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HomeMy WebLinkAbout0048 CAPTAIN ALDEN'S LANE - Health 48 CAPTAIN ALDEN'S A= 146 090 y 12 CUAMONWTE.ALTH OF M.ASSACHL'SETTS w �Q EXECUTIVE OFFICE OF ENVIRONMENTAL F.A JUL 1 1999 DEPARTMENT OF ENVIRONMENTAL P EC �I �� y �►Ji ONE_ti1N'TER STREET. BOSTON. MA 02108 617-29' ` op g WILL1AV F.WELD TRUDY COXE Governor Secretan ARGEO PAUL CELLUCCI DAVID B.STRUHS Lt.Govemor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Commissioner PART.A �s CERTIFICATION Property Address: Zace.0 . ^ 54 � dS 4�'✓:.� -0 Address of Owner: Date of Inspection: Z__ g8 (If different)' Name of Inspector: 1l,4 i2a I am a DER approved system inspector pursuant to Sectign 15.340 of Title 5 (310 CMR 15.000) Company Name: -1 ti <, s/ �Jk,' Se'✓c t c Mailing Address: /y 47 Wghi"-f S . 10,ae�.-, Telephone Number: (���'_�� 0 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the .information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based,on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: Passes _ Conditionally Passes Needs Further Evaluation By the Local Approving Authority Fails QC4=42 112 4/ Inspector's Signature: Date: /7� The Svstem Inspectors all submit a copy of this inspection report to the Approving Authority within thirty (30) days of completing this .inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. INSPECTION SUMMARY: Check A, B, C, or D: AI ,SYSTEM PASSES: y 1 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. COMMENTS: B) SYSTEM CONDITIONALLY PASSES: One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Indicate ,yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If "not determined", explain why not. The septic tank is metal, 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 exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 04/25/97) Page 1 of 10 DEP on the World Wide Web: http:ltwww.magnet.state.ma.us/dep p SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM 1J p PART A CERTIFICATION (continued) Property Address,�;��j"Cpd ;C41)'� Owner: Date of Inspection: _ ..6- /7- B) SYSTEM CONDITIONALLY PASSES (continued) Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health). Describe observations: broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed 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. t) 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 pri\5, is within 50 feet of a bordering vegetated wetland or a salt marsh. Z) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT 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 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. 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). 3) OTHER (revised 04/25/97) Page 2 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: +1-7 1,71j, '71 Owner: �i+vtvl L!r:a �ts Date of Inspection: D) SYSTEM FAILS: You must indicate either "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 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 neces&ary to correct the failure. Yes No Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or ctiWed SAS or cesspool. Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesslwol. Liquid depth in cesspool is less than 6" below invert or available volume is less than 112 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped _. Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface wa i 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 ponion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water suppiy well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well wafter analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E) LARGE SYSTEM FAILS: You must 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 facility with a design flow of 10,000 gpd or greater (Large System) and the system is a significara 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 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 11 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. i (revised 04/25/97) Page 3 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST .7 /�/cI�H �y�y'l Os rvilll Property Address: u -7 Owner: Date of Inspection: -/� -99 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. 