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HomeMy WebLinkAbout0080 FOX HOLLOW LANE - Health 80 Fox Hollow 'Lane Osterville P • A = 145 006002 ', m < COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION 1 +5 AP DEC 2 TOWN OF BARNSTABLE TITLE 5 HEA'TH DEPT, OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 60 Fox 0/%t✓ L/!/ e✓vi 7 )c Owner's Name: Ta�e x Owner's Address: ss Date of Inspection: Name of Inspector. leaaepPint) — �,' Company Name: ✓ p— EG/ Mailing Address: 6 qoL Telephone Number: So 8 CERTIFICATION STATEMENT j I certify that I have personally inspected the sewage disposal system at this address anti 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 m the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to tion 15.340 of Title 5(310 CMR i5.p04, The system � Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: The system inspector shall submit a copy of this inspection report to the A vin Authority DEP)within 30 ° g ty(Board of Health or days of complet _g 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 ©bP.The original should be seat to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not addrei!hqw the system will perform in the future under the.name or different conditions of use.. Page 2 of l l OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued} ,00% Property Address: 0a < o w �,✓ owner: Date of faspectiou: Aj" Inspection Summary: Check AAC,D or E/ALMM complete all of Section D A. S em Passes: ` I have not foand any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist Any failure criteria not evaluated are indicated below. Comments: Wpaired.)The nt Conditionally Passes: e or more system comvonents as described in'the"Conditional Pass"section need to be replaced or system, upon completion of the replacement or repair,as approved by the Board of Health,will pass. A—mwer yes,no or not determined(Y,N,ND)in the for the following statements.If"not det=ina'please explain. 'Me septic tank is metal and over 20 years old"or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent.System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. 'A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced 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 Healtb): broken pipe(s)are replaced obstruction is removed N9 explaitt: page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 60 FeX Owner. J/y! ✓1/i' a Bate of inspection: / :oCondiftons rther Evaluation is Required by the Board of Health: exist which require further evaluation by the Board of Health in order to determine if the system is failingio protect p&k+ealths,saky or the environment. L System will pans unless Board of Health determines in accordance with 310 CMR 1&303(1)(b)that the system h not- uwAouing in a-m nner which will prated public-health,-Wety and the envirenmem: Cesspool-or privy is within-50 feet of a surface - — Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. Sy.�tem will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary.to a surface water supply.. The system has a septic tank and SAS and the SAS is within.a Zone 1 of a public water supply. — The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**.Method used to determine distance **This system passes if the well water analysis,performed at a DEP certified laboratory,for colifgrm bactena and volatile organic compounds indicates that the well is free frorn pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 plm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form 3. Other, I Page 4 of 11 OFFICIAL,INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) P gwrty Address:. ox /,ot,./ L.y Owner: Date of Lispection: 6 O D. System.Failure Criteria applicable to all IYltema; You must indicate"yes!'or"nd'to each of the following for all inspections: Yes No/ ✓_fkuc p of sewage into facility or system component due to overloaded or clogged SAS or cesspool r/ Discharge or ponding of effluent to the surface of the ground or SAS or cesspool surface waters due to an overloaded or .S liquid level in-the distribution box above outlet invert due to an overloaded or clogged SAS or �sp°°1 d depth in cesspool is less than 6„below invert or available volume is less than'/Z day flow — — Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number Of times pumped — Ff portion of the SAS,cesspool or privy is below high ground water elevation. ✓.Atty portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface ✓_1-By portion Of a cesspool or privy is within a.lone 1 of a public well. r�// Portion of a cesspool or privy is within 50 feet of a private water supply well. — Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for 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 S ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.