HomeMy WebLinkAbout0033 KING ARTHUR DRIVE - Health 33 KING ARTHUR DRIVE, OSTERVIELI
A=
r
'1
I e
�I
0
v
� �'�'� TO OF BARNST LE
�I
LOCATIO . /
/- 'deSEWAGE #
V'iLLAGE ASSESSOR'S MAP & LOT/��G��y
NAME&PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) I (size)
NO.OF BEDROOMS
BUILDER O OWNE
PERMIT DATE: DATE:
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
k
as aw
y�
sa 39
L'r `A-T ION SEWAGE PERMIT NO.
VI1LA
INSTA LLER'S AME & ADDRESS
42,111,4
B UILDE R OR OWNER
a
DATE PERMIT ISSUED
DATE COMPLIANCE ISSUED ����
,a
i
�-'—
��� �.
S � .
TOWN OF BARNSTABLE
LOCATION SEWAGE #
VILLAGE ASSESSOR' MAP &LOT/ �. 0
"1�' fSQIC`10�P�NAME&PHONE NO. og o��p
SEPTIC TANK CAPACITY /DC"C' Cl�l A AOUA
LEACHING FACILITY: (type) lt✓�,LD� f`/ (size) y d�
NO.OF BEDROOMS �.
BUILDER OR OWNER
PERMTTDATE: COMPLIANCE DATE:
Separation Distance Between the:
t��cam —� y�� t4F
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
Via,y
3°
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
d DEPARTMENT OF ENVIRONMENTAL PROTECTION
M
Q
OV
V�
by0
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION 3 79c?
Property Address: 33 King Arthur Drive
Osterville MA 02655 1
Owner's Name: Patti&Jeffrey Hekking j
Owner's Address: 5409 Venus Terrace
Port Charlotte FL 33981 k C
Date of Inspection: June 19,2006 Job# 06-160
..
CD
Name of Inspector: PATRICK M.O'CONNELL
P c5 Ma
Company Name: SEPTIC INSPECTION SERVICES CO.
Mailing Address: 189 CAMMETT ROAD , „
MARSTONS MILLS MA 02648 �`'}
Telephone Number: 508-428-1779 t
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
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: � Ilk • //�����
_X_ Passes Z '%
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails LL ;
Signature:Inspec
tor's g �A6�4's Si Date: 6/19/06 ��'�•,•�� � �•pQ•����
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 buyer, if applicable,and the approving
authority.
Notes and Comments: Tank is not in need of pumping at this time.Leaching pit is currently half full with a
high stain line indicating pit has 12-14"of effective leaching.
' ****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.
i
Page 2 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 33 King Arthur Drive,Osterville
Owner: Patti&Jeffrey Hekking
Date of Inspection: June 19,2006
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
_XX_ 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 years old*or the septic tank(whether metal or not)is structurally
unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the
existing tank is replaced with a complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
Observation of sewage backup or break out or high static water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with
approval of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will
pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain:
Page 3 of 1 I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 33 King Arthur Drive,Osterville
Owner: Patti&Jeffrey Hekking
Date of Inspection: June 19,2006
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.
_ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a
private water supply well". Method used to determine distance
"This system passes if the well water analysis,performed at a DEP certified laboratory,for 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:
Page 4 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 33 King Arthur Drive,Osterville
Owner: Patti&Jeffrey Hekking
Date of Inspection: June 19,2006
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all inspections:
Yes No
_X_ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
—X— Discharge or pond ing of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
_X_ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
_X_ Liquid depth in cesspool is less than 6"below invert or available volume is less than_day flow
_X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped
_X_ Any portion of the SAS,cesspool or privy is below high ground water elevation.
_X— Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
_X_ Any portion of a cesspool or privy is within a Zone 1 of a public well.
_X_ Any portion of a cesspool or privy is within 50 feet of a private water supply well.
_X— Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis. [This system passes if the well water analysis,
performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria
are triggered. A copy of the analysis must be attached to this form.)
_No_(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 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
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.
Page 5 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 33 King Arthur Drive,Osterville
Owner: Patti&Jeffrey Hekking
Date of Inspection: June 19,2006
Check if the following have been done. You must indicate"yes"or"no"as to each of the following:
Yes No
_X _ Pumping information was provided by the owner,occupant,or Board of Health
_X_ Were any of the system components pumped out in the previous two weeks?
_X_ _ Has the system received normal flows in the previous two week period?
_X_ Have large volumes of water been introduced to the system recently or as part of this inspection
_ _X_ Were as built plans of the system obtained and examined?(If they were not available note as N/A)
_X_ _ Was the facility or dwelling inspected for signs of sewage back up?
_X_ _ Was the site inspected for signs of break out?
_X_ _ Were all system components,excluding the SAS,located on site?
_X _ 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?
_X_ _ 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
_X_ _ Existing information. For example,a plan at the Board of Health.
X_ _ 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)]
Page 6 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 33 King Arthur Drive,Osterville
Owner: Patti&Jeffrey Hekking
Date of Inspection: June 19,2006
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): 3 Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x tt of bedrooms):330
Number of current residents: 3
Does residence have a garbage grinder(yes or no): No
Is laundry on a separate sewage system(yes or no): No [if yes separate inspection required]
Laundry system inspected(yes or no):
Seasonal use:(yes or no):No
Water meter readings, if available(last 2 years usage(gpd)): two years total: 155,000 gal.=212 gpd.
