumping,condition of inlet and outlet tees or-baffles,depth of liquid level in relation to outlet invert, structuroHntegrity, evidence of leakage,etc.) PUMP tank ever 2-3 years r,Inlet & outlet tees are present . ;1 GREASE TRAP: (locate on site plan) Depth below grade: Material of constructionAf concretalt metaWW Fiberglass4),9 PolyethyleneV other(explain) '414 Dimensions: ,(J Scum thickness: Distance from top of scum to top of outlet tee or baffler Distance from bottom of scum to bottom of outlet tee or baffle:�� Date of last pumping: Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage,etc.) Grease trap is not present . revised 9/2/98 Page 7of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C , SYSTEM INFORMATION(continued) PropertyAadress:356 Bridge Street Osterville ,Mass . Owner: James Wood Date of tr,&peca : 9/2 2/9 9 TIGHT OR HOLDING TANK4t1li,(Tank must be pumped prior to, or at time of, inspection) (locate on site plan) Depth below grade: Material of construction;OL,4-concrete,! metal�AFiberglasWtPolyethylenal/�other(explain) Dimensions: 14 Capacity: WA gallons Design flow: gallons/day Alarm present Alarm level: Alarm in working order:YesAZ4 No,& Date of previous pumping:_ A14_ Comments: (condition of inlet tee, condition of alarm and float switches,etc.) il; t or holding tanks are not !rPsPnt _ DISTRIBUTION BOX:,/ (locate on site plan) Depth of liquid level above outlet invert:_ Comments: (note-it level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) — Distribution box has 3 laterals - No PvidpnrP of enlir(c rnrry near No P v i r(P n r a o f leakage into o r—out—e-fthe—box. PUMP CHAMBER:Al'oUe. (locate on site plan) Pumps in working order:(Yes or No)-4!A Alarms in working order(Yes or No) Comments: (note condition of pump chamber,condition of pumps and appurtenances,etc.) Pump• chamber is not prPSPnt - revised 9/2/98 Page 8of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) PmpwyAddrss3:356 Bridge Street Osterville ,Mass . Ownet: James Wood Data of kupection: 9/2 2/9 9 SOIL ABSORPTION SYSTEM(SAS).2,4 X (louts on silo plan,If possible:excavation not rsqulrsd,location may be approximated by non intrusive methods) If not located, explain: Type: leeching pits, number.,Q, 1 leaching chambers,numbs leaching galleries,number: leaching trenches,number, length: y leaching fields, number, dimenslons overflow cesspool,number: Alternative system: Name of Technology: 646 Comments: (noto condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.) oamy sand to meth um f; nP ganrl Mn siOne hydraulic-; —fa-1-use nr nnnr(; no Qn; 1.c d r.T;>:ege4aitisFt -8 na CESSPOOLS: (locate on alto plan) Number and configuration: Depth-top of Uquid to Inlet invert: Depth of solids layer: Depth of scum layer: Dimensloha of cesspool: MatorWs of construction: Indication of groundwater: Allf Inflow(cesspool must be pumped as part of Inspection) esspoo s are not present Comments: (note condition of soil, signs of hydraulic failurs,.lovel of ponding,conditlon of.vegetation, etc.) esspoo s are not present PRIVY:'yjW1L (locate on sits plan) Materjals of construe qn: �/� Dimensions: Depth of solids: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation;etc.) Privy is not 12rPGanr revised 9/2/98 Page 9ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORA PART C SYSTEM INFORMATION(con*x.+od) Prop+rgAd&—:356 Bridge Street Osterville ,Mass . Ownses ,James Wood Da,or V apecdon. 9/2 2/9 9 SKETCIi OF SEWAGE DISPOSAL SYSTEM: Include des to at least two permanent re)ersnce landmarks or benchmarks locate all wells wlWn 100' (Locate where public water supply comes Into house) 0 ' revised 9/2/98 Pail 10of 11 M ' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Prop,nyAd&".,: 356 Bridge Street Osterville ,Mass . Owner; James Wood Data of Inspection: 9/2 2/9 9 NRCS Report name Soil Type_ Typical depth to groundwater USGS Date websito visited Observation Wells checked Groundwater depth: Shallow. Modorate Deep _ SITE EXAM Slope Surface water Check Collar Shallow wells Estimated Depth to Groundwater Feet , Please Indicate all the methods used to determine High Groundwater Elevation: �Obtalned from Design Plans on record 5Of b,.,v=ds(Abutting property, bservation hole, basement sump etc.) ormined from 1oca1 conditions Checked with local Board of health Checked FEMA Maps L/Chacked pumping records _zchocked local excavators,Installers Used USGS Data Describe how you established the High Groundwater Elevation. (Must be completed) Used water contours tnpp. Gahrety & Miller Model 12/16/94 revised 9/2/98 Page 11 or 11 i a•TRR1A.—R IT'�rTr tTalrflR'IT.+fflTfT TRT.fRafl:•RTT.7frJ1RPRRRt iIRR�J T7Y1Rv1 mT ?' •rn•F►••r-.Tlrnrr:.T-.r•••� TOWN OF Barnstable BOARD OF HEALTH SUBSURFACE SEWAGE I)ISP'USAL SYSTEM INSPECTION FORM - PART D CEII'f I Fl CAT I UN I �•rT'ITT•••t:I—T./iR�.T.TP17.1T.A1•Rt.SI T11r i1TIi'T7tT1:T�.t•Ir'{tTR�7'R1R�T�R.OVe'f i�'IOT1.�1f�'�f TIn •.+•.rtT•T�'1.