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. l/ _ 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 v.,as inspected for signs of breakout. .1n cJ,.c�"�� All system components, excWeI4ftg 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: The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of 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 unacceptable) [15.302(3)(b)) Szaviud 04/25/97) Page 4 of 10 r - } SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORNS PART C SYSTEM INFOR TJON j7/A1- 4"q Property Address: yg L`XT, ~ 7� Owner: �p�.yr.0t I u )'Is Date of Inspection: G-/, -y8 FLOW CONDITIONS RESIDENTIAL: Design flow: p.d./bedroom for S.A.S. Number of bedrooms: 3 Number of current residents:&+L Garbage gri:.der (yes or no):_ Laundry cor•nected to system (yes or no): 5 Seasonal use tyes or no): Water meter readings, if available (last two (2) year usage (gpd): Sump Pump Ives or no):—A&— Last date of occupancv:—.e--�%7--ro COMMERCI.4UINDUSTRIAL: Type of establishment: Design flow: allons/day Grease trap present: Ives or no)_ Industrial Waste Holding Tank present: Ives or no)_ Non-sanitary waste discharged to the Title 5 system: (yes or no)_ Water meter readings, if available Las: date of oa:cupancv. I OTHER: ;Describe' Last date of occupancy. GENERAL INFORMATION PUMPING RECORDS and source of information: System pumped as part of inspection: (,yes or no) /►-14;1 If yes, volume pumped: f;allons 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) I/A Technology etc. Copy of up to date contract? Other ,APPROXIMATE AGE of all components, date installed (if known) and source of information: /1�t/Qu�'f Sewage odors detected when arriving at the site: (yes or no)_ � I (revised 04/25/97) Page 5 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) "/a dS/�v✓i/lt Property Address: 0 G�pT4�..}}~- ��y Owner: Tub ps!�w fel Date of Inspection: BUILDING SEWER: (Locate on site plan) Depth below grade: Material of construction: _cast iron _ 40 PVC _ other (explain) Distance from private water supply well or suction hr.F Diameter Comments: (condition of joints, venting, evidence of leakage, etc.) SEPTIC TANK:_ (locate on site plan) Depth below grade: 12 material of construction: concrete metal _Fiberglass _Polyethylene _other(explain) If tank is metal, list age _ Is age confirmed by Certificate of Compliance _(Yes/No) i Dimensions: X � '� Sludge depth: 0"- Distance from top of sludge to bottom of outlet tee or baffle:-21 6 Scum thickness: 0" — /" Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: 20" How dimensions were determined: M'&l sl+ 1 .dtr Comments: (recommendation for pumping, condition of inlet and outlet teespr baffles, depth Rf liquid I vpL p relation to outlet invert, structural integrity, evidence of leakage, etc.) .2 GREASE TRAP: (locate on site plan) Depth below grade: 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: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) (revised 04/25/97) Page 6 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C I SYSTEM INFORMATION (continued) �� Property Address: �� Cr, , .