Sump pump(yes or no): No
Last date of occupancy: Currently Occupied
COMMERCIAL/IN DUSTRIA L
Type of establishment:
Design flow(based on 310 CMR 15.203): gpd
Basis of design flow(seats/persons/sqft,etc.):
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/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records: Tank pumped January/February 2006
Source of information: Owner
Was system pumped as part of the inspection(yes or no): No
If yes,volume pumped: gallons--How was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM
_X_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)
_Tight tank —Attach a copy of the DEP approval
Other(describe):
Approximate age of all components,date installed(if known)and source of information:
1978
Were sewage odors detected when arriving at the site(yes or no): No
Page 7 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 33 King Arthur Drive,Osterville
Owner: Patti&Jeffrey Hekking
Date of Inspection: June 19,2006
BUILDING SEWER: XX (locate on site plan)
Depth below grade: I'
Materials of construction:_cast iron _X_40 PVC_other(explain):
Distance from private water supply well or suction line:
Comments(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK: XX (locate on site plan)
Depth below grade: 1'
Material of construction:_X_concrete_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)
Dimensions:8.5'long x 5.2' wide—1000 gal.
Sludge depth: I"
Distance from top of sludge to bottom of outlet tee or baffle:29"
Scum thickness: trace
Distance from top of scum to top of outlet tee or baffle: 6"
Distance from bottom of scum to bottom of outlet tee or baffle: 14"
How were dimensions determined: STICK WITH HINGE FLAP.
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels
as related to outlet invert,evidence of leakage,etc.):
Liquid level at bottom of outlet invert,baffles are intact and clear.
GREASE TRAP: No (locate on site plan)
Depth below grade:_
Material of construction:_concrete_metal_fiberglass_polyethylene_other
(explain):
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels
as related to outlet invert, evidence of leakage,etc.):
Page 8 of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 33 King Arthur Drive,Osterville
Owner: Patti&Jeffrey Hekking
Date of Inspection: June 19,2006
TIGHT or HOLDING TANK: No (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:
Capacity: gallons
Design Flow: gallons/day
Alarm present(yes or no):
Alarm level: Alarm in working order(yes or no):
Date of last pumping:
Comments(condition of alarm and float switches,etc.):
DISTRIBUTION BOX: XX (if present must be opened) (locate on site plan)
Depth of liquid level above outlet invert: 0"
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.):
No solids or high stains present. Liquid level at bottom of single outlet pipe.
PUMP CHAMBER: No (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.):
Page 9 of I 1
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 33 King Arthur Drive,Osterville
Owner: Patti&Jeffrey Hekking
Date of Inspection: June 19,2006
SOIL ABSORPTION SYSTEM(SAS): XX (locate on site plan,excavation not required)
If SAS not located explain why:
Type
_X leaching pits, number: One 6x6 pit.
_leaching chambers,number:
_leaching galleries,number:
leaching trenches,number, length:
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.): Leaching pit is currently half full with a stain line indicating 12-14"of effective leaching
CESSPOOLS: No (cesspool must be pumped as part of inspection) .(locate on site plan)
Number and configuration:
Depth—top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater inflow(yes or no):
Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
PRIVY: No (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.):
Page 10 of I I
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 33 King Arthur Drive,Osterville
Owner: Patti&c Jeffrey Hekking
Date of Inspection: June 19,2006
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.
King Arthur Drive
4
6
41
30
2
36
r
Page 11 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 33 King Arthur Drive,Osterville
Owner: Patti&Jeffrey Hekking
Date of Inspection: June 19,2006
SITE EXAM
Slope None
Surface water None
Check cellar Dry
Shallow wells None
Estimated depth to ground water : More than 20 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:
Observed site(abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health-explain:
Checked with local excavators, installers-(attach documentation)
_X Accessed USGS database-explain: USGS topo map and town GIS
You must describe how you established the high ground water elevation:
Town groundwater contour map shows water below el.20 and topo map shows property at el.50.
• �., '. `�.. a -jl�:t ' (.w. (per
.1 ....�... .fie -
N _ O
BORTOLOTTI CONSTRUCTION, iNC. " tom 3 1
765 WAKEBY ROAD,MARSTONS MILLS, 70A 0 y�°tig9�ST 998
AP•R s 508-771-9399 508428-8926 FAX: 508-418-9399
1998
O tok'Nofeg SUBSURFACE SEWAGE DISPOSAL SYSTEM INSI.V T
HEAL THpRENPs glE O F
PART A jd
CERTIFICATION
Property Address: _.
Date of Inspection: lspector's Nan c:
Owner's Name and Address: - JO
CERTIFICATION STATEMENT:
I certify that I have personally inspected the sewage disposal system at thi:.,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'n.*r 1enance of on-site sewage
disposal Ostems. The System:
V Passes :,,. :'
Conditionally Passes
Needs Further Eva tion B it oval Aproving Authority` , ; -,
Fails 3��Insp or's,Si nature: Date '
The System Inspector shall submita copy of this inspection report to the':•'gi,? oving authority within thir-
ty(30)days of completing this,inspection. If the system is a shared sy rr:1 er has a design flow of 10,000
gpd or greater,the inspector and the system owner shall submit the reposi,k:a the appropriate regional
office of the Department of Enviromnental Protection. The original should. sent to the system owner
ti and copies sent to the buyer,if applicable and the approving authority.