} (Yes/No),The system fail9,I have determined that one or more of the above failure criteria exist as described in 310 CUR 15.303,therefore the system fails.The system owner should contact the.l3oard of Health to determine what will be necessary to correct the failure, E. Large Systems: To be considered a large system the system mug serve a facility with.a design Dow of 10 gpd. ,0N10 gpd to 1S,000 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) es ao the system is within 400 feet of a surface ddnldng water supply the system is within 200 feet of a tributary to a surface driakog water supply — _ system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped �o a It of a public water supply well If you have answ "yes!'to any question in Section E the system is considered a significant threat,or answered yes" in Section 9 above the large system has failed,The owner_or operator of any large Syster_n 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 ofrcc of the Depattntent, page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST - property Address: 0 F� l�0 ln/ L-41" O rv� Owner. i lf- Date of Inspection: / d6 Check if the following have been done.You must indicate`yes or"noP as to each of the following. Ye�No Pumping information was provided by the owner,occupant,or Board of Health v Were any of the system components pumped out in the previous two weeks Has the system received normal flows.in the previous twow eek period Vl Have larWwlumes of-water-been introduced to the system recently or as part of ibis inspection Were asbuilt plans of the system obtained and examined?(If they were not available note as N/A) Was the facility or dwelling inspected for signs of sewage back up Was the-site inspected for signs of break out Were all system components,.excluding the SAS,located on site ere the septic tank manholes uncovered,opened,and the interior of tank far of th es or tees,material of construction,dimensions, in condition ns,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 y The she and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no xisting inforthe on For example,a plan at the Board of Health _ _ Determined Geld(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CARR 15.302(3)(b)j Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS • SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: Fo )c /Q(„/ L r✓� Oa Cs� Owner: "j- Date of Inspection: " 0 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 Number of bedrooms(actual): .� DESIGN flow based on 310 CM/R 15.203(for example: 110 gpd x#of bedrooms): Number of current residents: Does residence have a garbage grinder(ves or no): Is Uundry on a separate sewage system(vesor no):A-0 [if yes ate inspection required] Laumdry system inspected(yes or no): Seasonal use: (yes or no) _ Water meterreadings if available(last 2 ears usage- Sump pump(yes or no): Last date of occupancy; r to rnt� COMWERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR I5.203): - gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present.(yes or no):_ Industrial waste bolding 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): Pumping Records GENERAL INFORMATION . Source of information: "jr_ D fives _ Was system pumped as part of the inspection(yes or no):_ If yes,volume pumped:__gallons—How was quantity pumped determined? Reason for TYP SYSTEM Lf tank,distribution box,soil absorption system Single cesspool Overflow cesspool —�vY Shared system(yes or no)(if yes,attach previous inspection records,if any) InnovatiVe,/Alterna rve 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 age of all components,date installed(if known) of iaforrrnaUion: Were sewage odors detected when arriving at the site(yes or no):L(/9 Page 7 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(contimied) )Property Address,_�C • Fox /lo/%w G-. pf a✓v� e , Owner: Date of Inspection: /_Tr1 4/pY BUILDING SEWER(locate�ga site plan) Depth below grade:�,/ Materials of construction:_cast iron 4 PPVC other(explain): Distance from private water supply well or suction line: Cornments(on