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Home My WebLink About0239 HICKORY HILL CIRCLE - Health 239 Hickory'Hill Circle_ Osterville -P _ A = 121 D29 IJn I • Commonwealth of Massachusetts .. -Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments . 239 Hickory Hill'Cir Property Address Matt Balboni Owner Owner's Name information is Cist. MA 02655 6-21-12. required for every - page. City/Town _ State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in,any way. Please see completeness checklist at the end of the form. • Important:When A. n ��uuutnpuq E , filling out forms Ge eral Information i HOFMgs,,,�� on the computer, S �, .AN kp.• use only the tab 1. Inspector: �., o?:' ; key to move your _�: JAM ES N cursor-do not James D. Sears =o. m" use the return = SEAR$ ` key. Name of Inspector Capewide enterprises,LLC, '��r•cFRTIF�� Company Name INS? E 153 Commercial St. Company Address Mashpee MA 02649 Cityrrown State Zip Code 508477-8877 S1623 Telephone Number. License Number x , B. Certification I certify that I have personally inspected.the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system,inspector pursuant to Section 16.340 of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 6-21=12 nSpector's Signature Date The system'inspector shall submit a copy of this inspection report to.the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP The original shouldIbe sent to the system owner and copies sent to the buyer, if applicable, and the approving'authort�r . ****This report only describes conditions at the time of inspectioiii and under the conditions of use at that time.This inspection does not addres's how the system,will, erform in the future under the same or different conditions of use. 01 �iJ 15ins•11110 'Title 5 Official lnspectlon'Form:Subsurface Sewage Dispo§aI System•'Page 1 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form h : Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 239 Hickory Hill Cir Property Address Matt Balboni , Owner Owner's Name - information is Ost. MA 02655. `6-21-12. required for every - _ page. Cityrrown State , Zip Code Date of Inspection B. Certification (cons.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System'Passes: ® 1 have not found 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: , '3) 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: Check the box for"yes",'"no"or"not determined"'(Y, N, ND)for the following statements. If"not determined,"please explain. , The 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: Y "❑ N' -❑ ND(Explain below): `. 15ins-11/10 y Title 5 Official Inspection Form:'Subsurface'sewage Disposal System•Page 2 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments i 239 Hickory Hill Cir Property Address Matt Balboni Owner Owner's Name information is ' required for every Ost. MA 02655- 6-21=12. page. Cityrrown State, Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): Observation ofsewagebackup 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.,, ❑ Y ❑; NI" ,❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑' N •❑ ND(Explain below): , ❑ distribution box is leveled or replaced ❑ Y , ❑ N ❑ ND(Explain,below). f ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑_N ❑ ND(Explain below):: EI obstruction-is removed y ❑ Y :❑ :N. ❑ ND;(Explainbelow):_ C) further Evaluation is Required by the Board of Health; ❑ Conditions exist which require'further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public:health, safety and the environment: ` El.I Cesspool or privy is within 50 feet of a surface water- El -Cesspool or privy is within 50 feet of a bordering vegetated wetland ora salt marsh 9 • t5ins•11/10 TIBe 5 Official Inspection FormJSubiurface Si w% pe'Disposal System•Page 3 of 17 i Commonwealth of Massachusetts W Title 5 Official Inspection Form ; Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 239 Hickory Hill Cir Property Address Matt Balboni ` Owner Owner's Name ` information is r required for every Ost. MA 02655 6-21=12. page. City/Town State Zip Code Date of Inspection B. Certification (cost.) ' e 9 2. System will fail unless the Board of Health(and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has 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 apublic water supply. The system has a septic tank and SAS and the SAS;is within 50 feet of a,private water supply well. El The system has a septic tank and•SAS and the SAS is iess,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 fecal. coliform bacteria indicates absent and the presence of ammonia,nitrogen and nitrate nitrogen is equal to or less than.5;ppm,:provided-that no other:failure criteria are:triggered.;A,copy of the analysis must be attached to this form. 3. Other. , D) System Failure Criteria Applicable to All Systems:F You must indicate"Yes"or,,".No"to each of the following;for all-inspections: Yes No Backup of'sewage into facility or system component due to overloaded or El ® i z clogged SAS or cesspoolEl - Discharge of ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ` • ` ❑ Static liquid'level in the distribution°box:above outlet invert due to an overloaded or clogged SAS or cesspool ® Liquid depth in cesspool is less than 6"below invert or available volume is less than %day flow t5ins-.11/10 Tide Official Inspection Form:Subsurface SewageiDisposal System•!Page 4 of 17 Commonwealth of Massachusetts r Title :5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 239 Hickory Hill Cir j Property Address Matt Balboni Owner Owners Name information is :- required for ever� Ost. MA d 02655 6-21-12. page. CityrTown State -Zip Code Date of.Inspection B. Certification" (cont.) Yes No El ® Required:pumping rnore'than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times�pumped: ❑ ® Any.portion of the SAS, cesspool or p"rivy is below high ground water elevation. El ® Any portion'of cesspool or privy is within,100 feet of a surface water_ supply or. . tributary` to.a surface water supply '. , ❑ 4 � `.Any portion of,a cesspool or.privy.is within alone 1 of_a public well. El ® -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. [This • . system passes if the well water analysis, performed at a DEP certified laboratory.,for.fecal coliform bacteria indicates absent and the presence _ of ammonia nitrogen.and nitrate nitrogen is equal to or.less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] • The system is a cesspool serving a facility with a design-flow of,2000gpd- ® 10 000gpd. 0 ® The system fails.] have determined that one or more.of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The r system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a„ design flow of 10,000 gpd to 15,000 gpd.' For large systems, you must indicate'either'"yes"or'"no".to each of the following,in addition to the questions in Section D. Yes No r, k the system is within 400 feet of a surface drinking water supply ❑° ❑ the system is:within 206 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 t' If you have answered"yes"to"any question in Section E the system is considered a significant threat,'- or answered "yes" in Section D above the large system has failed. The owner or operator of any large fi system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate. regional office of the Department. - t5ins•11/10 Title 5 Official Inspedlon Form:Subsurface Sewage Disposal System•Page 5 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 5 239 Hickory Hill Cir p Property Address Matt Balboni Owner Owner's Name information is required for every Ost. MA ,n 02655 '6-21-12. page. CitylTown State Zip Code Date of Inspection C. Checklist . Check if the following have been done. You must indicate,'yes"or"no"as to each of the following: Yes No ❑ ® Pumping information" as provided by the owner, occupant; or Board of Health ❑ .0 Were any of the system components pumped out in the previous two weeks? i ® ❑ Has the system received normal�flows in the previous two week period? Have arge volumes of water been introduced to the system-recently or as part of this inspection? Z .❑ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ®, ❑• Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was`the site inspected-for:signs-of-break out? ® ❑ Were all system components, excluding the SAS; located on site?' ® ❑ Were the septic tank manholes uncovered, opened,and the interior of the tank inspected:for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ® ❑. Existing information. For example, a plan at the Board of Health. Determined:in the,field(if any of the failure criteria related to Part C is at issue approximation of distance is,unacceptable),[310 CMR 15.302(5)] D. System Information Residential flow Conditions:-, Number of bedrooms(design): " 4 Number of bedrooms(actual): 440 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#'of bedrooms): 3 t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 239 Hickory Hill Cir Property Address Matt Balboni Owner Owners Name information is Ost. y L' MA 02655 6-21-12. required for every page. Cityrrown State Zip Code Date of Inspection D. System Information Description: The system:is-a 1000 Gal Pre Cast Tank D Box'and Precast Pit W/two leaching trenches, t I Number of current residents: 2 Does residence have-a garbage grinder? - ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ., t ❑- Yes ® No Seasonal:use? ❑ Yes ® :No Water meter readings, if available last 2 ears usage d -see aft gp 9 ( y 9 (gP ))�� Detail: Sump pump? ❑ Yes ® No• Last date of occupancy: y present.Date Commercialilndustrial-Flow Conditions: Type of Establishment: , Design flow:(based.oh,310 CMR 15.203):, - Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft.,etc.): y Grease trap Present? ❑ Yes ❑ No. Industrial waste holding tank present? j ❑ Yes ,❑ No ` Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No " Water-meter readings,-if available: t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 f Commonwealth of Massachusetts ; fD Title 5 official Inspection Form� Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 239 Hickory Hill Cir d Property Address + Matt Balboni Owner Owner's Name information is required for every Ost: MA 02655 6-21-12. page. Citylrown State Zip Code Date of Inspection D. System Information (cont.)' Last date of occupancy/use: Date Other(describe'below): General'Information t Pumping Records: y Y Source of information: NA Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume;pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ • iSingle cesspool 8 ❑ Overflow cesspool :Privy ❑, Shared system(yes or no) (if yes, attach previous inspection records, if any) Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): t t5ins-11/10 " Title 5 Official•Inspection Form:Subsurface Sewage Disposal System•Page of 17 Commonwealth of Massachusetts Title 5 Offi ial Inspection Form1 Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 239 Hickory Hill Cir Property Address Matt Balboni Owner Owners Name information is required for every Cist. MA 02655 6-21-12.