INSPECTION SUMMARY:
A)SYSTO PASSES:
V I have not found any information which indicates that the sync:++violates any of the failure
criteria as defined in 310 CMR 15.303.'Any failure criteria n4 evaluated are indicated
below.
B)SYSTEM CONDITIONALLY PASSES;
One or more system components need tote replaced.or rep.:.it a t.. 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 d.>:r,,i o;iination in all 'instances. If
"not determined",explain why not.
The septic tank is metal,cracked, structurally unsound,show,_,-,..v bstantial infiltration or
exfiltration,or tank failure is imminent. The system will P,.ss inspection if the existing sep-
tic tank is replaced with a conforming septic tank as approwA by The Board of Health. .
Sewage backkup or breakout or high static water level obsem,,.: i in the distribution box is due
to broken or obstructed pipe(s)or due to a broken,settled ou auieven distribution box. The
system will pass inspection if(with approval of The Board+:C Iz;alth):
- 1 -
+ (i
i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
CERTIFICATION (continued) ,r
IG r �'�i •
r 'p Broken pipe(s)replaced t''` ^ n�a•,�t
r
Obstruction is removed 1:a"t.
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): r
Broken pipe(s)are replaced
Obstruction is removed
C)FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
Conditions exist which require further evaluation by The Board of Health in order to determine if
the system is failing to protect the public health,safety and the environment.
1)SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE
SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE
PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
Cesspool or privy is within 50 Feet of a surface water
Cesspool or privy is within 50 Feet of a bordering vegetated wetland or a salt marsh.
2)SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER
SUPPLIER;IF APPROPRIATE)DETERMINES THAT THE SYSTEM IS FUNCTION
ING`114 A MANNER THAT PROTECT THE PUBLIC HEALTa AND SAFETY AND THE
ENVIRONMENTi
The system has a septic tank and soil absorption system and is within 100 Feet to a surface
water supply or tributary to a surface water.supply.
The system has a septic tank and soil absorption system and is with a Zone I of a public
water supply well. !�
The system has a septic tank and soil absorption system and is within 50 Feet of a private
water supply well.
The system has aseptic 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 melt.is free from pollution from
the facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less
than 5 ppm. --
D)SYSTEM FAILS:
I have determined that the system violates one or more of the following failure criteria as defined
in 310 CMR 15.303. The basis fc this determination is identified below. The Board of Health
should be contacted to determine what will be necessary to correct the failure.
Backup of sewage into facility or system component due to an overloaded or clogged SAS
or cesspool.
Discharge or ponding of efiuent 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 drat,to an overloaded or
clog-ged SAS or cesspool:
Lig uddepth in cesspool is less than G"below invert or available:volume is less than 1/2
day flow.
Required pumping'more titan 4 times jif the'last-year NOT due to clogged or obstructed
pipe(s): Number of times pumped
-2
SUBSURFACESEWAGE`DISPOSALSYSTEM'INuFECTION 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' K,
a surface water supply.
Any portion of a cesspool or privy is within a Zone I of a publi;.well.
Any portion of a cesspool or privy is within 50 Feet of a privaU'r;{:;ker supply Well.
Any portion of a cesspool or privy is less than 100 Feet but greater than 50 Feet from a private t
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 colifoi-T bacteria,volatile organic _4
compounds,ammonia nitrogen and nitrate nitrogen. =
E)LARGE SYSTEM,FAILS: i
The following`criteria apply to a large system in addition io the criteria above:
The design flow of a system is 10,000 gpd or greater(Large System;; aul the system is a significant
threat to publichealth and safety and the environment because onr, oL- more of the following
conditions exist
The system is within 400 Feet of a'surface drinking water supply
The,system is`within`200 Feet of a'tributary" o a"surface drirla.cg water supply �+
The.system is located in a nitrogen sensitive area Interim'%°°vcllhead-Protection Area
(IWPA)or a mapped Zone II of a public water supply
The owner`or operator of any such system shall bring the system and fac►'i�y t61to full compliance with the
groundwater treatment program requirements of 314 CMR 5.00 and 6.00., Please consult the local
regional office of the Department for further information.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Check ifthe following have been done:
k/ &l
Pumping information was requested of the owner,occupant,anc+ ard of Health.
✓ None of the system components have been pumped for atleast tv j weeks and the system has
been receiving normal flow rates during-that period. Large v()"mtuas of water have not been
introduced into the system recently or as part of this inspectiog;.
As built plans have been obtained and examined. Note if they a,a raot available with N/A.
The facility or dwelling was inspected for signs of sewage back"e:p,
t
_The system'does not receive non-sanitary or industrial waste flc�a.
The site- was inspected for signs of breakout. 4
`t °All.systern components,excluding the.Soil Absorption System,,':'nti.y been located on site.
The septic tank manholes were uncovered,opened,_and,the intr,, 1), of the igptic tank was in- '
rr= .'" i k i ,s, ed fducondition of baffles or tees;material of construc6l)-t.,dimensions,depth of liquid,
epth of sludge,depth of scum.
he size and location of the Soil Absorption:System on the site:'yeas been determined based on
existing information or approximated by non-intrusive metlw,,"is rY . .,
J`�a
r
,.. -
t. is ;{ a tF sy •;.T
!
`SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART I)
CHECKLIST(continued)
T facility he facili 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
RFSIDF.NTLAL:
Design Flow:_g25 3vllons Number of Bedrooms: Nun r of Current Residents-
Garbage Grinder: Laundry Connectcd To System:— seasonal Use:
Water Meter Readi s,if ilable:
Last Date of Occupan JA
mzv `
COMMERCIALtINDUSTRIAL:
Type of Establishment:
Design Flow:_,, _::Qallonstday Grease Trap Present: (yes or no)
Industrial Waste Holding Tank Present:
Non-Sanitary 1Naste Discharged To The Title V System: ""`
Water Meter Readings,If Available: Last Date of Occupancy:
OTHER: Describe)
Last Date of Occupancy:
GENERAL INFORMATION
PUMPINGRECORDS and source of information:OA dk�lT
System Pumped_as.part of inspectio ,� � lions
, r
Reason for pumping:
TYPE OF SYSTEM:
_LeSlepdc Tank/Distribution Box/Soil Absorption System ,
Single Cesspool
Overflow Cesspool
Privy
Shared System(If yes,attach previous inspection records,if any)
Other(explain):
ROXIMATE AGE of 1 co nets,date installed(if known)and source.of information!
3
Sew he odors detected when arriving'af'the site: X_))
SUBSURFACKSEWAGEADISPOSAL SYSTEM.9 SPECTION FORM
PART C 4
GENERAL INFORMATION; (continued)
SEPTIC TANK:
Depth below grade: Material of Construction: oncrete__in tal FRP_Other
(explain) --_- —
Dimisions: �'Sludge Depth: Scum ThKei cress: (/ytG
Distance from top of sludge to bottom of outlet tee or
r,
Distance from bottom of scum to bottom of outlet tee or baffle:_
Comments:(recommendation for pumping,condition of inlet and outlet tee:;or baffles,depth of liquid
level in lation o utlet invert,structural integrity,evidence of leakage,etc.) D
it
riln
ury
->
GREASE TRAP:
Depth Below Grade: Material of Construction:_concrete_._,_ metal FRP_Other
(explain) - -
Dimensions: Scum Thickness: _
Distance from top of scum to top of outlet tee or baffle:_ ,,
Comments: (recommendation.for pumping,condition of inlet and outlet tc c s uor balMes,depth of liquid
level-in relation to-outlet invertstructural-integrity;,evide ace°of leakage, .fq,,)
.. _..._ ..__...._ - f t i
TIGHT OR HOLDING TANK: C�
Depth Below Grade: Material of Construction:_concrete metal_FRP_Other(explain)
Dimensions: Capacity: gallons Design Flow:_. gallonstday
Alarm Level:
Comments: (condition of inlet tee,condition of alarm and float switches,etc.)
at J z_ F:d
DISTRIBUTION BOX:_ _ --
Depth of liquid level above outlet invert•
Comments: (note if 1 el and distribution is equal,evid ce of solids care:wt;:-,evidence of age' to
or out o box etc.) t
v ,
w _.µPUMP"CHAMBER: ':.
...Pump is,in.working order:
___Comments: (note condition of pumpchamber,condition of pumps and aplutrtenances,etc.) r
et
I
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,sigi of hydraulic faiire level�g,condition o>ive Beta 'on,
etc.) ,1
CESSPOOLS:
Number and configuration: Depth-top of liquid to inlet invert:
Depth of solids layer: Depth of scum layer: Dimensions of Cesspool:
Materials of construction: Indication of groundwater.:
Inflow(cesspool must be pumped as part of inspection)
Comments: (note condition of soilk,signs of hydraulic failure, level of pondiugRcondition of vegetation,
etc.)
PRIIVY:�
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 I�R>PICTION FORM
. - - Th"
PART C _ '
SYSTEM INFORMATION (con'i;med)
SKETCH OF SEWAGE DISPOSAL SYSTEM:
Include ties to adeast two permanent refcreuccs, landmarks or'bcnch6mrkS.
Locate all wells within 100 Feet.
,�". - .,. t:. i� S`� _ ', '.�:+� ST ,.. i Pi�+S +,.-:fzF R•"3��.;
DEPTH TO GROUNDWATER: !
Depth to groundwater: / Feet
Method of Det 'nation or Ap roximatiou:
ATLANTIC ENVIRONMENTAL
P.O. BOX 2384
MASBPEE,MA 02649
Attn: Commonwealth of Massachusetts Date: 06/19/96
Town of Barnstable
Board of Health
367 Main Street
Barnstable, MA 02630
From : Mr Michael DeDecko 101�
Po Box 2384 t
Mashpee MA 02630 A S -
k
A � 9L9
Dear Board of Health Official;
I certify that I have personnally inspected the sewage disposal systems at the following
address : 33 King Arthur Drive. Osterville, Ma.
The informations reported are true, accurate and complete as of the time of the
inspection.
If you have any questions regarding this inspection, please contact me at this number:
(508)477-14-20. Thank you.
Si cerely,
Mic ael gDeDeco
phone 508 477-1420
Commonwealth of Massachusetts
Executive of Environmental Affairs
DEFT
Department of
Environmental Protection
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
Property Address: 33 Ding Arthur Drive. O sterville, M a.