� ���i��� GiiV J US/ e v;'Ile Owner: Date of Inspection: TIGHT OR HOLDING TANK: !Tank must be pumped prior to, or at time, of inspection) (locate on site plan) Depth below grade: Material of construction: _concrete _metal _Fiberglass _Polyethylene _other(explain) i Dimensions: Capacin-: gallons Design flow: gallons/da% Alarm level: Alarm in working order _ Yes; _ No Date of previous pumping: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX:_ (locate on site plan; Depth of liquid level above outlet inven:Q_ Comments: mote if level and distribution is equal, eviden/c'e of solids carryover,.evide cee+ offlleea-kage into or out of box, etc.) p- n x ?L PUMP CHAMBER: (locate on site plan; Pumps to working order: (Yes or No) Alarms in working order (Yes or Not Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) (revised 04/25/97) Page 7 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C /' r1 SYSTEM INFORMATION (continued) Property Address: `�� �r t.�. /7�C�Oh �iyj„� �✓�//.'' Owner: Date of Inspection: SOIL ABSORPTION SYSTEM (SAS):_ (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: Type: leaching pits, number: leaching chambers, number:__ leaching galleries, number: i leaching trenches, number,length: leaching fields, number, dimensions: overflow cesspool, number: Alternative system: Name of Technology: Comments: (note condition of soil, signs of hydraulic failure level f ponding, condition of vegetation, etc.) CESSPOOLS: _ (locate on site plan) Number and configuration: (Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: materials of construction: Indication of groundwater: inflow (cesspool must be pumped as part of inspection) Comments: mote condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY: _ (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) (revised 04/25/97) Page 8 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: %,g Owner: fU�Q j �NTsS Date of Inspection: 6-17-98 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) t 3 5.2 (revised 04/25/57) Pag• 9 of 10 SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 7�4ai Owner: T.0/" e IN.� Date of Inspection: L• 6-17- 99 Depth to Groundwater 3 Feet Please indicate all the methods used to determine High Groundwater Elevation: Ci`Obtained from Design Plans on record v` Observation of Site (Abutting property, observation hole, basement sump etc.) Determine it from local conditions L11 Check with local Board of health Check FEMA Maps L� Check pumping records Check local excavators, installers ri Use USGS Data Describe in your own words how.you established the High Groundwater Elevation. Must be completed) rD 441X at AW4 H" ""s J rr / i 14� 115-Z .may 1r-a_ ba//c��•� c� ��D% .T iv<r��l' (revised 04/25/97) Page 10 of 10 I TEST HOLE I NOV. 9, /976 ALDEN LANE j PALL I GARDNER - IN_P u".n E I /0:3.OD _ { N ELEV./b.0 Pkoc. -TEST ROLE t. LDT 4 3 14,11 LOT 6 / ;O. 21? LOPM AIrJ j = LINE 6•LEACH / I I SUBSO/L i •? qA PIT { RESERVE45 ELEV. 6.o � •. � NO InJRTER ENC0:1/JT_f•:�,� q�''- TOLAIN WATER /S AYA;%Ati� LOT S ' 15060 I /03. 00 /3 U/ D/n/r S cTFSAC L 2G cJ7��ME�/TS SC'4 L`- j 40' F',onV T 5/DE. eo 2 3 ciE��coMs � SEPT/G iyS TEM COn/S T2 UG T/O.V SHAt G'On/G0.2M TO MA55 OES/G/v FLOW _ SAL. G,4 E.n/✓/20n//!G-n/TAL CODE TITLE P LE.4C<-/ 2ATE e6ou/.CMG-o TOP OF NEALT7,/ TZBGULAT/On/S o' / ao D L;70A/t ::Cnt,'F.L: --L /�/HNHciLc.iCUV E,:2 le, cX T&n/ TO IJ 1 / i`O ,a2.=✓ENT �;niG_� { T s 4•01A. '..rl,";• /O�L.J'4,-.c., _% "T' M/N Jirtai -/ F�/r D. •: J ..D Ai I 1 Y 1OOcJ Minl / 14 Q/I -r- /Nvf-Zr �� y,SrCan/E i '_'__5-- GALLON/ /N✓E2r /n/VEeT % i CA PA C/T Y TANKV, rWAT C 4 I Bcrcu.. O L:Sy .2T/vHT /NVEer ;:i 1 1 a/r4/ { F • J /NVE 37 { NO G-AAe6ACE Cara/nNDEc_P_ ;vl l ✓ I ' j 20' M/n//A4C/M ' SITE PZ-A N S/ P`-,✓:���•>�_�' _5c"��J���Ism Qt,qIYST,9-OLEZdk1L L�'L=S �'•�F�.%E.v:.:E_ L*r_.LA'li- _LQZ-..�.fJS.�f•'.�.,�/y- - s 5 "�. SEPT/C TANK, L;>/j T,Q/BVT/ON �Oh 3s. .-PLtsE.� .. _ �SOUTLEr.S ) AND LEA.'/,//A✓/� f�/T ' TO BE OF X-1 I/FOQCcIJ COAJG,LETF- j [� COn/G•,e el-r6 V.5l}/ 3000 —DAM ►..0 T E.LLt. JL I,L_ 5��:/f_FL 20000 d .. i f!