• page. Cityfrown State 'Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: NA _ Were sewage odors detected when arriving at the site? '❑ Yes ® No Building Sewer(locate'on site plan): 2- Depth below grade: ' 'F • feet Material of construction:;' + Z cast iron' Z 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting,evidence of leakage,�etc.): House to tank cast-iron, other,pipeing 4".pvc sch 40 Septic Tank(locate on site plan): -. . 16 . 'Depth below grade: feet Material of construction: 4 , ® concrete . ❑•metal ❑fiberglass ❑ polyethylene- ❑ other(explain) If tank is metal, list age: years w1s age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑, Yes ❑ No rDimensions: 1000 Gal Pre Cast Sludge depth: t5ins-11/10 Title 5 Official Inspection Form:'Subsurtace Sewage'Disposal'system-Page 9 of 17 I Commonwealth of Massachusetts Title 5 Official .Inspection Fora _ Subsurface Sewage Disposal System Form-Not for Voluntary Assessments t 239 Hickory Hill Cir Property Address Matt Balboni Owner Owner's Name ` information is ' required for every Ost. MA 02655 6-21-12. page. Cityrrown State Zip Code Date of Inspection. D. System Information (cont.) h .Septic Tank(cont.) 2s„ .Distance from top_of sludge:to;bottom.of outlet tee or�baffle Scum thickness 2 Distance from top of scum to top of outlet tee or baffle 12" Distance frornibottom of scum to:bottom of outlet tee or:baffle 1611 Asbuilt How were dimensions determined? Tape, - Sludge Judge Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank at working level, Tank and covers at 16", in and outlet baffles, no sign of leakage or over loading i Grease Trap(locate on site plan): Depth below grade: feet Material of construction: • ❑concrete ..[]:metal* ❑fiberglass ❑ polyethvlene ❑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: Date t5ins--11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal system-'Page 10 of 17 Commonwealth of Massachusetts ; Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 239 Hickory Hill Cir T Property Address Matt Balboni Owner Owner's Name information required for every Ost. J MA. '• 02655 6-21-12. page. City/Town State - Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, .liquid levels as related to outlet invert, evidence-of leakage, etc.):- Tightor�Holding Tank�(tank must be-pumped-at time of.inspection)Ilocate onzite plan): Depth below grade: Material of construction: t ❑concrete ❑;metal ❑fiberglass' ❑ polyethylene • ❑other(explain): Dimensions: Capacity: gallons Design Flow gallons per day Alarm;present: ° ❑ Yes .0•;No Alarm level: • Alarm in working order: ❑ Yes :❑ No: Date of last pumping: Date Comments(condition of alarm and float switches,•etc.):- • Attach copy of current;pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•11110 + Title 5 Official Inspection Form:Subsurface Sewage Disp osal posal System•Page 11 of 17 , Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal,System.Form-Not for Voluntary Assessments- M 239 Hickory Hill Cir F Property Address Matt Balboni Owner Owner's Name information is Ost. MA 02655 6-21-12. required for every - ` page. Cityrrown State • Zip Code Date of Inspection D. System Information (cost.) Distribution Box(if present must be opened) (locate on site plan): :Depth of liquid ilevel above outlet:invert D Comments(note if box is level and distribution to outlets•equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D Box is 16"x 16" 30''below grade w/cover at 1' box is clean and solid w/three lines out no sign of over loading or solid carry over 1r Pump Chamber(locate on site plan): Pumps in working order: El Yes ❑ No Alarms in working order: s ❑ Yes ❑ No Comments:(note condition of.pump chamber, condition rof pumps znd appurtenances, etc.): Soil Absorption System (SAS)(locate on site plan, excavation not required): If SAS not located, explain why: x t5ins-11/10 Title 5'Official Inspection Fann:Subsurface`Sewage'Disposal'Sptem-'Page 12 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form , Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M ,o 239 Hickory Hill Cir y Property Address Matt Balboni µ Owner Owner's Name ' information is st. MA 02655 6-21-12. required for every O ' page. City/Town State Zip Code ? Date of Inspection D. System Information ,(cont.) Type ® ° 1 "leaching Apits' � - � ^;number: ❑ leaching chambers• number: ❑. leaching galleries i, ` number:', ❑ leaching trenches number,'length` ® leaching fields- ' numbec,:dimensions: 2-4'x40'x2' ❑ overflow cesspool number: ❑ °. innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure,<level of,ponding, damp soil, condition of 'vegetation, etc.): Leaching is one 1000 Gal precast pit pit at 28" below grade w/cover at 8"30"water two trenches 4'x40'x2',camera out lines no sign of over loading, solid carry over or holding water Cesspools (cesspool must be pumped as part of inspection)(locate onsite plan): Number and configuration Y Depth—top of liquid to inlet invert j Depth of solids layer , Depth of scum layer iDimensions,of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No 15ins-11/10 Title 5:Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official ' I.nspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 239 Hickory Hill Cir , Property Address Matt Balboni Owner Owners.Name _ information is required for every Ost. MA 02655' 6-21-12. page. CityrFown State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure,,level of ponding, condition of vegetation, etc.): Privy(locate on site plan): µ Materials of construction: Dimensions • Depth of solids Comments(note condition of soil,signs of hydraulic failure,]evel of=ponding,conditions of vegetation, etc.): t5ins•11/10 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 239 Hickory Hill Cir Property Address + Matt Balboni Owner Owner's,Name r information is Ost. : r MA 02655 $-21-12. ~ required for every page. City/rown State Zip Code Date of Inspection D. System Information (cunt.) Sketch Of Sewage Disposal System: Provide a view 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 watersupply enters the building. Check one of:the'boxes below: r ® hand-sketch in the area below ❑ drawing attached separately cz S— 1�0 O • ,ti AN ' A r S9 } �F 33 t5ins•11110 Title 5 Official Inspection Form:'Subsurface Sewage Disposal'System•Page 15 of 17 Commonwealth of Massachusetts' Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ' 239 Hickory Hill Cir Property Address Matt Balboni Owner Owner's Name information is Ost. `f MA 02655 6-21-12. required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) ; Site Exam: ❑ Check Slope . ..L El Surface water ® Check cellar ❑ Shallow wells r 12+, Estimated depth.to'bigh ground water: feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: " ' Date s Observed site(abuttingproperty/observation,hole within 150 feet of SAS) ® Checked with local Board of Health _explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS.database-explain:. You must describe how you established the high groundwater elevation: Per past report original design plan 12' no Ywater " r i P <t • Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•11/10 - Title 5 Official Inspection Form:Subsurface• sped Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 -Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments , M ''( 239 Hickory Hill Cir - x Property Address- Matt Balboni Owner Owners Name a e information is Ost.. MA 02655 6-21-12.required for every ' page. Citylrown *' State _ Zip Code Date of Inspection E. Report Completeness Checklist ` ® Inspection Summary:A, B, C, D, or E checked` Inspection Summary D (System;Failure.Criteria,Applicable to All Systems):completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage'Disposal Systein either drawn on page 15,or attached in separate file' t ,� r _ e b n.y.. .. 4} • 1 - s R. r `fir - t5ins-11/10 Title"5 Official Inspection Form:Subsurface Sewage'DisposalSystem-'Page 17 of 17 f Jun. 19. 2012 0:20AM No. 6470 P. 2 C,O-MM.WATER DEPT ' CUSTOMER STATEMENT ACCT NO 4,631 6/18/2012 BALBONI,MATT1f EW LOCATION: _ 239 HICKORY MILL CIR , OST L.6 MAP.A UH0j4: 121029 . Consumption History LAU READ 12/31/11 91 6 0030111 , 85 26 • 12/31/10 59- F 22 06/30/10 31, 16; Y 12/31/09 4. 21 -15 06/30/09 6 6 03/09/09 © 0 03/09/09 1151 U TRANSACTION HISTORY DATE DESCRIPTION 0 to 30 31-to 60 61 to 90 Over 90 10/02/2000 MINIMUM BXLL , 0.00 0.00 0.00 15.00 11/14/2000 PAYMENT, 0.00 0.00. .0.00 -15.00 01/01/2001 MIN EX ,•0.00 0.00 0-00 52,70 03/03/2001 M ' 0.00 0.00 0.00 0.61 04/02/2001 MIN INT 0.00 0.00 0.00 15.61 06/01/2001 INT 0.00 0.00 0.06 0.62 ' 07/02/2001 MIN VT EX 0.00 0.00 0.00 82.50- 08/01/2001 DEMAND 0.00 0.00 " 0.00 lo.0a 09/01/2001 INT 0.00 0.00 0.00 1.77' 09/10/2001 PAYMENT 0.00 0.00 0.00 -163.81 10/01/2001 MIN •0.00 0,00 . 