Address of Owner: John Mc Laughlin
(if different) 64 Cross Street. Hingham, Ma 02043
Date of Inspection: 06/17/96
Name of Inspector: Michael DeDecko
Company Name, Address and Telephone number: Atlantic Environmental
P.o Box 2384 - M ashpee Ma 02649. Tel : (508) 4771420
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 S ignatur Date: 06/18/96
The system Inspector shall submit a copy of this inspection report to the Approving
Authority within thirty (30) days of completing this inspection. If the system
is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the
system owner shall submit the report to the appropriate regional office or the Department
of Environmental Protection.
The original should be sent to the system owner and copy sent to the buyer, if applicable
and the approving authority.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A .
CERTIFICATION (continued)
Property Address: 33 King Arthur Drive. 0sterville, Ma.
Owners : John Mc Laughlin
Date of Inspection : 06/17/96
INSPECTION SUMMARY:
Check A, B, C, or D
A) SYSTEM PASSES:
A I have not found any information which indicates that the system violates any of the
failure criteria as defined in 310 CM 15.303. Any failure criteria not evaluated are
indicated below
B)SYSTEM CONDITIONA
LLY PASSES:
---- One or more system components need to be replaced or repaired. The system, upon
completion of the replacement or repair, passes inspection.
Indicate yes, no, or not determinate (Y,N, or N D). Describe basis of determination in all
instances. If "not determinated",explain why not.
---- The septic tank is metal, cracked, structurally unsound, shows substantial infiltration or
exfiltration , or tank failure is imminent. The system will pass inspection if the existing
septic tank is replaced with a conforming septic tank as approved by the Board of
Health.
---- 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
n
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address : 33 Ding Arthur D rive. O sterville, M a.
O caner : J ohn M c Laughlin.
Date of Inspection : 06/1796
C) FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
---- Conditions exist which require further evaluation by the Board of Health in order to de-
termine if the system is failing to protect the public health , safety and the environ-
ment.
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 SAFETYAND THE ENVIRONMENT:
---- Cesspool or privy is within 50 feet of a surface of water
---- Cesspool or privy is within 50 feet of a bordering vegetated wetland or a small
marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER
SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNC-
TIONING INAMANNER THAT PROTECT THE PUBLIC.HEALTH AND SAFETY
AND THE ENVIRONMENT.
---- The system has a septic tank and soil absorption system and is within 100 feet to a
surface water supply or tributary to a surface water supply.
---- The system has a septic tank and soil absorption system and is within 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 analy-
sis 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 notrogen is equal to or less than 5 ppm.
D) SYSTEM FAILS:
-- I have determined that the system violates one or more of the following failure criteria
as defined in 310 CM 15.303. The basis for this determination is identified below.
The Board of Health should be contacted to determine what will be necessary to cor-
rect the failure.
--- Backup of sewage into facility or system component due to an overloaded or
or clogged SAS or cesspool.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 33 King Arthur Drive. O sterville, M a.
Owner: John Me Laughlin
Date of Inspection : 06/17/96
D) SYSTEM FAILS (continued)
-- Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool.
--- Static liquid level in the distribution box above outlet invert due to an over-
loaded or clogged SAS or cesspool.
--- Liquid depth in cesspool is less than 6" below invert or available volume is j
less than 1/2 day flow.
--- Required pumping more than 4 times in the last year NOT due to clogged
or obstructed pipe(s).
number of times pumped
--- Any portion of the Soil Absorption System, cesspool or privy is below the high
groundwater elevation.
--- Any portion of cesspool or privy is within 100 feet of a surface water supply
ortributary 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 ana-
lysis. 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.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
,
Property Address: 33 King Arthur Drive. 0sterville, Ma.
Owner: John Mc Laughlin
Date of Inspection : 06/17/96
E) LARGE SYSTEM FAILS:
The following criteria apply to large systems in addition to the criteria above :
The design flow of system is 10,000 gpd or greater Large System and the system
is a significant threat to public health and safety and the environment because
one or more of the following conditions exist : -
--- the system is within 400 feet of a surface drinking water supply
--- the system is within 200 feet of a tributary to a surface drinking water supply
--- the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area - IPA) or a mapped Zone II of a public water supply well.
The owner or operator of any such system shall bring the system and facility into full compli-
ance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00.
Please, consult the local regional office of the Department for further information.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 33 King Arthur Drive. O sterville, M a
Owner: John Mc Laughlin
Date of Inspection: 06/17/96
Check if the following have been done :
-x Pumping information was requested of the owner , occupant and Board of
Health.
--x None of the system components have been pumped for at least two weeks
and the system has been receiving normal flow rates during the period. Large
volumes of water have not been introduced into the system recently or as part
of this inspection.
--x As built plans have been obtained and examined. Note if they are not available
with N/A.
--x The facility or dwelling was inspected for signs of sewage back-up..
--x The system does not receive non-sanitary or industrial waste flow.
--x The site was inspected for signs of breakout.
--x All system components, excluding the Soil Absorption System, have been
located on the site.
---x The septic tank manholes were uncovered, opened and the interior of the sep-
tic tank was inspected for conditions of baffles or tees, material of construc-
tion, dimensions, depth of liquid, depth of sludge, depth of scum.