condition of joints,venting evidence of leakage,etc.): SEPTIC TANK:_(locate on site plan) Depth below grade: Material of consinrction:__metal_fiberglass_polyethylene other(explain) If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of Dimensions x Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: o? Scum thickness: # Distance from top of scum to top of outlet tee or bale:_ Distance from bottom of scum to bMW pf outlet tee or bale: How were dimensions determined: re!G #Rq is '-ae'vi c Comments(on pumping recommendations,inlet and oudet tee or baffle condition,structural integrity,liquid levels Mated to outlet invert,i of leakage,e .): . e GiNt A✓i A/0 z + • GREASE TRAP:A_4=te on site plan) Depth below grade: Material of consauction:_concrete_metal fiberglass _polyethylene other (explain): Dimensions: Scum thickness: Distance fmm 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((n pumping recommendations,inlet and outlet tee or baffle condition,structural Wpoty,liquid levels as related to outlet invert,evidence of leakage,etc.): �j Paze 8 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS • SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continced) Property Address 10 & c %/ow �/_-A/ owner: S/h• v, E)3 CS, Date of Inspection: , K TIGHT or HOLDING TANK: /t/ (tank must be pumped at time of inspec,Kionxlocate on site Imo) Depth below grade: Material of constiuction _ concrete metal fiberglass polyethylene.,,. other(explain): Dimensions: - } Capacity: gallons Design Flow: Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last purnlnng Comments(condition of alarm and now switches,etc.): DLSTMUTION BOM (if present must be open//ed)(locate on site plan) - Depth of liquid level above outlet invert: V70/e,O'C.. Comments(note if box is level and distnbution to outlets equal,any evidence of solids carryover,any evidence of leakage into,pr out of box,etcy); • / Levy. Oax 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 apputenances,etc.): t i page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS •• SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(contimu4 Puroperty Address: ro T/Q� 0 Owner. cJ�: Date of Inspection SOIL ABSORPTION SYSTEM(SAS): pocate on site lam excavation not Plan, required) If SAS not located wMlain why: T L/ leaching pits;number:- leaching chambers,number leaching galleries,number: leaching trenches,number,length: �� � ,0 d� leaching.fields,number,dimensions: overflow cesspool,number: innovativetalternative system Ty�e of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc): /�� ' 01 � /Gc� �• i Wes, CESSPOOLS: (cesSpool must be pumped as part of mspectionxlocate 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 gmun&VWer inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: 0-0cate 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.): �` 1 b • Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY AS SESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: F�!jC Owner: /f'!• Date of Inspection: p� 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, (1/ 0 �/ 33 p� ag 3 A3- oDiLlf ' l/ W - 33 I post 11 of 11 OFFICIAL INSPECTION FORM' NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE-DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continuo property Address: Fox ROAD ✓ L,v o ' Od 6S� pwner. Date of Inspection: at 0 SM EXAM p Slope o2 7 Surface water Check cellar ShaIlow wells Estimated depth to ground water/ / feet Please:indicate(check)all methods used to determine the high ground water elevation: m system design plans on record-H clwcked,date of design plan reviewed site(abutting popeny/observation hole^within 150 feet of SAS) necked with local Board of Health-explain: y-'A,.,:7 S Chocked with local excavators,installers-(attach documentation) / Accessed USGS database-explain: You must describe It ou established the highground ater elevation: � .7• /� �1 Or(� � Irr.� Mw �` Ov�e- 1 , % , k � Ono �1 / 4'o � • 4-w = i6 .9 CO%j.\10\%%TALTH OF N ASSACHUSETTS EXECUTIVE OFFICE OF E?