0.00 15:o0 - 11/09/2001 PAYMENT 0.00 0.00 ;' 0.00 -15:00 01/01/2002 MIN EX 0:00 0.00 ' 0.00 177.40' 03/04/2002 INT . 0.00 0.00 0.00 2.07 04/01/2002 bUN.INT 0.00 0.00 0.00 P17.07 ' 06/01/2002 Mr 0.0.0 0.00 0.00 2.29 06/1012002_ PAYMENT 0.00 0:00 0.00: 196:54 #alaice Due: 0.00 • Gnnilnn•� �:c�� . n�:�rn �tnz/sl/so • � :u1o�� r Commonwealth of Massachusetts Title 5 Official, Inspection form �... Subsurface Sewage Disposal System Form -Not for Voluntary Assessments T M 239 Hickory Hill Rd Property Address - Fannie Mae ' Owner Owner's Name information is required for Osterville 'j g. MA 02655 10-24-08' ` every page. City/Town State Zip Code' Date of Inspection Inspection results must be submitted on this form. Inspection form_ s may not be altered in any way. A. General Information - t 1. Inspector: Shawn Mcelroy_ Name of Inspector Upper Cape Septic Services sy Company Name 29 Atwater Dr Company Address "A t rw E. Falmouth a.> 'MA`" a -V- - fi2536 City/Town State p Code 508-495-0905 S13971 c Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this'address and that the . information reported below is true, accurate and complete as of the time-of the inspection. The inspection was performed based on my training and"experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 1.5.000).The system: ® Passes , r.r ❑ :Conditionally Passes. El--Fails ❑ Needs Further Evaluation by the Local Approving Authority 10-25-08 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the' report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the'bu.yer; if applicable, and the approving authority:. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. .` x t5insp official document,03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System*-Page 1 of15 • Commonwealth of Massachusetts 4 W Title 5 Official Inspection 'Form Subsurface Sewage Disposal System Form -Not for.Voluntary Assessments wM ' 239 Hickory Hill Rd Property Address Fannie Mae Owner Owner's Name information is required for Osterville MA 02655 10-24-08 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found 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: System is in good working order with no sign of failure. 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. Answer yes, no or not determined (Y, N, ND) in the ❑ for the following statements. If"not determined,"please explain. ❑ The septic tank is metal and over 20 years old"or 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: r ❑ 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 t5insp official document•03/08 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15 Commonwealth of Massachusetts J. V 7.,, ..«4- t , Title 5 Official Inspection Fo`M Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 239 Hickory Hill Rd Property Address Fannie Mae "f\« Owner Owner's Name r information is Osterville r MA 02655 - 10-24-08 'required for - � + every page. City/Town t State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of-Health.(cont.):e:. Icy ❑ 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: r , ** This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform ,. bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no-other failure"criteria are.triggered:A copy;of the analysis must be attached to this form. 3. Other. - > °^,-.r.�;n, • t H=,1•r.yeti... 1 . ' D) rSystem`Failu•re'Criteria Applicable to All Systems: You must indicate`--`Yes"or"•No",to,each of the>following,for.all inspections: Yes No •r«.,, Erg _ . ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool' Discharge or ponding of effluent,to the surface of the ground or surface waters El `® = `due to'an overloaded or clogged SAS or cesspool - Static liquid level in the distribution box above outlet invert due to an'overloaded or clogged SAS or cesspool" El ® Liquid depth in cesspool is less than 6".below invert or available volume is less than '/2 day flow . yI,,.s ! rw •.,. , t, ® :.. Required pumping more than 4 times in;the last year NOT due to clogged or # obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. j El �, Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. t5insp official document•03/08 Title 6 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15 1 1 Commonwealth of Massachusetts Y Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 239 Hickory Hill Rd Property Address Fannie Mae Owner Owner's Name information is required for Osterville MA 02655 10-24-08 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ distribution box is leveled or replaced ND Explain: ❑ .The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed ND Explain: C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has 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. t5insp official document-03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15 Commonwealth of Massachusetts :. Title 5 Official Inspection Foam f: Subsurface Sewage Disposal System Form -Not for,Voluntary Assessments ,-,_ M / 0 239 Hickory Hill Rd f` Property Address 4 Fannie Mae w Owner Owner's Name information is required for Osterville MA 02655 10-24-08 ' every page. City/Town j State Zip Code Date of Inspection ` B. Certification (cont.) ; D) System Failure Criteria Applicable to All Systems (cont.): ,-.•: :,: Yes No ; ❑- ® Any,portion of.a cesspool,ior privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water,supply well. ❑ ®, .,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 fecal colifortm bacteria indicates absent and the presence ' of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, y provided that no other failure criteria are triggered.A copy of the analysis and chain of.custody must be attached to this form.] - ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. . . F. .,, r, ; The system fails. I have determined that one or more.of the above failure El - ® " 'criteria exist'as described in.310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to'determine what will be ' necessary to correct the failure.' E) Large Systems: To`be considered a large system the'system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems,you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No V ❑ ❑. r 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 I If you have answered `yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CM 15.304. The system owner should contact the appropriate regional office of the Department. t5insp official document•03f08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 239 Hickory Hill Rd Property Address Fannie Mae Owner Owner's Name information is required for Osterville MA 02655 10-24-08 every page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done.You must indicate "yes"or"no" as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ®` ❑ Existing information. For example, a plan at the Board of Health. ® .❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CM 15.302(5)] t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form :� s Subsurface Sewage Disposal System Form 7 Not for Voluntary Assessments 239 Hickory Hill Rd Property Address Fannie Mae # Owner Owner's Name , information is required for .Osterville r MA 02655 10-24-'08. every page. City/Town State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms (design): 4 Number,of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x #of bedrooms): 440 Number of current residents: =t. 1 0 Does residence have a garbage.grinder? ;.. . ,;;>A t ❑ Yes ® No Is laundry on a separate sewage system?'[if,yes separate.inspection required]= ? ❑ Yes ® No Laundry system inspected? ` _#,". : r ❑ Yes ® No Seasonal use? - El Yes ® No Water-meter readings, if available (last 2 years usage (gpd)):; Sump pump? ❑ Yes ® No Last date of occupancy: 8-08 t Date Commercial/Industrial Flow Conditions: Type of Establishment: a , Design flow(based on 310-CMR 15.203):_ s Gallons per day(gpd) Basis of design flow'(seats/persons/sq.ft., etc.): - r Grease trap present? 1 :' f. ,:r; 1. ❑ Yes' ❑ No Industrial waste holding tank present? '( ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No. Water meter.readings, if available:: ,' ";,t Last date of occupancy/user M Date Other(describe): t5insp official document•03/08, Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page of 16 Commonwealth of Massachusetts " i W Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 239 Hickory Hill Rd ` Property Address Fannie Mae Owner Owner's Name information is required for Osterville MA 02655 10-24-08 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: N/A Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. . ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: 2000 Were sewage odors detected when arriving at the site? ❑ Yes ® No t5insp official document-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15 Commonwealth of Massachusetts ; ,. ., *} . '.� :i,;y .ry ►. Title 5 Official Inspection Forri°i Subsurface Sewage Disposal System Form -Not for.Voluntary Assessments,.-. 