---x The size and location of the Soil Absorption System on the site has been deter-
mined based on existing information or approximated by non-intrusive methods
---x The facility owners and occupants if different from owner were provided with
information on the proper maintenance of Subsurface Disposal System.
r
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 33 King Arthur Drive. 0 sterville, M a
Owner: John Mc Laughlin
Date of Inspection: 007/96 _
RESIDENTIAL:
Design flow: gallons
Number of bedrooms : O'er
Number of current residents: 0
Garbage grinder (yes or no): t,1 O
Laundry connected to system(yes or no): LJ s
Seasonal use (yes or no)*: N d
Water meter readings, if available:
Last date of occupancy :
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow : gallons/day
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
PU M P N G R E CO R D S and source of information
System pumped as part of inspection(yes or no):. ...!(� ....:.
if yes, volume pomped: .................... gallons
Reason for pumping ..... ......... _ .
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 33 King Arthur Drive. O sterville ,M a .
Owner: John Mc Laughlin
Date of inspection: 06/17/96
TYPE OF SYSTEM
Septic tank/distribution box/soil absorption system
--- Single cesspool
--- Overflow cesspool
--- Privy
--- Shared system (yes or no) (if yes, attach previous inspection records, if any)
--- Other (explain)............................................. .............................................
APPPBO IMATE,AGE of all components, date installed (if known) and source of information
:..!mac,-.....LCt.�4.'. ................................................................................
................................................................................................................................................
................................
Sewage odors detected when arriving at the site: (yes or no).....N.
SEPTIC TANK: �: ..
(locate on site plan)'
Depth below grade: ........
Material of construction: ...(.. concrete ......... metal ........ FR P ........ other (explain)
.........................................................................
Dimensions:
�r-A 5�1 _
Sludge depth:....9.'...... r
Distance from top of sludge to bottom of outlet tee or baffle:.......3a`................
Scum thickness :....
Distance from top of scum to top of outlet tee or baffle: .............z.........I..............
Distance from bottom of scum to bottom of outlet tee or baffle :....1..L.: ............
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.)............ .........
�.�....:.�.... .-. :S GT R431... :5 �' ... {!)c±, ..�...d`�.s�...`�..5d l d -..�.. :..
p
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 33 King Arthur Drive. O sterville, M a
Owner: John McLaughlin
Date of inspection: 06/17/96
N -
GREASE TRAP : C�
(locate on site plan)
Depth below grade: ...............
Material of construction: ........concrete.........metal........FRP........other(explain)....
.............................................................................................................................
Dimensions:...............................
Scum thickness:..................I......
Distance from top of scum to top of outlet tee or baffle:.......................................
Distance from bottom scum to bottom of outlet tee or baffle:...............................
Comments:
(Recommendation for pumping condition of inlet and outlet tees or baffles, depth of liquid
level in relation to outlet invert, structural integrity, evidence of leakage, etc.)........................
................................................................................................................................................
................................................................................................................................................
TIGHT OR HOLDING TANKS:...N ...
(locate on site plan)
Depth below grade:...............
Material of construction:........concrete........metal.........FR P..........other (explain)..........
................................................................................................................................................
Dimensions:............................
Capacity:....................gallons
Design flow:...............gallons/day
Alarm level:..............................
Comments:
(condition of inlet tee, condition of alarm and float switches,etc.)
................................................................................................................................................
..............................................:.................................................................................................
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 33 King Arthur Drive. O sterville, M a
Owner: John McLaughlin
Date of inspection: 06/17/96
DISTRIBUTION BOX:..�'L.�
(locate on site plan)
Depth of liquid level above outlet invert:..qykj..A �T
Comment:
(note if level and distribution equal evidence of solids carryover, evidence of leakage into
or out of box, etc.).. S).6Q...G
PUMP CHAMBER:...00...
(locate on the site)
Pumps in working order: (yes or no)...............
Comments:
(note condition of pump chamber, condition of pumps and appurtenances, etc.)....................
.......................................:.........................................................................................................
................................................................................................................................................
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:
t
leaching pits, number: ...\.1.\O.x.t...p
leaching chambers, number:....:...
leaching galleries,number:........... ,
leaching trenches, number, length:.....................'
leaching fields, number, dimensions:...................
overflow cesspool,number:..........
Comments:
(note condition of soil , signs of hydraulic failure, level of ponding, condition of vegetation,
etc �n .. .. .�.....t9.. .t.. �,.s,.a�I.. �:4n�zr:.4��.......
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property address: 33 King Arthur Drive. O sterville, M a
Owner: John M c Laughlin
Date of inspection: 06/17/96
CESSPOOLS:.....I�O....
(locate on site plan)
Number and configuration: .....................................
Depth-top of liquid to inlet invert: ...........................
Depth of solids layer: ...............................................
Depth of scum layer: ...............................................
Dimensions of cesspool: ......................
Materials of construction: .....................
Indicator of ground water: ....................
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 : .....
(locate on the site)
Material of construction: ...................................
Dimensions: ......................
Depth of solids: ................
Comments:
(note condition of soil, signs of hydraulic faHure,level of ponding, condition of vegetation,
etc.).
................................................................................................................................................
................................................................................................................................................
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address : 33 King Arthur D rive. O sterville, M a
Owner: Jahn Mc Laughlin
Date of inspection: 06/17/96
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks locate at
wells within 100'
I
A .