`-\;IRON'�4ENTAL AFFAIRS DEPARTMENT OF ENVIRONN E\TAL PROTEGTIO, ONE WINTER STREET. BOSTON. MA O=tC'S bl S="•`:C't' ��' .J RECEIVED UILL1AS'F.WELD — AUG 6 1998 TRUDY COS: Gov=...... � T04VNOFBARNSTABLE `4 SG:TC:2 ARGEO PALL CELLL'CCI ��-, HEALTH DEPT. DAVID B STRL'1: LLGovcmor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPF OWN FORM Commission PART A " .01 1101 S CERTIFICATION �� Lad — ��a�'� ^ • Property Address; Q VO)( LovJ LtU, MT-M",3%\k&,- -Address of Ownez: Date of Inspection: `7t '7I "qf different) = i'Mouk Z- Name of Inspector: H-,i r`^n I 1 E��C�� 1 Qc 2= VkA_ 1 am a DEP ap roved system inspector pursuant to Section 15.340 of Title S (310 CMR 15.000) 1 Company Name:�}-� o 071-1'e En rr r 0.1 P M Mailing Address: in /;o,< Ji-H'15Lalp Telephone Number: . r5'* Sc. z— /Lt Zo CERTIFICATION STATEME\T. I ce.^.ifi that I have pe•sonall\ inspected the sewage disposal syster-1 at this address and tha: the information reported be!o% is true. accurate and comolete as o:the time of inspeco G o-. The inspe .on was performed based on my training and experience in the proper.funcnor, and maintenance of on-sae sewage disposa� systems. The system : Passes� . Concit-onaii, Passes _ leecs Furtne- Eva!uanon E, the local .Approving Authonn Fa.,, �`Inspector's Signatures�1' s l Date: T:1e 5­s:e r Ins:eao- sha!' submit a coPe or this inspection reoor, to the Approving Authoriry within thirty (301 days of completing this inspe �on. If the system is a shared systern o• has a deslgri now of 10,000 god or greater, the insoec or and the systeT owner sha!i submit c the repo- to the aporooriate regional office of the Deparment of Envirenmenta' Frotec-oor.. The ong-na! should be sent to the system ovv-ne and copes i-nc to the buve% if applicable. and the aporoying authorir\. INSPECTION SUMMARY: Check A, B, C, or U Al �SYSTEM PA55ES: 1� I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CmR 15.30: �C Any failure criteria not evaluated are indicated below. COMMENTS: BI SYSTEM CONDITIONALLY PA55ES: One or more system components as described in the 'Conditional Pass' section need to be replaced or repaired. The system, upc completion of the replacement or repair, as approved by the Board of Health, will pass. Indicate yes, no, or not determined (Y, N, or NDi. 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; the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tar, failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank w approved by the Board of Health. (rev�.,.d 04/2S!97) page 1 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A _ CERTIFICATION (continued) - - Property Addcass: Owner. Date of Inspection: 81 SYSTEM CONDITIONALLY PASSES tcontin,�-d Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipets) or due tc 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 broker obstructed pipets). The system will pass _ s}s eq p P B inspection if twith approval of the Board of Heaith): - - - broken pipets) are replaced- obstruction is removed C) FURTHER EVALUATION 15 REQUIRED BY THE BOARD OF HEALTH: Conditions exist which reouire furthe• evaluation by the Board Health in order to determine if the system is failing to protect the public health, safer}• and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETE INES THAT THE SYSTEM 15 NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or priv1 is within 50 feet of a surfade water Cesspoo! or pri%� is w ithin 50 feet of a YLIH ering vegetated wetland or a salt marsh. 2) SYSTEM KILL FAIL UNLESS THE BOARD OF H (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM 15 FUNCTIONING IN A MANNEZ THAT PROTECTS THE PUBLIC HEALTH AND SAFME AND THE ENVIRONMENT: The sys;ern has a septic tank and it absorption system (SAS) and the SAS is within 100 ieet to a surface water supply or tributan to a surface water supp The system has a septic tank a soil absorption system and the SAS is within a Zone I of a public water supoiy well. The system has a septic tank d soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tan and soil absorption system and the SAS is less thar, 100 feet but 50 feet or more from a private water supply well, niess a well water analysis for eoliform bacteria and volatile organic compounds indicates that the well is free from poll ion from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Meth used to determine distance (approximation not valid). 3) _ OTHER - (revises! 