—..A -TYPE OR PRINT CI.EARLY- PROPERTY INSPECTED STREET ADDRESS356 Bridge Street Osterville ,Mass . ASSESSORS MAP, BLOCK AND PARCEL # OWNER' s NAME James Wood ' PART D - CERTIFICATION NAME OF INSPECTOR Joseph P.Macomber Jr . COMPANY NAME J. P.Macomber �& Sortlnc. COMPANY ADDRESS Box 66 Centerville ,Mass . 02632 Street Town or City State LIP COMPANY TELEPHONE ( 508 ) 775 - 3338 FAX ( 508 1 790- 1578 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 omplete 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: -Z Systeui 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 failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form. System FAILED* The inspection which I have con acted has found that the system fails to Protect the public he;zlth and the environment in accordance with Title 5 , 310 CMR 15 . 303 , a`nd as specifically noted on PART C - FAILURE CRITERIA of this inspection form . Inspector Signature i Date ecopy of this certification must be provided to the OWNER, the BUYER Dn where applicable) and the DOARD OF HEAL1'lI, * If the inspection FAILED, the owner or*"** ' erator shall upgrade within one year of the date of the inspection, unless allowed ort required he m otherwise as provided in 3,10 ChIR 15 , 305 , partd.doc �101 N BORTOLOTTI CONSTRUCTION,INC. NOV 2 765 WAKEBY ROAD,MARSTONS MILLS,MA 02648 1996 508-771-9399 508428-8926 FAX: 508428-9399 �F SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A S" CERTIFICATION Property Address: .3 s(�p Date of Inspection:/o-oZS-1?, Inspector's Name:-�Ro ff-vL JJ,, �'. er's Name and Address:Sh It .G,' I d CERTIFICATIONSTATEMENT: I certify that I have personally inspected the sewage disposal system at this address and that the informa- tion reported below is true,accurate and complete as of the time of inspection.The inspection was per- formed based on my training and experience in the proper function and maintenance of on-site sewage disposal stems. The System: 7 Passes Conditionally Passes Needs Further Ev luation By the Local Aproving Authority Fails Inspector's Signature: Date: The System Inspector shall submit a copy of this inspection report to the Approving authority within thir- ty(30)days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer,if applicable and the approving authority. INSPECTION SUMMARY,' �I! A)SYST)RAI PASSES: I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. B)SYSTEM CONDITIONALLY PASSES; One or more system components need to be replaced or repaired. The system,upon comple- tion of the replacement or repair,passes inspection. Indicate yes,nor,or not determined(Y,N,OR ND).Describe basis of determination in all instances. If not determined",explain why not. The septic tank is metal,cracked, structurally unsound,shows substantial infiltration or exfiitration,or tank failure is imminent. The system will pass inspection if the existing sep- tic tank is replaced with a conforming septic tank as approved by The Board of Health. Sewage backkup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of The Board of Health): -1 - O r � SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM { PART A CERTIFICATION(continued) Broken pipe(s)replaced Obstruction is removed Distribution Box is levelled or replaced The System required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of The Board of Health): Broken pipe(s)are replaced Obstruction is removed 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 the public health,safety and the environment. 1)SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 Feet of a surface water Cesspool or privy is within 50 Feet of a bordering vegetated wetland or a salt marsh. 2)SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER,IF APPROPRIATE)DETERMINES THAT THE SYSTEM IS FUNCTION- ING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system and is within 100 Feet to a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and is with a Zone I of a public water supply well. The system has a septic tank and soil absorption system and is within 50 Feet of a private water supply well. The system has a septic tank and soil absorption system and is less than 100 Feet but 50 Feet or more from a private water supply well,unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from the facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. D)SYSTEM FAILS: I have determined that the system violates one or more of the following failure criteria as defined in.310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of efluent 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 clog- ged 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 -2- } SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 Feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I of a public well. Any portion of a cesspool or privy is within 50 Feet of a private water supply well: Any portion of a cesspool or privy is less than 100 Feet but greater than 50 Feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic compounds,ammonia nitrogen and nitrate nitrogen. E)LARGE SYSTEM FAILS: The following criteria apply to a large system in addition to the criteria above: The design flow of a system is 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: The system is within 400 Feet of a surface drinking water supply The system is within 200 Feet of a tributary to a surface drinking water supply The system is located in a nitrogen sensitive area Interim Wellhead Protection Area (IWPA)or a mapped Zone II of a public water supply well. The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Check if the following have been done: ., ✓Pumping information was requested of the owner,occupant,and Board of Health. None of the system components have been pumped for atleast 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 system does not receive non-sanitary or industrial waste flow. _,_/The site was inspected for signs of breakout. _/All system components,excluding the Soil Absorption System,have been located on site. ✓The septic tank manholes were uncovered,opened,and the interior of the septic tank was in- spected for condition of baffles or tees,material of construction,dimensions,depth of liquid, �,,depth of sludge,depth of scum. r/The size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods. 3- SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST(continued) ►/ The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of Subsurface Disposal System SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION / FLOW CONDITIONS RESIDENTIAL: V Design Flow: qO allons Number of Bedrooms: Number of Current Residents: ¢6 Garbage Grinder: Laundry Connected To System: Seasonal Use: 8 Water Meter Readings, if available: Last Date of Occupancy: 62/ WeeL`ee 04 y COMMERCLAI INDUSTRIAi.:/1�6 Type of Establishment: Design Flow: gallons/day Grease Trap Present: (yes or no) Industrial Waste Holding Tank Present: Non-Sanitary Waste Discharged To The Title V System: Water Meter Readings,If Available: Last Date of Occupancy: OTHER: Describe) Last Date of Occupancy: GENERAL INFORMATION PUMPING-RECORDS and source of information: System Pumped as part of inspection: If yes,volume pumped: gallons Reason for pumping: TYP"F SYSTEM: V Septic Tank/Distribution Box/Soil Absorption System Single Cesspool Overflow Cesspool Privy Shared System(If yes,attach previous inspection records,if any) V7'Other(explain): <2 Ce si�6-2o/S AP OXIAVE AGE of all co ponents,date installed(ifi known)and source of information: m Sewage odors detected when arriving at the site:. -4- I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C GENERAL INFORMATION (continued) SEPTIC TANK: Depth below grade: a Material of Construction:�concrete metal FRP Other (explain) Dimisions: Sludge Depth: �� / Scum Thickness: $�� Distance from tolf of sludge to bottom of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidm7s�gi ��' S cTj GDiGS GREASE TRAP: Depth Below Grade: Material of Construction:_concrete metal FRP Other (explain) — — — Dimensions: Scum Thickness: Distance from top of scum to top of outlet tee or baffle: Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage,etc.) TIGHT OR HOLDING TANK; Depth Below Grade: Material of Construction:_concrete_metal_FRP Other(explain) Dimensions: Capacity: gallons Design Flow: gallonsMay Alarm Level: Comments: (condition of inlet tee,condition of alarm and float switches,etc.) DISTRIBUTION BOX: t/ Depth of liquid level above outlet invert: �//��%�G Comments:(note if level and di$Abu 'on is e evi ce of solids c over,evidence of leakage'nto or out of box,etc. ��r L PUMP CHAMBER Pump is in working order: Comments: (note condition of pump chamber,condition of pumps and appurtenances,etc.) -5- SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C 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,number: Leaching chambers,number: Leaching galleries,number: Leaching trenches,number, length: Leaching fields,number,dimensions: S ne_ S — 3 Overflow cesspool,number: Comm�ents: (note ndi�}'on of soil,signs of ydraulic failure 1 vel of nding, ndi/tin of vegetation, etc)1J��G G�/ /i/�P ��° i /� Cjl CESSPOOLS: Number and configuration: / B/Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of Cesspool• S' Materials of construction eindication of groundwater: Inflow(cesspool must be pumped as part of inspection) Comments: (note condition of soilk, signs of hydraulic failure of ponding,condi 'on of vegeta/t}on, etc.) 'Cv �G �� L�J� o�p -V PRIVY:. Materials of construction: Dimensions: Depth of Solids: Comments: (note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation, etc.) -6- SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) SKETCH OF SEWAGE DISPOSAL SYSTEM: Include ties to atleast two permanent references, landmarks or benchmarks. Locate-all wells within 100 Feet. \a o � ` o , DEPTH TO GROUNDWATER: Depth to groundwater: /© � . Feet Method of Determination or Approximation: -7-