2
LA o
DEPTH TO GROUNDWATER:
Depth to groundwater: . .�....feek
�..�•..a V5��.��-�
Mekho determination or a praximative:
�:�� .............................. ..........
No..............4........ Fzcs..............................
THE COMMONWEALTH OF MASSACHUSETTS ~
BOAR® OF H A
. h� �_6� -- v .."�. oF..... .�. -N..... ...... '- ------------
lq�l
Appliration for Uhi uiial Workii Corm rurtion Fcrutit
Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal
S st at
��,, ll h . '
70 ....-`� �� 1=!.1.!� �- 1� ..�± r -�--------- ------- �1-. J. ........................................................
�Lo on-Address or Lot No.
w er Address
a _........ . --•• .... y .._ '.e .... ........................................
Installer / Address o
U Type of Building Size Lot..O/4�_.._.___Sq. feet
Dwelling—No. of Bedrooms......... ................................Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
Other fixtures ......................
W
Design Flow......... .........................gallons per person per day. Total daily flow............. ®': ..................gallons.
WSeptic Tank—Liquid"capacit}tr llons Length................ Width................ Diameter---------------- Depth................
x
Disposal Trench—No..................... Wi h_-•--__.--_•-_- Total Length----- ___._._ __. Total leaching area..__,_fj_�.-_-sq. ft.
Seepage Pit No._._._6 Dia ..._.._... Total leaching area......sq. ft.
Z Other Distribution box ( ) Dosing tank ( ) ;PC
Percolation Test Results Performed by..........................................................................
Date........................................
aTest Pit No. 1................minutes per inch Depth of Test Pit....... Depth to ground water.......................
fs, Test Pit No. 2................minutes per inch Depth of Test Pit.,................... Depth to ground water--_____-___-.-_--._____-
R' -----------------------
-------------(------r------------------ --- .--
O Description of Soil------. r ..U.l,..- .......e�- -----T ..... .-•'l2-.;.4/ .... ..
W
W ------------------------------------------------------------------------------------------------------------------------ ••-------------------------------------------.................................
UNature of Repairs or Alterations—Answer when applicable........................:...................................................................... a
------------------------------------------------------------------------------------------------•••••-••••-•---•------••••------•-•----•••.....0•--•--••..........................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of'I'LL 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health.
ign ......................40-o'n
�yfDate
Application Approved By••.•••-•7;1r_2 / .w .--•
Date
Application Disapproved,f or the following reasons-------------------------------------------------------------------------------------------------------.....-•--
•----------------------------------------------------------------------------------------------------------------•---------•-------------------------•----------------------...........................
Permit No................. .
••---•-••------•----._...... Issued. ��..'r.�-----1_. ..J --a�------
--- Date
No..•...... ......_ Fss..x....._............._
THE COMMONWEALTH OF MASSACHUSETTS
Y-
BOARD OF H-i AL.T
Appliration for Dtopooal Works Tontrnrtion ramit
Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal
4 stem at
a� � ? . ........................................................
6ILa on Address oar Lot No.
er� �t Ad�ess
.�c....____d� ( ' _... ____-------...... ........----••--
Installer Address
U Type of Building
Size Lot__d3* ..................Sq. feet
Dwelling—No. of Bedrooms____._;,...................._..........Expansion Attic ( ) Garbage Grinder ( )
a
aOther—Type of Building ..._........................ No. of persons............................. Showers ( ) — Cafeteria ( )
dOtherK fixtures __ ....................................................-------------------------------•---------•-------------•-----•-------------
W 'Design Flow____.__..�p.. ............ .____gallons per person per day. Total daily flow............7.a_.!?..................gallons.
WSeptic Tank—Liquid capacit}l0 allons ' Length_______________ Width................ Diameter _:..____:___._ Depth................
x .Disposal Trench—No...................... Width......... ! Total Length Total leaching area____`�_�1__1_...sq. ft.
Seepage Pit No------ r/`�Dia _____________ ____¢ g eld� _::_.___*___ Total leaching area__- ...sq. ft.
z Other Distribution box ( ) Dosing tank ( ) —Oh 0M.
Percolation Test Results Performed by". ----------------
Date
Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water.....................
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
________________ _ _
O Description of Soil........-....6
V
W =------------------------------•-------
U Nature of Repairs or Alterat> ---•--------------•---•--•-•-_••••• ---•-•---•--
nswer when applicable_________ _________ ______________________________________________ ______________________
Agreement:
The undersigned agrees t?:,, all the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITI:I; 5 of to 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.
gned- E ---------•- -----------------•--------
Date
Application Approved B VV4"'' ...:__ _.::._ _ f �_.___ s ''
Dto
Application Disapproved for the following reasons------------------•--------------------------------------------•----------------------------•••••---------••••••.
..............................•-••------•-•---------••-•-•--..:---••-----------•........-----•----••--•-•••••-•••--•--••-•-••--••••-------•-•----••••----•••••--•••-•--••-------•--•---•---•-•-----•-••-
PermitNo..............................=.......................... '`. Issued----= .......................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
G - -..,... :............................
(Irrtif irFate of TompliFanrle
THIS—IS TO CERTIF�Y �{ at th .6vidual Sew,ge Disposal System constructed or Repaired ( )
by ------ - ......Z ............................... ".. -"-"- --------•---•----•---•--•. . ............................
