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HomeMy WebLinkAbout0015 GALAHAD CIRCLE - Health 15 GALAHAD CIRCLE, OSTERVILLE -A= 145 066 I; a e r/ 10 R®USFIEL® SANITARY SERVICE ® 451 ROUTE 6A P.O. BOX 438 ✓(JN ' EAST SANDWICH, MASSACHUSETTS 02537 h .7 (617) 888-2010 �� 499S ILI � � � SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Address of property I S GA�.�i HBO /R�Zc� 0Sr6X VtI16; MASS. Owner 's name �,STA-7-E Ole= 4-,DtJ,41Zp L. ✓E2S Date of Inspection /Z, 7.S PART A CHECKLIST Check if the following have been done: Pumping information was requested of the owner, occupant, and Ord 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 th e system recently or as part of this inspection. /V As built plans have been obtained and examined. Note if they are not available with N/A. s inspected for signs of sewage back-up. The facility or dwelling was i p g 9 _� Y The site was inspected for signs of breakout. /N a4u Dour All system components, the SAS, have been located on the site . The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. The size and location of the SAS on the site has been determined based on existing information or approximated by non-intrusive methods.. The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of SSDS. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION FLOW CONDITIONS If�residential _ %Z _number of bedrooms _,,,0_ number of current residents —QL- 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: f 97(t3 Last date of occupancy GENERAL INFORMATION Pumping records and source of information: IVO System y m pumped as part of inspection, yes or no if yes, volume pumped Reason for pumping: Type of system __jt!-f 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: _)VO Sewage odors detected when arriving 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: zel material of construction: L-- concrete metal FRP other(explain) dimensions: `� e6 ,!w —_� ��® !� ZZ � a y sludge depth " distance from top of sludge to bottom of outlet tee or baffle 31! scum thickness -4' distance from top of scum to top of outlet tee or baffle .20`,1 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 repairs, etc. ) 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 CHAMBER: (locate on site plan) pumps in working order, yes or no Comments: (note condition of pump chamber, condition of pumps and appurtenances, recommendations for maintenance or repairs,etc. ) 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 — �_ 16ffzF Pyq0y f leaching chambers and number IV ¢ 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 pondirig, condition of vegetation, recommendations for maintenance or repairs, 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: (riots condition of soil, signs of hydraulic failure, level 'Of ponding, condition of vegetation, recommendations for maintenance or repairs,etc. ) PRIVY : (locate on site plan) materials of construction dimensions depth of solids Comments: (note condition of soil, signs of hydraulic failure, level Of . ponding, condition of vegetation, recommendations for maintenance or repairs,etc. ! 11 . L 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 1001 0 DEPTH TO GROUNDWATER depth to groundwater method of determination or approximation: Zo G OCCNl� GcJ r`"� SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C FAILURE CRITERIA Indicate yes, no, or not determined (Y, N, or ND) . Describe basis of determination in all instances. If "not determined" , explain why not) Backup of sewage into facility? Discharge or ponding of effluent to the surface of the ground or surface waters? I� - Static liquid level in the distribution box above outlet invert? Liquid depth in cesspool <6" below invert or available volume< 1/2 c flow? 1" 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? �( Is any portion of the SAS, cesspool or privy; _.� below the high groundwater elevation? within 50 feet of a surface water? N within . 100 feet of a surface water supply or tributary a surface to water supply? f Ce within a Zone I of a public well? within 50 feet of a bordering vegetated wetland or salt marsh (cesspools and privies only, not the SAS) ? within 50 feet of a private water . supply. 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 analysi for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. 