04.15/3') page 2 of 10 d SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOR." PART A CERTIFICATION (continued) Property Address: ' Owner: Date of Inspection: D] SYSTEM FAILS: You must indicate either -Yes- cr `No* as to each of the following: I have determined that the system violates one or more of the following failure criteria a- for n 310 CMR 15.303 The oasis for this determination is identified below. The Board of Health should be contacted to determi a what will be necessary to correct the failure. Yes No Backup of sewage into facility or system component due to an overloaded or ogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogge-? SA5 or cesspool. S;a:ic !iouid leye! in the distrib.ition bo> above outlet invert due to cve'toaded or clogge� 5�5 or cesspco! lieuid depth in cesspool is leis than 6- below invert or avail/Io ume is less than 1/2 day fiov. Reau'red pumping more that 4 times in the last year NOT dogged or cbstruc;ec pipe s . tiumoer of times pumped _. An%- portion o'the So!l Adsorption Syste/feo( ol or riv)• is below the high greundwate• eievancr: Am. por::on o:a cesspool or privy is w'itee: of a surface water supply or tributar to a surface Ovate' suppi) Ant potion of a cesspoc' or privy is w ite I of a public well. Any pe-io- e'a cesspool or prw� is witet of a private water supple well Am• por.or. o. a cesspool or prnti• is les0 fe--t but greater than 50 fee: frcm a private wares sucoh• well with no acceo-.able %ate• qualir anahvsis. If the been analyzed to be acceptabie. anach c00% of we!I water analysis for cohiorm bacteria volatile organic Compmonia nitrogen and nitrate nitrogen. El LARGE SYSTEM FAIL5: You must indicate either -Yes- or -No- as to each of a following. The ioliowmg criteria app;% to !urge syste in addition to the criteria above: The system se-,,es a iacilirt with a desig flow. of 10,000 gpd or greater (Large System; and the s\•stem is a significant threat to public hea!th and safer} and the enviro ment because one or more of the following conditions exist. Yes No . the system is within 400 eet of a surface drinking water supply the system is within 2 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 wrapped Zone II of a public water supply ell) -- _--• : The owner or operator of any such s stem 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-furthe.r.iniormacion:--- - _ --- SLISSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: Owner: , l A�N v-C •Z Date of Inspection: Check if the following have been done: You must indicate either 'Yes' or 'No' as to each of the following: Yes No NoPumping 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 recentl.. or as pan of this inspection. As built plans have been cotained and evarnined. Note if they are not available with N,A. The fault. or dwelling ..as tnsp&=ed for signs o' sewage back-up. _ The s.-stem does not receive non-sanitary or industrial waste flow. _ The site %%as inspected for signs of breakout. All s.sterr. co^tponen _. ezcludine the Sot Aosorpuon System, have been locate✓ on the site _ The septic tank rnanheies Nere uncovered'. opened'. and the interior of the septic tank %%as inspe^e^ icr condition of bariies or tees, matera; o'construction, dimensions, deptn of liquid, depth of sludge, depth of scum. The size and locat.on of the Soil Absorption S.-stem on the site has been determined base' on _ The fac,l-t, o..ne• ,anc occupants. t.'diieren: trom owner were provided with information on the prope• raintenance of Sub•Suriace Disposal Svsterr.. Existing information. E. Plan at E.0 H. _ Determ-ned in the field tc an% of the failure criteria related-to Part C is at issue, approximation ei distance is unacceotabie (15.301.3i;bil SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Propert% Address: 9 G Owner: ' / 1 "V Date of Inspection: �l � U FLOW CONDITIONS RESIDENTIA ;_ Design TIoN d..bedroorr. for S.A., Number of bedrooms Number o`current residents Garbage g-, der (yes or nog Laundry cor—ected to system (yes or no` Seasonal use ryes or no- 1�Ji Water meter readings. if available (last two i2 vear usage tgpd): 1�5 Sump Pump (ves or not Las date o- occupancy COMMERC14UINDUSTRIAL: Type of establishmen: Design fio%% 122!10nsrda� Grease trap present Ives or no_ Indus:rial %%aste Holding Tani; present -yes or no_ Non-saneta� Haste d-scnargec to the Tt:ie 5 sysem ;yes or no_ 1larer meter readings if a�ailabie Las:Fa:e o: c• OTHER: .De:cribe Last care of occuca-ic. GENERAL INFORMATION PUMPING RECORDS and source of in prrr .a:.or. System pumper as par, or inspec-oon: (ves or no d..l If ves, volume pumped _ gallons Reason for pumping TYPE OF SYSTEM _ Septic tankldistnbution box.Isoil absorption system Singe cesspool Overflow cesspool Prig) 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: Sewage odors detected when arriving at the site. (yes or not (revised 