239 Hickory Hill Rda Property Address a Fannie Mae Owner Owner's Name information is MA 02655 10-24-08y •' required for Osterville. ,. every page. City/Town + State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): Depth below grade: ,..r.. �'' r:' a a i t 18' feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: •,` Comments (on condition of joints,venting, evidence of leakage, etc.):!,),•,` t Good condition. Septic Tank(locate on site plan):,,r } . . Depth below grade: T' 12"feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene .. ❑ other(explain) If tank is metal, list age: . . • .,.y 3. a . "1. •year's'" Is age confirmed by a Certificate of Compliance? (attach a copy of certificate), ❑ Yes ❑ No -------------------------------------------------------- ------------------ ---------------------------- ----------------- Dimensions: 1000 Gal Sludge depth: Distance from top of sludge to bottom of,oubet tee or.baffle , t: 20" 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 16" How were dimensions determined? Tape t5insp official document r 03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System r Page 9 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 239 Hickory Hill Rd Property Address Fannie Mae Owner Owner's Name information is required for Osterville MA 02655 10-24-08 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Septic tank in good condition with all baffles installed. Grease Trap (locate on site plan): Depth below grade: feet 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: Date Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection)(locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 15 Commonwealth of Massachusetts - f,, :,_,,° ::; � �.•..' Title 5 Official Inspection .1=orr z Subsurface Sewage Disposal System Form -Not for Voluntary Assessments • 239 Hickory Hill Rd - Property Address d Fannie Mae ►. t, Owner Owner's Name information is Osterville f MA 02655 10-24-08 required for - every page. City/Town State Zip Code Date of,lnspection D. System Information (cont.) 7 r y , Tight or Holding Tank (cont.) ~ r ,5. . .. �. Dimensions: Capacity: - gallons Design,Flow: r.F t gallons per-day' Alarm present: ,❑ Yes ❑ No,t• _ Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches,etc.): r },, "Attach copy of current pumping contract re uired)..Is,cop•y*attached?ayched?1 ,,:❑ Yes ❑ No Distribution Box (if present must be opened) (locate on,site.plan): Depth of liquid level above outlet invert , Comments (note if box is!level and distribution to outlets equal, any evidence of solids carryover, any . evidence of leakage into or out of box, etc.): Good condition. �F Pump Chamber(locate'on site 041):' Pumps.in working order: ❑ 'Yes i ❑ No Alarms'in working order: , ❑ Yes ° ❑ No t5insp official document-03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page.11 of 15 l Commonwealth of Massachusetts g Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM 239 Hickory Hill Rd Property Address Fannie Mae Owner Owner's Name information is required for Osterville MA 02655 10-24-08 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not'located, explain why: Type: ® leaching pits number: 1-1000 Gal ❑ leaching chambers number: ❑ leaching galleries number: ® leaching trenches number, length: 1-4'x30' 1-4'x50' ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leach trenches in good condition with no sign of back-up in surrounding stone. t5insp official document-03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 16 Commonwealth of Massachusetts , Title 5 Official Inspection" Form— Subsurface Sewage Disposal System Form'-Not for.Voluntary Assessments' - w ,M 239 Hickory Hill Rd Property Address t + Fannie Mae " Owner Owner's Name information is required for Cisterville " " '" MA 02655 10-24-08 every page. City/Town ' State Zip Code' Date of Inspection D. System Information (cont.) Cesspools(cesspool must be.pumped as part of inspection) (locate on"site plan): Number and configuration - 2 Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t __ i 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.): w t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 239 Hickory Hill Rd Property Address Fannie Mae Owner Owner's Name information is required for Osterville MA 02655 10-24-08 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 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. I ' �7 VL !r A A -6_ ya> A -F-33 t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 15 ppp,—, a Commonwealth of Massachusetts Title 5 Official Inspection Form ; Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 239 Hickory Hill Rd Property Address Fannie Mae Owner Owner's Name information is required for Osterville MA 02655 10-24-08 every page. City/Town State Zip Code Date of Inspection D. System Information cont. v (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar I ❑ Shallow wells Estimated depth to high ground water:` 12 feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site�(abut ing property/observation hole within.150 feet of SAS) ® Checked with local Board of Health -explain: ® Checked with local excavators, installers-(attach documentation) ® Accessed USGS'database-explain: You must describe how you established the high groundwater elevation: . Original design plans show no water at 12'. F t5insp official document-03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 15 . ................. TOWN OF BARNSTABLE LOCATION -23!j Yz� h�& CIA41,C— SEWAGE # aOcnO -4-31r� E ASSESSOR'S MAP & LOT VILLAG INSTALLER'S NAME&PHONE NO. U SEPTIC TANK CAPACITY ' /0 0 siz LEACHING FACILITY: (type) ( e) I NO.OF BEDROOMS- BUILDER OR OWNER PERMITDATE: 'q --S --db COMPLIANCE DATE: 97 ZZ/79 Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching,Facility Feet Private Water Supply Well and Leactfing,Facility (If any wells exist on site or within 200 feet of leaching facility) r Feet Edge of Wetland and Leaching Facility(If any wetlands exist Feet within 300 feet of leaching facility) Furnished by J ........... Ole 9'e -7 o � O - Iv tot �� r a i 1 i C) F� � P z - `T•. t HA IPA Y- , :. .`BORTOLOTTI4CONSTRUCTION, INC. ,f+ ''oEP� ,b 765 WAKEBY ROAD,MARSTONS MILLS,MA 02648 508-771-9399 508428-8926 FAX: 508428-9399 A SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM t PART A CERTIFICATION Property Address: Date of Inspection: a Ins is Name: Name and Address: . Q7 IQ D �EBTIIICATION 4TAT M NT• - 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 systems. The System: Passes r Conditionally Passes ` NeedkFurther Ev on v Local Aproving Authority 'a 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 A)SYSTEM PASSES: I have not found any information which indicates that the system violates any of the failure criteria as defined in 31U CN�IR 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 eAl.tration,or tank failure is imrninent. 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 of 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 _ _ 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 IN A MANNER THAT,PROTECT THE PUBLICZEALTH,AND,SAFETY AND THE ENVIRONMENT: The system has aseptic 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)dYSTEM FAIISS: �f I have determined that the system violates one or more of the following failure criteria as defined in 3 0 CMR 15.303. The basis for this determination is identified below. The Board of Health sho d 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,invervdue to.an overloaded or clog- -d •ged SAS or cesspool: ',.` ' =• ,-Liquid depth'in cesspool is less than 6"below.invert,or,availabie,volume,is less than 1/2 day flow. Required pumping more than 4 times in the last year NDI due to clogged or obstructed pipe(s). Number of times pumped 2 SUBSURFACE SEWAGE DISPOSAt 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 FAE S: 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 460 Feet of a surface'ilnnk ng watersupply.^ The system'is within'200'Fee`t of a tributary io a surface dri ng'water supply The system is located in a nitrogen sensitive area Interim Wellhead Protection-Area L (IWPA)or`imapped 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., t SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Check if the following have been done: ✓romping information was requested of the owner,occupant,and Board of Health. V 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. ne system does not receive non-sanitary or industnal:waste flow; W The site was inspected for signs of breakout.: . , 0:;All.syAcm components;•excluding the Soil Absorption`System;.have been.located on site. _&Z he septic tank manholes were uncovered,opened,and the interior of the septic tankpwas in- ". _ ed for-coil tion of.ba8les or tees,material of construction,'dimensions;depth of liquid, epth of sludge;depth of scum. .;. 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 DISPOSALSYSTEM 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 RESIDE ITIAIg Design Flow:VW✓ allons Number of Bedrooms: 7 NulDber of Current Residents: Garbage Grinder:_ Laundry Connected To System: Seasonal Use: Water Meter Readings, if ailable: . . Last Date of Occupan . ' COMMERCLAIANDUSTRIAt:_ -Type of Establishment: Design Flow: aallons%day :Gi6se Trap Present.(yes or no). _. . -Industrial Waste Holding Tank Piesent: 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 umped: willons Reason for pumping: TYPE OF SYSTEM: Septic Tank/Distribution Box/Soil Absorption System Single Cesspool Overflow Cesspool Privy hated System(If es,attach revious inspection records if any ,,yy Other(explain). �� APPROXIMATE AGE of all components,date installed(if known)and source of, information: Sewage__ rs detected when.arriving at the site:.. -4- . _.._ t SUBSURFACE SEWAGE DISPOSAL;SYSTEM IN FORM PART C GENERAL INFORMATION (continued) SEPTIC TANK: Depth below grade: /! Material of Construction: concrete metal FRP Other (explain) — Dimisions:RA—Wo'X Sludge Depth: Scum Thickness: Distance from top 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, s tural integri ty, evidence of leakage.etc.) t GREASE TRAP:w 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.bafffes;'depth'of hgtud 4 level in relation to outlet invert, structural`integrit};evidence"of leakage. TIGHT OR HOLDING TANK: ,^/0 Depth Below Grade: Material of Constnuction: concrete—metal—FRP—Other(explain) Dimensions: Capacity: gallons Design Flo«: gallons/dav Alarm Level: V Comments: (condition of inlet tee. condition of alarm and noarswitclies:et(?)