13 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM / PART D CERTIFICATION Name of Inspector 60WY DCAU F16 ,0 Company Name SC-C PR6 C 0,vC Company Address 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. C e k one: I have not found any information which indicates that the system fails to adequately protect public health or the environment as defined in 310 CMR 15. 303 . Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form. I have determined that the system fails to protect public health and the environment as defined in 310 CMR 15. 303 . The basis for this determination is provided in the FAILURE CRITERIA section of this form. Inspector' s Signature<:1_~11_4_1,;e/_ e�. ' , Date Original to system owner Copies to: Buyer (if applicable) Approving authority �t 05 - to / LOCATE ON SEWAGE PERMIT NO. V 1.ILLAGE O S 1�f7 Li/GfF /V I N S T A LLER'S�� NAME & ADDRESS BUILDER OR OWNER DATE PERMIT ISSUED, DAT E COMPLIANCE ISSUED �/U�.S � �, � ��� �� � � �� 0 �To..�.....G�_7... r ►r c FE$...r d..» - THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH App irFatiun for 11hipug ai Works Toustrnrtiun Vamit Application is h eby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at* ... .... ... SE.. Lo s or Lot No. ...... 1.:.... L4 '�. ............ ..... ........................ -- ...................... ................... Owner Address w ..... t.. •••... ........................................... ............................. ._......._.._.................................. Installer Address Type of Building Size Lot............................Sq. feet -.--•-----------------------------Ex Expansion Attic Garbage Grinder V Dwelling—No. of Bedrooms._:...•— p (� g Other—T e of Building No. of persons............................ Showers — Cafeteria a Other fixtures ••-••-•-••-••-•-••------•--•--•• - w Design Flow...........1�...........................gallons per person per day. Total daily flow............. .!2..0..........__......gallons. WSeptic Tank 1 Liquid capacity. a �'gallons Length................ Width................ Diameter---------------- Depth................ x Disposal Trench—No..................... Width S....._...._.... Total Length.......... -...... Total leaching area-.10.(-......sq. ft. Seepage Pit No...... ............. Diameter.................... Depth below inlet.......--........... Total leaching area..................sq. ft. Z Other Distribution box ( i) Dosing tank ( ) alh�t • j X— /1— 7 7 Percolation Test Result Performed by.:-t..................................................................... Date........................................ 14 Test Pit No. 1.... -__minutes per inch Depth of Test Pit.................... Depth to ground water........................ Gz, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a' A • • ••. .... ........................................................ O Description of Soil........ .' ." 2� f --- --- ---------- -- x �.� _._ s 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:IT E 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Signe .•.�'1. ...........................................•.---- Date Application Approved BY � � ........... ... ` 2 Date Application Disapproved for the following reasons--=--------------------•------------------=-----------------•--------------------•-------------------......--•- -•-•-----•----------•-•--•--------•----•-•---------•--------•----•---------•-----•--------••-•------...--•-•--•--------•---------•-•-•-•---•---•-•--•----••------•----••-•-......-----•--•------------- Date PermitNo..................-,.........................:............. Issued....................................................... Date ...+�+ - Igo.--.......----0... : Fizs...�1��....-...:._ THE COMMONWEALTH OF MASSACHUSETTS s BOARD OF HEALTH 1 ............OF..... . Applira tilan for Disposal Works Tous#rnrtion Prrmit Application is h reby made fo ' a Permit to Construct ( ) or Repair ( , ) an Individual Sewage Disposal System at: „ ........ .. .... ........ - ; ------------ .......t.......................................................... Lo s or Lot No. g .. ........ .................................... f W F Owner Address a .......... .......� L ......... ............. ... ..................•--------•------- -.-.-.--•--••------------------•------------_------ Installer � Address ' UType of Buildi Size Lot............................Sq. feet Dwelling—No. of Bedrooms.... ................................Expansion Attic ( Garbage Grinder (AQ) Other-Type,,of Building ........_.. No. of persons............................. — a ------- ---------•-•--•------•----- _... ------- ( ) Cafeteria F' Other fix S ...............