04/25/97; Page 5 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: ��;Tp n �o L•s ►s Owner: Date of Inspection: BUILDING SEWER: F (locate on site Otani 1v Depth below grade. Material of construction. _cast iron _40 PvC _other texplain, Distance from private water suppl, well or suction I,-< Diameter Comments: )condition of loints, venting, evidence of leakage, etc.) SEPTIC TANK: S )locate on site 4pnarl �t Depth beloN grade Material of construction _concre:c _me:a _F oe g ass _Polyethylene _othenexpla n If tank is meta:. Its: age _ I; age coni.rmec o, Ce^•fica:e os Compuance _(he&'No Dimensions Sludge depth b'( N Disiance from top o: s!udee to bottom o; cutie: tee o• ba�,e �_ ,t Scum thickness _ t� Distance from top o: scum to top o` outle: tee or bade�_ .i Distance from bosom o; scu—� to bo-on o, outie: tge e• ba*:,e t G • f-+ov`• dimensions v`ere determinec o.S.;.t. Comments trecommendation for pumping condition o, inter and outlet tees or baffles, depth of liquid level in relation to outlet invert, �tru ram integrity, evidence of leakage. a:c i QUay1 t#i l 1 G 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, conch ion of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc., (re,*ixod 04/25.'97) Page 6 of 10 f . .� Y�7-r SL'BSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Propert% Address: O%ner: Date of Inspection: 7 H I`It, TIGHT OR HOLDING TANK: .Tank must be pumped prior to,.or at time, of inspections (locate on site plan, Depth below grade. Material of construction _concrete _metal _Fiberglass _Polyethylene _otherlexplain► Dimensions: Capacit\• gallons Design f101A gals(Ons."da. Alarm level A:arr.n in %korking orde• _ Yes. _ No Date of previous pumping Comments (condition of inlet tee. condition o- a!a•m and floc: switches. etc.) DISTRIBUTION BOX:-�M doca:e on site p a_ Death o; licuid le%e' aoo�e ou:ie: in%e' Corn-nent'_ incite :1 leve! and disirib1j-i-or.is 7ua• ev,dence Oi solics urrY-over e%idence of leakage into or out Of boa. etc.) t PUMP CHAMBER: (locate on site plan. Pumps in working order: (Yes or No- Alarms in working order (lees or No Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORk' PART C SYSTEM INFORMATION (continued) Property Addr-ss: Owner:.CA-,rAN .� Date of Inspection: SOIL ABSORPTION SYSTEM (SA5):- ,5 ;locate on stte.plan, ti possible: exca%a;ion not required. but may be approximated by non•tntrusrve methods. If not determined to be present, explain. Type: leaching pits. number.LXu leaching chambers, number:_ leaching galleries, number. leaching trenches. number.ien.gth: leaching fields, number, d,rnensions overflow cesspool, number Alternative system Name of Tecnnoiog-, Comments inote condition of soli, s!gr.s of hydraulic failure. level of ponding. condition of vegetation, etc.' CESSPOOLS: (locate on site plar. Numbe• and ccnfjgura:.on Depth-top of liquid to inlet inver, Depth of solids lave-- Depth of scum laver Dimensions of cesspool Materials of constructior Indication of groundv`ate- inflow tcesspool must oe pumpec as pan of ,nspection� Comments: ,(note 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.). tr.va,.e o�;zs/s-t Page a os 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM NFORMATION (continuedi Propert% Address: Owner: Date of Inbpection: j��� 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) C' P VQC0i i Ali-3L SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION"(continued) Property Ad tress Owner: Date of Inspection: Depth to Groundwater Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observation of Site (Abutting property. observation hole, basement sump etc.) Determine it from local conditions Cneck %.ith Iota! Board o• nea'tr Check FED A neaps Check pumping records Check local e*ca.ato-s installe,s Use LKS Da:a 4 Describe in you' o%.-. v.oro: co•.% %o- established tie !-ii¢h Groundwater Elevation. (Must be completed• t " lrwiu3 ;4 25'9 Page 10 of 10 * ASSESSORS MAP NO: 1 4S No._... G_ . I PARCEL.NO. - F� ...�® _ c� 6 THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEA TH OGv. ............ ....OF... 7zX. ..... f, Applirttt 'lln for lliivuiitt1 Workii Tun.6trnrtiun Vamit Application is hereby made for a Permit to Construct l ) or Repair ( ) an Individual Sewage Disposal system at - - .`�" '- -----•--••-•---•--. --•••-••......•-- �� ....AMC. __ . ..