� -'` DISTRIBUTION BOX: NO Depth of liquid level above outlet invert: Comments: (note if level and distribution is equal, evidence of solids cam-over, or out of box,etc.) evidence of leakage into PUMP CHAMBERCa Pump isrin working order: . Comments;(note.condition ofpump,cltamber, condition of pumps'and'appurtenances;'etc) 4 -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: Overflow cesspool,number: Comments: note condition of soil,si s of h draulic f 'lure level o ponding,conditi n of vegetation, ( !rn Y _ et ZXIAI 07 CESSPOOLS:A2V Number and configuration: ; Depth-top•of liquid to'mlet invert: r CA 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: (note condition of soilk, signs of hydraulic failure, level of ponding,condition of vegetation, etc.) PRIVY: AV Materials of construction: Dimensions: Depth of Solids: Comments: (note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation, etc.) -6. f 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. w_...a.•.........�_ ��#)A.s'.d`r _ .a{l�di -¢14a . 0... _3{d�nl f i�'L�y � _..a..... ..t..e. f. ii i.d/ J!4 ., "ii'r"'4,vT J DEPTH TO GROUNDWATER: Depth to groundwater: Feet Ntedjpd of Determinati n or Approximation: ef �Ar -7- Barnstable Assessing Search Results Page 1 of 2 Home: Departments:Assessors Division: Property Assessment Search Results 3 , 239 C Ry L L C C Owner: PINA, EDWIN J JR& GAIL Property Sketch Legend O Map/Parcel/Parce x sion i 121 /029/ I Mailing Address © +fL� ` PINA, EDWIN J JR&H GAIL y 3� 3 P 0 BOX 974 OSTERVILLE, MA. 02655 2005 Assessed Values: x: Appraised Value Assessed Value Building Value.: $ 113,900 $ 113,900 Extra Features: $24,600 $24,600 Outbuildings: $0 $0 Land Value: $ 153,400 $ 153,400 Interactive Property Map: Ma re wires Plug in: �O�' Totals:$291,900 $291,900 1 have visited the maps before _�F, Show Me The Mao April 2001 photos available — Sales History: Owner: Sale Date Book/Page: Sale Price: PINA, EDWIN J JR& H GAIL 7/10/2000 13121/159 $201,000 GLADDING, DAVID J&PEACOCK, JOHN 10/1/1999 12578/040 $ 151,500 ODONNELL, JAMES F&SHIRLEY ET AL 10/15/1987 6003/088 $ 140,000 BLOOM, RICHARD P& KAREN L 6/15/1985 4592/297 $95,000 NIELSEN, NIELS P 11/15/1983 3938/118 $70,000 2005 REAL ESTATE Tax Information: Tax Rates: (per$1,000 of valuation) Land Bank Tax $52.98 Town Fire District Rates Other I $6.05 Barnstable-Residential $2.12 Land B. Barnstable-Commercial $2.80 C.O.M.M. FD Tax(Residential) $294.82' C.O.M.M. All Classes $1.01 Cotuit FD-All Classes $1.28 Town Tax(Residential) $1,766 Hyannis-Residential $1.52 Hyannis-Commercial $2.39 W Barnstable-Residential $1.44 http://www.town.bamstable.ma.us/tob02/Depts/AdministrativeServices/Finance/Assessing... 8/29/2005 Barnstable Assessing Search Results Page 2 of 2 W Barnstable-Commercial $2.10 Total: $2,113.80 Due to rounding differences these values may vary Land and Building Information Land Building Lot Size(Acres) 0.36 Year Built 1973 Appraised Value $ 153,400 Living Area 1184 Assessed Value $ 153,400 Replacement Cost$ 129,416 Depreciation 12 Building Value 113,900 Construction Details Style Raised Ranch Interior Floors Carpet Model Residential Interior Walls Drywall Grade Average Heat Fuel Gas Stories 1 Story Heat Type Hot Water Exterior Walls Wood ShingleClapboard AC Type None Roof Structure Gable/Hip Bedrooms 3 Bedrooms Roof Cover Asph/F GIs/Cmp Bathrooms 1 1/2 Bathrms Total Rooms 6 Rooms - Extra Building Features Code Description Units/SQ ft Appraised Value Assessed Value FPL1 Fireplace 1 $2,600 $2,600 BLA Bsmt Liv-Aver 1000 $22,000 $22,000 Property Sketch Legend BAS First Floor, Living Area FST Utility Area(Finished Interior) UAT Attic Area(Unfinished) BMT Basement Area(Unfinished) FTS Third Story Living Area(Finished) UHS Half Story(Unfinished) CAN Canopy FUS Second Story Living Area(Finished) UST Utility Area(Unfinished) FAT Attic Area(Finished) GAR Garage UTQ Three Quarters Story(Unfinished) FCP Carport GRN Greenhouse UUA Unfinished Utility Attic FEP Enclosed Porch PTO Patio UUS Full Upper 2nd Story(Unfinished) FHS Half Story(Finished) SFB Semi Finished Living Area WDK Wood Deck FOP Open or Screened in Porch TQS Three Quarters Story(Finished) http://www.town.bamstable.ma.us/tob02/Depts/AdministrativeServices/Finance/Assessing... 8/29/2005 a � Ltd e • �.44" r I _ ,,t4 a — P .. r ._ ap `• arTLti * S X >� C ti I-f-e P, 4,1 _ t a [ a '. AU6 29- 2005 yr. a �"• —-. a4 7 c -A-t . i Af n, opJA a R � } f �' "` �. _ F; �1 � . ��; ��r. � 4 ;:_�; .. r.-,(� �� '� ' - - ..t �� 1 r'�'° � >' a, - � - �;� i �— �,� Nti s '.,;t_,` — , _.� '.i �e — ;� '� r. 14 1 � _ � ;r� -�� — � � F �fi i F Q *F !� � " r .s r ti. ti I, IJ r f J 4' t Ate. " 1 f+ ff' s._ Nor ---WW TWIT yr_ - A 'ri�q__ter•#"7ee.o ,��y- '' � t 1 rr a - ,._-- - „.r,,,,_,- _,fir--•r .r, Alm i MA Ism f A.. - t _ 'LOYY,tV O B ARNST LLEE . .00A ll�ION �3/ 114e Qry �I;11 1/ SEWAGE # ASSESSOR'S MAP&LOT NSTAL,_ER'S NAME&PHONE NO. ;EP'nC TANK CAPACITY JOd 0 XACHING FACII(.I' Y: (type., d``1°r (size) 40.01FUDROOMS .._ WILDER OR OWNER 'ERMITDATE; _COMPLIANCE�CONdI'LlA1Vt I7A°Pl?: separation Distance BeMen thc: I. vlaximarn Adjusted Groundwater Table to the Bottom of Leaching Facility eet a ivaate Water Supply Well ;and Leaching Facility Of my wills exist on site or witkdn 200 feet of leaching facility) .Y. .Fe "sdge of Wedand and Leaclung Facility(if any wetlands exist withia300f, t flcachin k'acilky) feet. cd •©5 �5 1 I1 8-H- a3" - 'y'' S -l9' 'A - F- 59' TOWN OF BARNSTABLE 3 �2aa -- 3 Z LOrATION o2 � �s�-� SEWAGE � 9 VILLAGE D 5T" i/. '//`P ASSESSOR'S MAP & LOT 121141,9 INSTALLER'S NAME&PHONE NO. ��f y SEPTIC TANK CAPACITY 1000 A LEACHING FACILITY: (type) l T AND -2 %�f�. s`Yz -49��/ /�°•Y C'40.OF BEDROOMS 4 ER'OR OWNER �N PERMITDATE: 3 A00 COMPLIANCE DATE: 7 7/D v Separation Distance Between the: Maximum Adjusted Groundwater Table to the 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 facility) Feet Furnished by T�Nk f A f3 3(�6 /N ,25 eq r�ir ya ��Ncy t�7a.v ep.2 ' 3 TOWN OF BARNSTABLE .0 LOCATION �3 f JiG �y �—& SEWAGE # a ®O - VILLAGE �`=dcil�4�/! ct' ASSESSOR'S MAP & LOT l/ INSTALLER'S NAME&PHONE NO. (IMP0�S6 SEPTIC TANK CAPACITY /®CJ ►ll LEACHING FACILITY: (type) I—J( e)il! NO.OF BEDROOMS BUILDER OR OWNER O /1/ PC AGd C P5 MITDATE: "3 �'�� 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 facility) Feet Furnished by 1 STA, - s 33 , fJ qL6� I 'i, . � 1,� I - 6 a.q L.Y 6 No. 1LOO.'— �j Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS Application for Migo.ol *pgtem Construction Vermtt Application for.a Permit to Construct X Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No.; d i,,ka r—Y Hily G i t C r., Owner's Name,Address and Tel.No. Assessor's Map/Parcel Installer's Name,A Almss,and Tel.No. Designer's Name,Address and Tel.No. %Oa dery P�,'T91f 'Rod, ogt Type of Building: Dwelling No.of Bedrooms / Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow <Y yO gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title _ Size of Septic Tank f 600 �r Type of S.A.S. j �.dG 1 RE/JGR£S Description of Soil :i A N a l �-ig U Nature of Repairs or Alterations(Answer when applicable) /.� 40 /X ��►v� Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this Board of Health. Signed Date Application Approved by Qk_ < _,, .. Date —3 --,If Application Disapproved for the following reasons Permit No. a=g2— 2 Date Issued yN0. Fee 5-0 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: _ -- Yes PUBLIC HEALTH DIVISION - TOWN OF BA.RNSTABLE, MASSACHUSETTS Tipprication for Mi.5pagal *pgtem Construction Permit; . Application for a Permit to Construct jam)Repair( )Upgrade( t )Abandon( ) El Complet !System ❑Individual Components -a Location Address or Lot No. rG a X y Owner's Name,Address and Tel.No. Assessor's Map/Parcel Installer's Name,jss,and Tel.No. Designer's Name,Address and Tel.No. PP IILIIg Rod, 3�1-. , i . Type of Building: l Dwelling No.of Bedrooms 7 Lot Size A sq. ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures s Design Flow 1 yd gallons per day. Calculated daily flow T gallons. Plan Date Number of sheets Revision Date Title M Size of Septic Tank 1 Type of S.A.S. �' AL AJQA_C.� s Description of Soil Nature of Repairs or Alterations(Answer When applicable) q0 f Date last inspected: ! Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code.and not to place the system in operation until a Certifi-_ sate of Compliance has been issued by this Board of Health. Signed iDaie 1 Application Approved by Date . l Application Di aPProved for the following reasons Permit No. 2— Date Issued --------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE; MASSACHUSETTS 6 Certificate of Compliance rr�� THIS IS TO @ERTIEY;,that t}e©n-si£e Sewn e fspbsal System Constructed(X)Repaired( )Upgraded( ) `•. Abandoned( )by t`�U �-�UCh.' I �I�? f �� at Hj c,ko a�ty H,Y t-/,k< £ has teen constructed in accordance with the provisio s of Ti l and the for Disposal System Construction Permit No.91-3 9- ^ dated �f : Installer Designer The issuance of this of �s /al-It not'be construed'eas a guarantee that the s< tem will-furi6tionLas designerd`� Date a f � [l ( Inspector y f�I� vJt_ ` if r !1 Il v ' — � M 3 / a---------------------------Fee d THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE} MASSACHUSETTS =isspozal *pgtem Construction Permit Permission is hereby granted to Construct ) epair( )U raj( &ban on( ) System located at a and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this,permit. Date: 3 �� Approved by cr,, 1 iIN. �. 