••... ) w Design Flow__........ ..:........................gallons per person per day. Total daily flow........ WSeptic Tank T Liquid capacity.jAkAgallons Length.,.............. Width................ Diameter________--_--_- Depth................ Dis osal.Trench—No.._....._ Width . Total Length x p _........-- ------•------- � ........�.k...... Total leaching area--4—A-1......sq. ft. Seepage 'Pit No :._-_.... . Diameter.................... Depth below inlet___:.__ Total leaching area. -"Sq. ft. Z Other Distribution box ( )_ Dosing tank`( ' '� '" ~' Percolation Test Result Performed by .....,�, .......................................................... Date........................................ Test Pit No. 1.. .....minutes per inch Deptl o Test Pit____________________ Depth to Found water........................ (z, Test Pit No.r2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Ri 4 a DDescription of Soil........ .-•-- f................................ �•� .�..............•..-----•--••-•••••................................................... 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 iTIL 5 of the State Sanitary Code,;._—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Signe . :7t :....... • . Application Approved B � Date ----------- Y Date s Application Disapproved for the following reasons:__'.............................................................................._..•••. ---------... k:. r Date Permit No............. ...............•-------- Issued.-----•---•------------------••---.........------•--... --------------= Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF EALTH, ........O F............ 1 . C&4_"....................:.................. (Irdifiratr of Teout liFanrr THI 1b7T C. T Y, That the Individual Sewage Disposal.System constructed ( ) or Repaired ( ) by .... --- -- / nstall .t - f1 p .AJ...ou �. ....... . has been installed in accordance with the provisions of T j�,of-The State Sanitary /Code as described in the application for Disposal Works Construction Permit No. Vt ..7.•._....... dated_p✓_�_~ .-. 't............. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM L EUN&TION SA ISFACTORY. DATE..... .. •-- ' -----�--•---. ...--•-••...::..............• . Inspector.....--•------•-- •-----•--------.._..--t ................................ THE COMMONWEALTH OF MASSACHUSETTS ,"U-1 BOARD HEALT ✓ R 7. ...... ...............................OF.::-.. ............... .. .............. No........................ FEE..... . . .......... °y Disposal IV rk.- ��rnr#Uan lernti� Permission h eby granted.. ' _ -- ...::. '--•---------------•-----------....._..... __ _ to Cons c ( or pai ( an dividt�al Se ge Disosal ystem �"✓'al Street as shown on the application for Disposal Works Construction Per o......... ........ Da ..'_./�__"1a:.. /��"' yy J / 'Board of Health . DATE........... ........ . ....................................._ , FORM 1,255 HOBBS & WARREN, 41Nd.". PUBLISHERS . O'Gr t��r..l bQ,Tp. - BOT-rOX/l AOVA r G,,p ST=. �PVt if TOTAL .42S ToT,a L T:>.d.l L�-f t=C.Q�I✓ t e 3W 61� { Pi rtZGUL&T100 Z&TE : � tr�3 �Lm li ©iz ^p lrCtQG+^53�33 �,,� ' y Q, 71.0 ....iXl..� �. aa'J J k ♦t� �? ` Il Y JLC t 400 - ,N� rr T sT Trkp ;,Wu _{el 4- ao.o C11.0 StlpiL 4 IW r�pfa tC7oC> ItN r1 bh>i - G,aL. RG 95 , `�oX 9b S ir7c i C> A taK SAWS GQ.L . �� 4t►�. LsAr-�.{ A PIT t`.V'" zi ....... C 1=C ct 1 P Lc,''-- L OU-TI OI,4 r/t U.S. I c CA L C= i k zto �?—r=- t ry Irol T"A T T 14 c.. 17w nia..t o fie., 'S Uc-c N tit_.to s.J I r-�-=1= y-a t.i GE. �-1C_P't::t�t:.l GC�rtrlt�l..�{5 �+,/ t.•C'i•� "t'I.�i �!'Q!� Li►:.lE: a.wa SETL�hc1!, �'C©�t�E��u�y or- TNT �-oT' 3� T3 -To w Li cl"' � 'f f3t, L OD wiZT 1-.A.1,J o T1415 Pt_Ai.-i IS L- OT ZASG-V 064 A-W Os Qvtl..c.t� o 114-9F LJ,*.A GREW i ;1 *Tl4- oPt='r ( , rj)1c,tstLD AP CA 1-t:�T' �',�, tJ�.Ch Ti.k . T7ty't'C.C'Mt►J�. LC�T' 1_ii�l�:��a w L...�� QL s,..t�tldjT• t,.©. THE BARNSTABLE COUNTY NATIONAL BANK of HYANNIS, Hyannis, Mass. J11-22 19_7 RETURNED UNPAID FOR WE CHARGED YOUR ACCOUNT ON ABOVE DATE FOR REASON MARKED (✓) PLEASE SEE REASON INDICATED 1 THAT THE AMOUNT IS DEDUCTED ON YOUR BOOKS SO THAT OUR ACCOUNTS MAY AGREE El FUNDS FUNDS Frederick L. MurrayAMT. f 25. 00 ENDORSEMENT 53-144 ❑ FEES ❑ MISSING REASON FOR TOTAL 25. 00 ❑ NOT AS DRAWN f , RETURN OTHER ❑ WRUNG BANK 111[THAN LISTED Refer t0 Maker ' BY mfr ❑ SIGNATUR-E !, ACCT.03-00007-2 ElFUNDSLECTEO I. N , OTHER REASON CHARGE Town of Barnstable - Treas . Acct. T. C. (SPECIFY) �. 60 Refer to Maker Mr. Lahteine f . — - ,p