- _ ---�- .. ................... o tion Ads--- oro. O ne Address f.5....... .......................... ?v �A- I st ]ler Address Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms.......... _._..Expansion Attic ( ) Garbage Grinder (AI�3 �t Other—Type of Building ............................ No. of persons__..-____-__-___..__-__--_._ Showers ( ) Cafeteria ( ) aOther fixtures ------------------------------------------------------ WDesign Flow.........�a. ..:...................gallons per person per day. Total daily flow.............................::_ .:::=..gallons. WSeptic Tank—Liquid capacity!�e?l*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 by........................................................................... Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ �Tq Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 9 -------------•----------------•----•------...............--------------••--...--••••-•---•-••--••--•......................................................... 0 Description of Soil.........................................................------•------•---•-------------------------•-•------------------•--•-•------------••......•-••••......---•-... x c, W --••------•-•------------------•---•--------------------•-•---------•-•-•--••••••-•-•••......---•--•--•--•------••----•----••-•---------------•-•---------------•-•---•-------•--•---••......•---••..... UNature of Repairs or Alterations—Answer when applicable............................................................:.................................. --•---------------------------------------------------•----•---•-------•---......_...-----------------------------------------------••-----••----------------•---•---------------------------------•--•. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of iITIE 5 of the State Sanitary Code—.The undersigned furth agre 4iot o place the system in operation until a Certificate of ompliance has be 1 sued by th oa f healt gnedL -••••...... . ............ •.. -----• •-- . l-lO.- ...t ,,//�� Dat Application Approved BY L%' ..... ............................. ............. P ---� -- D ate Application Disapproved for the follow reasons-------------------------------------•----------------------••-------------------•----•--._.....•-----......... •-----------------------•-••-•-•-••••----•--•-------••---•-•..............•------•-----•--.........-----•............................---•-----•--•---................................................... Date PermitNo..................................................._.... Issued....................................................... No................_....... Fims........................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...................OF....... ........./�?..y: .. ......----------- Appliratinn for Disposal Works Tonotrnrtion 1hrnti# Application is hereby made for a Permit to Construct �r Repair ( ) an Individual Sewage Disposal System at: •- � _ --- a Lotion}Add`rrss _ or I.9t=^No. w�� _.. .'.:E IZ4 1 .. hV`��-•-------•---- �...;:t!.... .. X rt 1l - 1 O�er ""`^^-•••�„ - •Address f �.. _1 �:+....................... ..._................ to 0!• ------ ........................... . , Inst ler Address dType of Building _ .� Size hot............................Sq. feet U Dwelling—No. of Bedrooms...........!.......____________________Expansion Attic ( ) r, Garbage Grinder Other—Type of Building ____________________________ No. of persons............................ Showers (1- — Cafeteria ( ) 04 Otherfixtures .--•--------•-- -----•--------•---•----------------•.------------•-------•---------•------------•--------------------._..........---••..........._.. Design Flow____._._.J<.; ____________________gallons per person per day. Total daily flow............................................gallons. W s � W Septic Tank—Liquid'capacity___.__._vr____gallons Length................ Width................ Diameter................ Depth................ x x Disposal Trench—No_....................iWidthr........ ........ Total Length, ........... Total leaching area..._,___..__________sq. ft. Seepage Pit No..................... Diameter..................... Depth%elow inlet.................... Total leaching area........:..._.._:Y.__.sq. ft. z Other Distribution box ( ) Dos><ng tank"'(,. r r Percolation Test Results Performed by________________ __ ............... --------------- Date........................ ................. as Test Pit No. I________________minutes per inch Depth of Test Pit... ................ Depth to ground water_.......................... (i Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ R+' --••-------------------------------•-----•••--•-••--•--- - -------.._..__.=t.............................................................................. Descriptionof Soil -•-----•--------•--...-•-----•............................................................. W . UNature of Repairs or Alterations—Answer when applicable_.__:'_________________________________________________________________________________________ -----------------------------------•----------------....--••---•----•---=---•--•---•-•-----------•------•---•-•-----------------------------------------•--------•----..__..__...__......__.._..._•----- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of�mpliance has bee issued by th _5oaYd.Qf health. igned___.__ Vic ' .-__---•_•_. ...::--:?�. ` c.-- '..... ............ ✓ tO �a `3 Date 4 Application Approved B ------------------------- ----_-_____.... _' .. Application Disapproved for the follow"rg reasons______________________ ......••---•----•-----------------------------------------Date --••-•---•-------------------------------•---•-------------------•---•--•-------.::--------•---•--.....----------•-------:._._._......._.....----•-----------------------------•----•------•---•-------- Date PermitNo.....-••--_... --••-------.-- Issued_------•--••--------- 'c-•-------•---•---••-------• - ..................••--•-------- Date THE COMMONWEALTH OF MASSACH U S"ETTS BOARD OF HEALTH—, y t. ..........................................OF..................................................................................... Trrfif iralr of Tompliatta x THIS IS TO CERTIFY, That the Individual ewage D' osal Systemconstructed or Repaired ( ) by `C �:..----- --------•--•--•- -------------•-•--• - Installer 1 .... ......_ at.-- -c7 if ---- � ---------F X...��o�r0W.......__... �..._..._.Q_Z ewe_!.{.._P_ has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the application fo,r_;-Disposal Works Construction Permit No �6_ __�-a__I'S........... dated.............................:.................. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT:BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE..... ............................. Irispecfor :___:.............................. :.:::-----••--- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH - - Disposal orks Tonstrnrti.un f rrutit to Construct r) or an Individual v on is reby Repair(ed�-- --� ..ag D s�ioyst-•------.'...:..................................................... . ...... _..� _.c-...at No....................................LD-1------�- ____---____r�54----: ...�._------.. Street as shown on the application for Disposal Works Construction Permit No. P_'.3 Dated......... [0 _�x............. .......................................... of ea --•••--- o T� DATE................................................................................ as FORM 1255 A. M. SULKIN• INC.. BOSTON • ,'/sue �r�c,. $�I\I 3 6Cu12ooN( _ i �. 6A1l..Y FLovJ = t 10 x 3 = 33o G-. P. D. �f- SEPT'I c. TANK = 33o X 11667. * 495 CG.P.O./ Z6 � �� Z Z, D IS P o S A L PIT -- V 5 E 1000 6-Al. s I OEwtA� /�1fZEA• � 150 5. F. / � Aso s.F P. o. : 29-0 �' P cs1G K) = 42-5 Co- P. D. z7 TOTAL_ DA%L-y F-.ou3 = 33o GP,o. _ tPERCocAiloQ RATE ' 1'�1,4 2 MiN: 02 ;J•LtN csr ► �s� 9 q K'tE Iv. ; fda 24 � . /o-:I (vl o -ULLRIAN C43 7 4 a Z tlo. ?S 33 y Ilk Ts z zy. 5 '� TE,ST'f,�a�-E `/�,Su//�.id�/- Off. �C'� '�'/G'�-l.Gtc/ �,,�� •. Z�a .1c Zio o �G 404 P.T A TAn/. ' v - p �/� •• 1%�• zY.z 2y - W 4 s H G-D ,;• G'E.2T/F/EO PG OT p!4i✓ .f ST N --Zz=-0 F��ILE THAT' vciv, -J��i 7 t� 4uL .4N�,,�ETI�/1G` ,eE4V/,�E'N1ENTS. O� Tf/� le-alb 7"OWiV OF 1,yCI�Z,�S�l jam[�" Aw7 /S NOT" .�3'�..� GI � T//!s�G•QiV %s iYo7-r3.4sEp Div.4iV/rY..ST,e— �/�WS/T.SU,2(/EYf>it/O Tf/E 4 i,4, S IY�t/,yE.e�4N.S.�a!/L 107 USEp TOWN OF BARNSTABLE_VQ r�'o'U� h/ LOCATION ��' SEWAGE # VILLAGE ��M.ems ASSESSOR'S MAP& LOT t INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY o LEACHING FACILITY: (type), u/ (size) c dr f NO.OF BEDROOMS -�— BUILDER OR OWNER P1TDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and ± , Feet Private Water Supply Well and Leaching Facility (If any weUs exist on site or within 200 feet of leaching facility) 10 !AI Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) N Feet i Furnished by G �G� 7 ? 5 d r 2 41 V• 6-3 ; 30 93 ate,