1 u6i99 NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. - CERTIFICATION OF SKETCH A�, APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT CW=OUT DESIGYED PLANS) L �9hereby certify that the application for disposal works construction permit signed by me dated conceruns the ,l OS�£„►Z,v i l�� property located at �-A�'� i�/ �j�Gl meets all of the following criteria: • Tne failed system is conne^ed to a residential dwelling only. There are no commercial or business uses associated with the dweldns. • The sail is classined as CLASS I and the percolation rate is less than or equal to 5 minutes per inch. • There are no wetlands within 100 fey,of the oroposed septic Tystern • There are no private wets within 150 feet of ire proposed septic sysem • T-here is no increase inflow and/or change in use proposed • 7here are no variances requested or ne`ded_ • The bottom of the proposed leacain;faclity will not be located less than five feet above the maxitnum adjusted- undwater table e!evaaon. (Adjust the goundwater table using the i'rimptor method when applicable] • If the S.A.S. will be located with'_ 0 feat of any vegetated wetlands. the bottom of the proposed leaching facility will net be located less than four eea 0,1) fee;above the maximum adjusted uoundwater,table e!evadort, Please complete the rolIowiu;: A) Too of Ground SSurface Eievadan(using GiS information) , > B) G.W. Eleiadon 6<1—-the F-igh G.W. ?adjustment DF ERENCE 3E 7,1V'—=N+' a.and 3 SIGNED Da.,L. (Sketch proposed plan of on bac:c). q: caich ioldrr.�.-c. .. �. l a i I ' � `V y. �d o . ��(�`�� ` �.� �� d , . � , . . � ��, � + � � � � � � 0 CONIMON\NTALTH OF bLaSSACHtiSETTS 1� _ o EXECUTIVE OFFICE OF ENVIRONN4EN AF DEPARTMENT OF ENVIRONMENTAL TECTION `` - SEP 17 1999 ONE HINTER STREE`. BOSTON 14A 0210E (617) i(�� • r - TdYVNHEALTM DIX s RUDY COXE ' Secretar. . $ DAVID B STRL-HS ARGEO PALL CELLUCCI Commissioner Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM. PART A �. CERTIFICATION Name of Owner Property Address: tT l�C� Ja,� �s � ddress of Owner: CJ 0 Date of Inspection: , // J Q�2Z `—A 4 0 S , Name of Inspector:(Please Print)/� C.// a. if' )ELKU i 1 am a DEP approved system inspector pursuant to Section 15.((340 of Title 5(310 CMR 15.000) m Copany Name: 14 r C P_k v 'ram a ,... e• io-+1 F _ Marling Address: '7. g�g h:e/4•< oZ,�4f C7 Telephone Number: 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 Inspector's Signature: "Date: 1 The System Inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or,DEP)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 Environistental Protection: The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. NOTES AND COMMENTS CQ� (, �,��Ga.,� UL ��R ,jt; c�� Uvv►Pca�� %�.ti-t j�Sf Q (,c� 0011)� c t Ga Q 1 d G C�Cfir`, lu t pzj 1 (J .0 0), revised 9/2/98 r.getorit C� Pnmed on Regalyd PAPrr .1-"+ L4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) %roperty Address�%"1� 11P. + �6i f,•1� Jwner• _ _ . Dati:-of,lrupection: - INSPECTION SUMMARY:.`Check.A,; B, C, or D: • ii r A. SYSTEM,PASSES: have not found,any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist. Any failure criteria not evaluated are indicated below. COMMENTS: B. SYSTEM CONDITIONALLY PASSES: Nz_-) 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 complying septic tank as approved by the Board of Health. _ 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). 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 revised 9/2/98 Page 2oru I SUBSURFACE SEWAGE DISPOSAL SYSTEM TEM INSPECTION FORM- PART A CERTIFICATION (continued) Property Address: Owner: - a Date of Inspection: 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 syste, is failing to protect the public health, safety and the environment: 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CM 15.303(1)(b)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 surface water Cesspool or privy is within 50 feet of a bordering vegetated we or a salt mars . ` •` II 2) SYrSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER UPPLIER,IF ANY)DETERMINESTHAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND AFETY AND THE 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 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 9/2/98- Page 3ofII r �- SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (contirwed) property Address: Owner: Date of Inspection: D. SYSTEM FAILS: You must indicate either "Yes" or "No" to each of the following: as described in 310 MR 15.303. The basis for this one or more of the following failure con ditions exist I have det ermined that correct the failure. determination is identified below. The Board of Health should be contacted to determine what ill be necessary to co Yes No _ Backup of sewage into facility or system component due to an overloaded or clo/Jed SAS or cesspool. _ Discharge or ponding of effluent to the surface of the ground or surface water/due to an overloaded or clogged SAS c, cesspool. _ Static liquid level in the distribution box above outlet invert due to an ove/r,oaded or clogged 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 cl ged 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. _ 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 $/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: 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: 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 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 upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional office of the Department for further information. j revised 9/2/95 Page 4of11 tea ' . r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST, ` Property Address: Owner: 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 Pumping information was provided by the owner, occupant, or Board of Health. ti 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. 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. F ' \ The site was inspected for signs of breakout.. _ All'system components, excluding 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.0.H. Determined in the field (if any of the failure criteria related,to Part C is at issue, approximation of distance is unacceptable) �. 115.302(3)(b)1 The facility owner (and occupants,if differersi from owner) were provided with information on the proper xnaintanaar-o-0f Subsurface Disposal Systems. y revised'.9/2/9.8 Page 5oftl :--3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM. PART C r SYSTEM INFORMATION 'roperty Address: �� i�!(i1�Jt U Owner: Date of Inspection: FLOW CONDITIONS RESIDENTIAL: Design flow: l.) g.p.d.lbedroom. Number of bedrooms (design): Number of bedrooms (actual): Uy Total DESIGN flow (: ,L Number of current residents: Garbage grinder(yes or no): tJ Laundry (separate system) 1 es or o) If yes, separate inspection required Laundry system inspected ye or no) Seasonal use (yes or no): Water meter readings, if available (last two year's usage (gpd): Sump Pump (yes or no): Pv Last date of occupancy:xQ.W 1 COMMERCIALlINDUS TRIAL: Type of establishment: Design flow: qpd ( Based on 15.203) Basis of design flow Grease trap present: (yes or no)_ Industrial Waste Holding Tank present: (yes or no)_ Non-sanitary waste discharged to the Title 5 system: (yes or no)_ Water meter readings, if available. Last date of occupancy: OTHER: (Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of infor�mta ion: 1��' t System pumped as part of inspection: (yes or no) I If yes, volume pumped: gallons Reason for pumping: TYPE OF SYSTEM Septic lank soil absorption system Single cesspool Overflow cesspool Privy Shared system (yes or no) (if yes, attach previous inspection records,if any) IIA Technology etc. Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other APPROXIMATE AGE of all components, date installed (if known) and source of information: Sewage odors detected when arriving at the site: (yes or no) revised 9/2/96 Page 6(if 11 i t SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM . PART C SYSTEM INFORMATION (continued) 'roperty Address: Owner: . Date of Inspection: BUILDING SEWER: (Locate on site plan) a ` Depth below grade:_ Material of construction: _cast iron_40 PVC_other (explain) Distance from private water supply well or suction line Diameter Y ` Comments: (condition of joints, venting, evidence of leakage,-etc.) SEPTIC TANK:_ ' (locate on site plan) _ Depth below grader Material of construction: ,concrete_metal_Fiberglass _Polyethylene—other(explain) If tank is metal, list age_ Is age confirmed by Certificate of Compliance_(Yes/No) Dimensions: Sludge depth:— �f— rt+ , Distance from top of sludge to bottom of outlet tee or baffle:—ILO ` Scum thickness:_ p .. Distance from top of scum to top of outlet tee or baffle:' rO I Distance from bottom of scum to bottom of outlet tee or baffle: I�{ How dimensions were determined: tl��CJ1RQ� 'omments: (recommendation for pumping condition of inlet and outlet tees of baffles, depth of liquid level in relation t outlet invert, structural integrity, evidence of leakage, etc.) v GREASE TRAP: (locate on site plan) x 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 9.