---Insteu• -------. i
at......... .......... ------••_ --.._f�-- - ----- . - =--•----•------ ...................................................
has been installed in accordance w the provisions of TITLE j of The State Sanitary Code as described in the
application for Disposal Works nstruction Permit No......................................... dated................................................
THE ISSUANCE OF THIS CERTIFICATE SHALOWT-sk,CONST UE® AS A GUARANTEE THAT THE
SYSTEM WILL CTION ATISFA ORY.
DATE........... .......`. �-- . �•• Inspector :........
THE COMMONWEALTH OF MASSACHUSETTS
BQAR D F HE�L, H.....OF..f.... .........::...... .:._.._.-_._.r........_.._._.._.........
No......................... FEE........................
Dispooa t Vorkg Ton .,.,, rrmat
Permission 's he bri Ited......1C -, *.�-'------- ........-- ------- --- •-•-•-------------------------------------
to Constru or Repair �)4 Individual Sewage Disposal System
atNo. j _ -4� 't - ;g ................................
as shown on the application for Vs4al Works Construction P t N _______ _________ ated..........................................
Boar of Health
DATE---------------------------- >_
---•---•----•---•----••...................•••---
FORM 1255 HOBBS.& WARREN. 1NC.. PUBLISHERS
�li,JGLb �L1M►L_�( .ra 3>✓D'1Z��NC ,; ,,_...:.�
U0 6ArLTsAr-C _C FZ �toESG
1 � 1rjd 1��{ 'F LOw _ 11 b � � t �3 b G•P•�• t.. ,
��F�T'IG T!->+�IIC. - 33b,r fSG % • 4�Cj 6.RD. '�_ !
USE=- l o 00 66 A L_
t
i
` �LSPC�SAL PIT - Use loco �:oL • � ` \ �
rt�wa.t L AV_&A = l50 s•�, ` '.q,j t - �' t-
G.P.V.
8df`1-OVA ,A2EA t r�o ST=
ToTtd L '1D ES16kl = .425
-roTot_ T:;>,&l L--( r-I1Dw = 33D 6F-rD.
11 MAN,� �. r i iI s SK
+ HOF \1`� '''„'' @��,�tL►•'Ac�Ayaln n - `_ 3$ ' � ; t Q' "•� .�rf ' }
0.
\kQ\'`N h1A6 G `.6�� t +�..� ' Y y 1 ' _ t ' r/ j '. $ ' ,y_ t• t ', C- r yl a -1 f:
v*c� RICHARD G r i t
A. yam �� ALA P3' J ..} a,_i• 1 r 1 t t 1 "' ! f l 1 t {
a.a O {i�•,y f,r t 1 1� v r t , , �' 1" t
i -� �'
41v QAXTER u, .. VJ
24048 O 3ON rr 1 f 1
Tn v �t U !e - ! I, t 1 , t Y ! t« r7 t L«tt
rsu
T
Tor Fwo
ram. - tot /^���//N�\ / _ •• //r.�.• �P/� ,,• _.�. t ��_ _ 1 ..,..
.p � 4
1
LOAM n. !f /P �OaG III � •� i i i°r �`r ;.
SUB 4r//P� �pIST Iw• Gaa. 96.70 •. t ` .'
Sot a_ { f .-Box 9 r,45 SE-PT IC
9S.0orw
INpN/�V $ / TANK (b
GaFv i LH t r t j ,
99 oa PIT
I ... ML t WASr•1ED ! , t i ! i � , i t t 1, ( ^� t-t_ � ,t.`
1 , I � t
, t � 1• 'j[
x
a
Przor-'1 L Y 1 I• ' r-t I
tOGA.TIO" .0STERv1 t- ! S _ ,
Mo Y✓AT � la/is/ j SG LC I iN:-GO FT,1jATC 1/z'3/
P�OPOS�S� I Ptrt�,1,1 ►c l_�t lZE►.IGE + r^Y,
t I Gt�ILTIF=�{ 'TL(A�f` TI-1G FOVNDATION'SN�"
fAt.IJ `7E'I L'<l�C1C L.O r ; 4- ZJ =n1.I 6CW%PLVG, W i1IA TW Z 61DeuI-1�
jQeAAE: . T� �F C. t
S4 .. 0
RcGtS tttZ�D i.A1.tG' 15uev�Yor s
ti 4
K t-1 OT LA",CC7 Ub�i /. W � ^Os?E2V�l.t.G - o' /�rCAsS•
iiJ4f�;J;✓lC_W i ��c1I'\/t=� j Y14L -OPI7.e -�Z 414CAJW ! }
t,. :Z'; '�I� .uSi'- Ta- -or~1 i=c'M.c!�11 .1 'C' -I.IF,IC.•.> r�l�.1cA.I-..tT cP� 'E .w►D�
AP p��IEL.r
.-t ttaa;_'cii ,.. L!..i •s.SUa rl y.. ?tj a �- n
i' l Q
i -t _J TG d DF-GK
MASTER —�ROOM
-a �=IVY _ O
- - = _
c�
UP
LIB (NC' ROAM
I_ oil
_ I
r � a
Y „
}
f
t
{
j
j
i
!i
LF-L
f N '
INC-ar # o6M
n d
If