-/O LOAD/n/G ,v79 L'•_'J1E::'1> /v; T T� ESE All .:,r7- ). E'''- :•^/:.... _ T`• G✓EC: 5 TJ TF.til (JNL > t�- �J 1 CERTIFY THE EXIST//VG FOUNDN?/O✓V /'.,.`''� ar�(r� '`SJVA./ LCl-lO/A./ ✓,EZ i LOG4710/✓ /5 COPP CT AS SN•J✓iN HN ? /7 Do-, S ~/FORN WITH Tl;, BU/CD/Nr, �E7/3:�:,r r+c:� .•:'.-T)c'Jv�._ _V" rc 7�:•./N :, tr OF /3AR1lJ STAL3LE / '�•''Isri�C;`�/f --- - --- --... ...... -- .. _ / �� N 4 '' o,T. </E/1L77.1 AC:" �•/- TOWN OF BARNSTABLE L3CAi,:JN © _ �F f k 4 SEWAGE # VILLAGE ©S'Ley vs ffe ASSESSOR'S MAP&LOT ` D INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY /d O U LEACHING FACILITY: (type) (size) NO.OF BEDROOMS B" OWNER O,," PET^MTTDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom.of Leaching Facility Feet i 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 r within 300 feet of leaching facility) Feet Furnished by .... M`C: Y'j� �} �'.. :'r.t• � �`rO �vS'P �T�rf.r OT •� 'tl b 4�f' t L Y THE FOLLOWING IS/ARE THE BEST IMAGES FROM POOR QUALITY ORIGINAL (S) I A-: DATA /� M -..��..-___I-- . _. j s� �-----__� — :; ' I 1 . � � �, , ` r��1_, -� ------ l__� 4 � ' 4 /"� I � / s /� _� / ._ �_ V CIO 7 r " SUBSURFACE SEWAGE t SEWAG�D IP�OP24 SYSTEM INSPECTION FORM �fa, Ito Address of property Owner' s name �'A�Ayin1 ��®��� SANE (° �,. i f�sn Date of Inspection s PART A CHECKLIST Check if the following have been done: ' � Pumping information was requested of the ow er, 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.' All 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 C site. ZThe 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. 1A 11 12 40 �C _. AUG 3 1 1995 N �o Now[ 5 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION FLOW CONDITIONS If residential number of bedrooms ,;(-_ number of current residents -ALL- garbage grinder, yes or no laundry connected to system, yes or no seasonal use, yes or no If nonresidential, calculated flow: Water meter readings, if available: �" "� ;- e.i, �00 ✓ � � 3 If �O Last date of occupancy GENERAL INFORMATION Pumping records and source of information: Y--. System pumped as part of inspection, yes or no if yes, volume pumped i✓=,°�'�: ./ 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) Other (explain) Approximate age of all components"Date installed, if known. Source of information: ,Nr L_ g , Sewa a odors detected when arrving:'at the site, yes or no 9 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B .SYSTEM INFORMATION continued SEPTIC TANK: (locate on site plan) depth below grade: material of construction: b concrete metal FRP other(explain) L n��w e'tP �!"'d/ .t i f �Pr'S n /,i•"l� l,'t �'T �• h✓T��1 ��/�<' dimensions: Z_ sludge depth } distance from top of sludge to bottom of outlet tee or baffle � scum thickness distance from top of scum to top of outlet tee or baffle io„ distance from bottom of scum to bottom of outlet tee or baffle Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, recommendations for repa�i-rs, etc. ) ,�v ( /l.�f./ / ;+i r✓+/ �C v/-�Gin/f' n %✓r /I "_l�'_i v i t' i•7% =/I//c: //iy !� '/ t'r�.l !. oh "r /'C:.-•:.� /.�•♦ 1 /r°r sT-/ n.•rfir/" Tre � 7C''ii ^ -. '"� a.- � d eYA�Ps:/ T� �l! •T •n;: // ts'r ...l_ �iLL�>. DISTRIBUTION BOX: (locate on site plan) depth of liquid level above outlet invert Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, recommendation for repairs, etc.) PUMP C BER: (locate o ite plan) pumps in work order, yes or no Comments: (note condition of pump chamber ndit of pumps and appurtenances, recommendations for mainten a or repairs,et . 