�2�98 Page7of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) 'roperty Address: 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) Dimensions: Capacity:__gallons Design flow: gallons day Alarm present Alarm level: Alarm in working order:Yes _ No_ Date of previous pumping: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) r 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, etc.) PUMP CHAMBER:_ (locate on site plan) Pumps in working order:(Yes or No) Alarms in working order(Yes or No) Comments: (note condition of pump chamber..condition of pumps and appurtenances, etc.) revised 9/2/98 page:8 ofII I , 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C G SYSTEM INFORMATION (continued) 4operty Address: TZ 1 11({ilfJlJ�1�� t f� Owner: " Date of Inspection: SOIL ABSORPTION SYSTEM(SAS): (locate on site plan, if possible; excavation not required, location may be approximated by non•intrusive methods) If not located, explain: Type: n leaching pits, number: t11�V _ leaching chambers, number:_ + . leaching galleries, number:_ u leaching trenches, number, length: leaching fields, number, dimensions: overflow cesspool, number._ Alternative system: Name of Technology: Comments: (note condivo of soil, signs of hydraulic failure, level of ponding, mp soil, on 'on of vegetation, etc.) ( �� 7 _ 1 p CESSPOOLS: a (locate on site plan) * J Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: )epth of scum layer: Dimensions of cesspool Materials of construction: Indication of groundwater. inflow (cesspool must be pumped as part of inspection) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY _ o ' (locate on site plan) w " Materials of construction: Dimensions: Depth of solids: Comments: ' (note condition of soil, signs of hydraulic failure, level of'ponding, condition of vegetation, etc.) 1 revised �_9/2/98 Page 9ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) property Address: 039 lwnef: Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) Aj k Z- 3 1 L!I revised 9/2/98 Page 10of11 f , SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) ropetty Address: �L s-� t' cG�vQi• C ` 1� Ow ner: CT Date of Inspection: NRCS Report name -- Soil Type— — Typical depth to groundwater USGS Date website visited Observation Wells checked Groundwater depth: Shallow Moderate Deep SITE EXAM Slope (� 7 Surface water MJ Check Cellar cif/} Shallow wellsl�tft Estimated Depth to Groundwater E kS Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observed Site (Abutting property, observation hole, basement sump etc.) G Determined from local conditions Checked with local Board of health Checked FEMA Maps Checked pumping records Checked local excavators, installers Used USGS Data M r Describes how you established the High Groundwater Elevation. (Must be completed) G revised 9/2/98 Page aof11 r • COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION. ,• AP _ 21 -ARCEL �.� DEC 2 1 2004 �— TOWN OF BARNSTABLE- TITLE 5 HEALTH DEPT. - OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: ;2 3 Owner's Name: j_..Pt« £ Owner's Address:_ r C Date of Inspection: /l.2-9— c7 Name of Inspector: lease print) P1V7 -/a'K//1 .7 1V Company.Name: E6w1t-5 Mailing Address: S�,'f O 4,9 5 T.3�yF .Avg Telephone Number: S-r- 6—7 7-e—02 spy CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP approved system inspector pursuant to Section 15340 of Title 5(310 CMR 15.000). The system �es. Conditionally Passes — Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: / -z v` The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit thereport to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. f -. Notes and Comments --� ****This report only describes conditions at the time of inspection and under the conditions of use at that t time.This inspection does not address how the system will perform in the future under the same or different %r r � conditions of use. CD 171 Title 5 Inspection Form 6/15/2000 page l Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTIO_N FORM PART A CERTIF/IC.A,TION(continued) Property Address: (10 3 07 7 - Owner: �.�u.�-►� Date of Inspection: I f 0 5/ Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: I have not found 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: 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. Answer yes,no or not determined(Y,N,ND)in the_for the following statements.If"not determined"please explain. The septic tank is metal and over 20 y ?s old*or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exf ation 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 cturally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available: ND explain: J Observation of sewage backup or bre out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settl or uneven di bution box. System will pass inspection if(with approval of Board of Health): oken pipe(s)are repl�ced obstruction is removed \,\ distribution box is leveled.or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the...Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: Title 5 Inspection Form 6/15/2000 2 i Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: D r1'�sc • o�-�rSS�' Owner: Date of Inspection: if 17-!j� C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluati by the Board of Health in order to determine if the system is failing to protect public health,safety or the enviro ent. 1. System will pass unless Board of Health deter 'nes in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which `"protect public health,safety and the environment: 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,safety and environment: — The system has a septic tank and soil abso tion system(SAS)and`the SAS is within 100 feet of a surface water supply or tributary to a surfAande pply. The system has a septic tank and SA is within a Zone 1 of a public water supply. — The system has a septic tank and SAS is within 50 feet of a private water supply well. The system has a septic tank and S is less than 100 feet but 50 feet or more from a private water supply well**.Metho usede distance **This system passes if the well water'analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form 3. Other: Title 5 Inspection Form 6/15/2000 3 I Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART-A CERTIFICATION(continued) Property Address: 3 144 /tea •�-los.� Owner• .us.,. -t.,.i�-� Date of Inspection: 1I 2V n°� D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No _ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ✓151scharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or slogged SAS or cesspool / Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or "eesspool ✓ Liquid depth in cesspool is less than 6"below invert or available volume is less than''/z day flow �ZRequired pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number times pumped r/ Any portion of the SAS,cesspool or privy is below high groundwater elevation. ✓}Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface �a e/ ter amply any portion of a cesspool or privy is within a Zone 1 of a public well. L/Any portion of a cesspool or privy is within 50 feet of a private water supply well. A�y portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis.[This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.]. ND (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system-owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes now, 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 LI/the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone H of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes"in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. 4 Title 5 Inspection Form 6/15/2000 Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: ..2.51 Owner: �tir�et Date of Inspection: // w 1 w Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes — Pumping information was provided by the owner,occupant,or Board of Health V-ere any of the system components pumped out in the previous two weeks? Has the system received normal flows in the previous two week period? ? Have large volumes of water been introduced to the system recently or as part of this inspection? Were as built plans of the system obtained and examined?(If they were not available note as N/A) J 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? Y Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no Existing information.For example,a plan at the Board of Health.' Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)] Title 5 Inspection Form 6/15/2000 5 Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: -�U°l 1wa-4 Owner: Date of Inspection: ///�lo FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): y Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203(for example: 11.0 gpd x#of bedrooms): Number of current residents: _ Does residence have a garbage grinder(yes or no): Lv Is laundry on a separate sewage system(yes or no): v[if yes separate inspection required] Laundry system inspected(yes or no):.. P Seasonal use: (yes or no):40 s-oo u Water meter readings,if available(last 2 years usage(gpd)): Sump pump(yes or no):LO Last date of occupancy: Srri/ ��f'•e COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 15.203): epd Basis of design flow(seats/p ons/sgft,etr,:)` - Grease trap present(yes or no). Industrial waste holding tank pr t'(yes or no): Non-sanitary waste discharged to a Title 5 system(yes or no):_ Water meter readings,if available: Last date of occupancy/use;'' OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: E'iU56'L ///d��D 3 Was system pumped as part of the inspection(yes or no):d D If yes,volume pumped:_gallons-How was quantity pumped determined? Reason for pumping: TYPEf3F SYSTEM eptic tank,distribution box,soil absorption system Single cesspool _Overflow cesspool Privy _Shared system(yes or no)(if yes,attach previous inspection records,if any) Innovative/Altemative 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): Appr99ximate age of all components,date installed(if known)and source of ipformation: Mvvsc (da,`c r i973 Sy5ra,d, 0=GWco-1 7/7/ov Were sewage odors detected when arriving at the site(yes or no): A49 6 Title 5 Inspection Form 6/15/2000 Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: -2 3 Owner: 9,O� Date of Inspection: 1 l /1 �f WELDING SEWER(locate on site plan) Depth below grade; _ � �� Materials of construction:_cast iron l4U PVC_other(explain): Distance from private water supply well or suction line: ;l/o Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK:_(locate on site plan) Depth below grade: � Material of construction _t�oncrete 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 certificate) e— Dimensions: A2 o ?c Sludge depth '2 " 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 baffle: y�� Distance from bottom of scum to bottom of outlet tee or baffle: How were dimensions determined: 94411:«� cz=i� Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet inv ,evidence of leakage,etc.): GREASE.TRAP:_(locate on site plan) Depth below grade: Material of construction:_con ete�rnetal—Aberglass polyethylene_other (explain): Dimensions: r Scum thickness: Distance from top of scum tp4op of utlet tee or baffle: Distance from bottom of l to bo om of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): I Title 5 Inspection Form 6/15/2000 7 Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C /SYSTEM INFORMATION(continued) Property Address: /Jyu� •colt.