10 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 / zo,,�; leaching chambers and number leaching galleries and number leaching trenches, number, length leaching fields, number, dimensions overflow cesspool, number Comments: (note condition of soil , signs of hydraulic failure, level of ponding, condition of vegetation, recommendations for maintenance or rep airs,etc. ) 14 1- CESSPOOLS (locate on site plan) : number and configur 'on depth-top of liquid to et invert depth of solids layer depth of scum layer dimensions of cesspool materials of construction indication of groundwa inflow (cesspool st be pumped as part of insp ion) i Comments: (note condition of soil, signs of hydraulic failure, level 'of ponding, condition of vegetation, recommendations for maintenance or repairs,etc. ) PRIVY: (locate on si lan) materials of construct ' dimensions depth of solids Comments: (note condition of signs of hydr is failure, - level of ponding, 'condition of v ation, recommendations maintenance or repairs,etc. ) --� THE FOLLOWING IS/ARE THE BEST IMAGES FROM POOR QUALITY ORIGINALS) I M -A= DATA .. 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION continued SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100 ' i �4 r� L.i DEPTH TO GROUNDWATER depth to groundwater method of determination or approximation: a 12 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C FAILURE CRITERIA ..i Indicate yes, no, or not determined (Y, N, or ND) . Describe basis of determination in all instances. If "not determined", explain why not) Al Backup of sewage into facility? Discharge or ponding of effluent to the surface of the ground or surface waters? A/ Static liquid level in the distribution box above outlet invert? A/ Liquid depth in cesspool <6" below invert or available volume< 1/2 day flow? Required pumping 4 times or more in the last year? number of times pumped Septic tank is metal? cracked? structurally unsound? substantial infiltration? substantial exfiltration? tank failure imminent? l Is any portion of the SAS, cesspool or privy: below the high groundwater elevation? _ within 50 feet of a surface water? !!� within . 100 feet of' ,a surface water supply or tributary to a surface water supply? PP Y• within a Zone I of a public well? A/ 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? 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. ,� 13 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART D CERTIFICATION Name of Inspector Company Name Company Address r - 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. Check one: I have not found any information which indicates that the system fails to adequately protect public health or the environment as defined in 310 CMR 15. 303 . Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form. I have determined that the system fails to protect public health and ( the environment as defined in 310 . CMR 15. 303 . The basis for this determination is provided in the FAILURE CRITERIA section of this form. Inspector's Signature j: Date y js Original to system owner Copies to: �;,... ,.� /:. , ;: r % A, Buyer (if applicable) Approving authority KEY NUMBER <6138 > NAME <LISTON, WALTER > B-C 1 B-C 2 B-C 3 B-C 4 ZOC STREET 48 CAPTAIN ALDEN WAY CITY OSTERVILLE ST MA ZIP 02655-1204 REF 1 REF 2 PHONE ( ) - REF 3 REF 4 METER NO. < 5715> DATE READING CONS STREET <CAPT ALDEN WY NO. 48> 06/30/95 12 10 CITY OST J L5 ST LOC 12/31/94 2 10 PHONE (508 ) 428-7163 10/05/94 0 0 10/05/94 718 8 ROUTE NUMBER 01 06/30/94 710 10 SERVICE DATE 05/01/79 12/31/93 700 19 METER DATE 10/05/94 06/30/93 681 11 CAPACITY 7 12/31/92 670 18 STYLE. T10F SIZE 1 RATE SCHEDULE KEY PIT PLASTIC NOTE RR LEFT SIDE ADDITIONAL CONS 0 ALTERNATE MIN 0 L__ f I • ,r - TEST HOLE NOV. 9, /976 A L D E N'. L A N E PAI,'L l GARDNER - IN_;PE^ )A ± ELEV,/8.0 WArEk TEST NOLE �.LOT 6 D at4 L Of)M Alva LOT 4 0,8+0 LINE LEACH / ` SUBSOIL j pir 7 1ST, Box ns O /,2� 29 /44 MEd lam.7 epr lC ` d TANK RESERVE j I -AND 7. 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