� i Owner: -� Date of Inspection: J a- 0 t/ TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal- fiberglass - polyethylene other(explain): Dimensions: fr' Capacity: ons Design Flow: allons/day Alarm resent es or no : P CY ) Alarm level: Al in wo g order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): r�� DISTRIBUTION BOX: (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert:W__11F�/-GL Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): uiJ�,pE.ycF o F �tt'eP}i vy�✓1 So%'o S o� 4r�/c.a� PUMP CHAMBER: (locate on site-plan) i Pumps in working order(ye or Alarms in working order(ye or no): Comments(note conditi of ump chamber,condition of pumps and appurtenances,etc.): Title 5 Inspection Form 6/15/2000 8 Page 9 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C 'SYSTEM INFORMATION(continued) Property Address: co- Owner: Date of Inspection: T^I '� SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why: Go cam.-too u r r eo/Ay TYFe leaching pits,number: leaching chambers,number:_ leaching galleries,number: c2 leaching trenches,number,length: X/�� / — 's 6)e y leaching fields,number,dimensions: overflow cesspool,number: _innovative/altemative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth—top of liquid to inlet' vert: Depth of solids layer: i Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater,nflow(yes or no):_ 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 oil,si s of hydraulic failure,level of ponding,condition of vegetation,etc.): Title-5 Inspection Form 6/15/2000 9 Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(condinued) Property Address: Owner: Date of Inspection: 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 � ANA OWT i Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: g r'O Owner: `15c&zxos; Date of Inspection: SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water V8 feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: 9bserved site(abutting property/observation hole within 150 feet of SAS) //Checked with local Board of Health-explain: Checked with local excavators,-installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: S Z IL - 4�!o !j� MAV-5 i oho �O fir i/ Nr i uJ a f— 3 G /9 o rysrr,ElrT Y Title 5 Inspection Form 6/15/2000 11 NDV-28_04 03:36 PM JANES E MURPHY 5084280802 R. 02 m TOWN OF BW-STABLF, bOs:AT1 0N _ SEWAGE 0 r .LAG A;SIESSGW S DAAP LOT 'i 1NS ALLE'A'S NAM A PHONE NO. � SFPInc TANK arAFACny LF.ACiG FAiT '; (tyi3 �" , - P JR NO.OF EEDROQMS, _ DULDER OR OWNER. QLC .,._...__-... m� COMPUANCE Separation Distmce totwaca the: Ni tun"ustrd Gro,ndwaw T8 le wd 130r"t of Leaching Fwility private Water suPply WeU wd LAAching FacARY (U any wells exist t on ails srX Witt n 2�fit or iea wing ffs lllty) Edge of Wag"d @Rd Leaching Facift(V any wotlands exist FM �+itltitt��$cet oP leachitmg fasi9ty) ,�,��--� Fwrilshed by i 1 3 QB 5 Ave t 00T µ rr� No.... .1-.__/._.. Fwic.. ................. THE COMMONWEALTH OF MASSACHUSETTS BOARD F HEA� H ....../...:fJ' 't�..-------OF................ a'� L��.T" Y-- 0� Appliration -for Uiiipuiitti VorkB Tontitrurtion Pprutit Application is hereby de for a Permit to Construct or Repair ( ) an Individu S age Disposal System at, ocat ri A dress r No -- -. _ -� wner A d ss Installer Address Q Type of Buildi Size Lot____________________ ______Sq. feet U Dwelling No. of Bedrooms---------- -.--.-----Expansion Attic ( ) Garbage Grinder ( )U Other=Type of Building ---------------------------- No. of persons._-___-__-____---_-_-..-_._- Showers ( ) — Cafeteria ( ) a d Other fixtures __ --------- - ------------- - -- ----- -------•---------- --- - ---------------------- -------------- W Design Flow____________________ ____.__...��_ gallons.per person per day. Total daily flow.._................................................_gallons. WSeptic "Tank i-Liquid capacity/j__!fd;allons Length_ ________________ Width_.. ---__--.._.. Diameter---------------- Depth-.-.-----_-._..- x Disposal Trench—No. .................... Width------------- _ _ o*In t -__ _ _ Total leaching area----.-.-_---.-.---_-sq. ft. Seepage Pit No.. ............... Diameter/-L1�5 qe � g< ___.sy. it. e th m et------ - ----------- Total leachiuea._____ z Other Distribution box ( ) Dosing tank ( ) e/ a Percolation Test Results Performed by................................................ ✓fir.......... Date... Test Pit No. 1----------------minutes per inch Depth of Test Pit---:................ Depth to ground water.._--_._--_-.--.--.--._. 4q Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water...----._---_---_----_ a ------...- 0 Description of Soil------------------ -- /....................... x W -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- U Nature 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 Article XI 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. Signed Dat Application Approved By------ --- r / Date Application Disapproved for the following reasons:.................................... �... ............................................................. •-----•--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- Date PermitNo......................................................... Issued..------......-------- ................................. Date y 1 NO..- � -----• Yuic.. ................... THE COMMONWEALTH OF MASSACHUSETTS BOARD �QF HEALTH ,�.��1ir�tinttflax �i��a�tt1 �ark� Cn�tt�tr�trtilatt �rrmit Application is hereby made for a Permit to Construct or Repair ( ) an Individu Swage Disposal Syst at I ,/ _..... ..._.. �C j •-- ccaon Address. p } or,L N �'OeZ4' W4,1.4--f. . .............................. ....I.... Owner . d s r Installer Addres_ `. � Type of Buildi Size Lot.............................Sq. feet U Dwelling �,No. of Bedrooms._.---__ ..............................Expansion Attic ( ) Garbage Grinder ( ) p.I Other—Type of Building ____________________________ No. of persons_-_-____---_______-___-_-- Showers ( ) — Cafeteria ( ) QI Other fixtures d --------------------------------------•------------------ - -- v. W Design Flow................... 1. :...��....__.__.. ,gallons per person per day. Total daily flow.........................................._gallons. P4 Septic Tank/-Liquid capacit, -- gallons Length................ Width.........------- Diameter---------.------ Depth___-___-.----- xDisposal Trench—No. ................... Width-------------_-- . T a#e, ._. -. Total leaching area.... ___....sq. ft. Seepage Pit No._�_______________ Diameter�ep .____ epth w inlet Total leaching ea__ sq. it. Z Other Distribution box ( ) Dosing tank ( ) °�`� '° " ."__ Percolation Test Results Performed by.......................................................................... Date----NV ;----------------------- Test Pit No. 1................minutes per inch Depth of Test Pit-_---_-.._________-- Depth to g-ound water.....:__.__-----__-.__.. Test Pit No. 2----------------minutes per inch Depth of Test Pit____________________ Depth to ground water.-.--.-__----_-._--__. -- ----------- - � ------ ------------------- -----------------•......•-••••......------••.... -------- ------------------------------------- D , 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 Article XI 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. Signed "t .........................................---------------•--- Application Approved By----- . _Dfa 'Kr ... Date Application Disapproved for the following reasons-................................... --------.........------------•-------------=------------------------••-•- -----------------•---------------------....---------------------------•-----------------------------------------•••-•----••---•--••••• ------------------------------------------------------------------ Date PermitNo..........--•--••--•................................... Issued-----_---------....................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........OF.........lf5.. w . . .. (Irrtif irttte of Trrmpliaurr THIN TO CEETIFY) Th,�t the Individual Sewage Disposal System constructe3 ( ) or Repaired ( ) .�" :� -------------------------- by..---- -..� - 1� ---9� --•-- L I tall at= .. ' -:... .a'` ._... _._.....�� ,A ......... ......---••----•------------------------- has been installed in accordance with the pr isions of Article XI of The State Sanitary Code s described in the application for Disposal Works Constructi Permit No.____r _ `- ----------------- dated-.--: - ,._._.... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A G ARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE � --rr- Inspector C. THE COMMONWEALTH OF MASSACHUSETTS BOARD qF HEALTH $ , } -� f� No. 0,4 �•--r-.. FEE. "�,......... Ui_npttiittt urk,i Qlamitrurthin Vamit .Permission 's ereb ranted____t' f �"`� _ - " to"Constru ( � ' o :e air ( )s-an ndividl�`s -a e ,'is §N �s -m Street _ as shown on the application for Disposal orks Construction nsEe'"nit N in. Dated-.. ...................... Board of Health DATE -- ---------- - FORM 1255 HO S & WARREN. INC.. PUBLISHERS