HomeMy WebLinkAbout0053 MEADOWLARK LANE - Health L
MEADOWLARK) '`-OSTERVILLE
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y TOWN OF BARNSTABLE
LOCATION SEWAGE # 3
VILLAGE ASSESSOR'S MAP & LOT
INSTALLER'S NAME & PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY:(type) J, 0 ®O (size)
NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER
BUILDER OR OWNER
73���03
DATE PERMIT ISSUED: !2—/�
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No
1 � `
= _ y
P
a '
t
�J ` FEB....... 0......
THE COMMONWEALTH OF MASSAC�d SETT , A P P R O V E D '
BOAR® OF HEALTH abId Conservation Co
mmission
®i.Cli�l.-..... OF.... rS..........------ 1
5 —/�
g d /
Appliration for Diipniial Works Tomarnrtion rrrmffDate
Application is hereby made for a Permit to Construct (f,) or Repair ( ) an Individual Sewage Disposa
System at: /�,,
ERGb L wiG �-�4�A 4s is l W R"
... ........_ -mil....!`#..... ..... 1......._... --•---•--- ................A............................................................
Location-Address or Lot No.
�� ... --------------------------- ----�J._....._P . - -�...... ............................
-16wner Address
a �1M= C.vt�i ��'� ®r
Installer I Address
Tye of Building Size Lot_.Q.1.7 _.......Sq. feet
U Dwelling—No. of Bedrooms-_3......................................Expansion Attic (&d Garbage Grinder (YJ05
aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
Q' Other fixtures --------------------------------------------------------------
Design Flow......r ..............gallons per person er da Total daily flow.........A%�Y.........................gallons.
WSeptic Tank—Liquid capacity..l ---gallons Length__ " Width__- Diameter'" Depth...
x Disposal Trench—No--------------------- Width.................... Total Length........./._.�..._...... Total leaching area---.._----•---......sq. ft.
Seepage Pit No.___---.I...___.... Diameter......14.......... Depth below inlet.....6........... Total leaching area.AA-� ......sq. ft.
Z Other Distribution box 4i Dosi tank duo
~ Percolation Test Results Performed by. ._.L _..1-°` _________________ Date........................................
a4 Test Pit No. L.AZ-_---__minutes per inch Depth of Test Pit---7. ......... Depth to ground water-------.................
(T4 Test Pit No. 2...4.7 -_._minutes per inch Depth of Test Pit.....13.......... Depth to ground water.....'............
Description of Soil_._ 2r1?.A ` .,.ice._ � '.. !'�= ---------------- -----•---- -•---------------------------•------
VNature of Repairs or Alterations—Answer when applicable...............................................................................................
....................................-...................................................................................................................................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental 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 ----- .i........................- ------- --- - ---_---------------- ----
Application Approved By ........---- ......$-_1-13 -?f
Application Disapproved for the following reasons- -------------- --.------- .........---- ----...----------`.....................--.......-------------------------------
------------------------------------------------------------------------------------------------------------------------- ....-.....-----......--------..............--------------------........ .. I--..------------------------------
Date
Permit No. ......? .-"' Issued --------------------------------............................------
Date
No.._ �. J.. ` F:cs.... .......
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.......G�f,.r .. .............- ..OF.....................................-- \ �.....................................
Appliration for Disposal Works Tonstrurtiun Prrmit
Application is hereby made for a Permit to Construct (N) or Repair ( ) an Individual Sewage Disposal
System at: 1
.. ....... -- ................. ._..... LLG-
............ •• ------------------------.....-----------------•---.._....
.........
..............
......----•--•----
Addr s ........... Lot No.
W Owner K _ Lin Address O I r) 5�
a •------•------------------------•-•---•---•-----•----••-----...............-•-----•--•-••-••••--•- --•--_....................-•--•-...........................9.......700
. ......--.........._......
Installer Address
d Type of Building Size Lot__1............ ........Sq. feet
Dwelling—No. of Bedrooms....:......................................Expansion Attic (k Garbage Grinder ( *;)
'k Other—T e of Building ............... No. of persons.................._..______ Showers — Cafeteria
P.I Other fixtures -------------------••--••-----•••.....................................................
Design Flow...... . ..� ....... ___gallons per person per da-y. Total daily Pow........ 4_...•.......... .............gallons.
WSeptic Tank—Liquld capacity..!..- _gallons Length---�._.......:.. Width..a...?...... Diameter::.............. Depth__."�....
x Disposal Trench—No. ............:....... Width.................... Total Length.................... Total leaching area._...y.............sq. ft.
Seepage Pit No----------
Diameter......!...._ Depth below inlet....._((.+9........... Total leaching area..`'1. ��_.....sq. ft.
z Other Distribution box (` Dosi tank 0"j,
'-' Percolation Test Results_ Performed by :!: --_:. ....`.... I..`.........._
a •------•_... Date........................................
Test Pit No. 1---`'_`"-------minutes per inch Depth of Test Pit---- ......... Depth to ground water....__:_"•'•"-_:-_---_-.
44 Test Pit No. 2--- ....minutes per inch Depth of Test Pit -.3.......... Depth to ground water
O Description otf\Soil �w 0 �r 0 1 Z 1=�; f t✓ :,A'r - O y
Ot""lYlJc/� J '----1 ) `AW I)
W r 1
a w
� a .�
, �. ........... ...... ..... .................... .••-•••----------------•---••-......----••........... ......................
UNature of Repairs or Alterations—Answer when applicable................................................................................................
------------------------------------------------------•----•------------------------........--•---------.......---------------------------------•••--••••-•...••••••••••••--•-----•---•----------•--•--
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environ tal Ch�—T unfilqsigned further > o�pl�ejtl�e
system in operation until a Certificate of Compli su by t
Signed ------ ----------------------------------------------------------------- ----------------------------- ........................................
Dare
Application Approved By ----------
...-.1 ........... - . ---. -------------------------------------------------- ......
Application Disapproved for the following reasons- -------------------------------------------------------- ----------------- -- - ----------------------- -------------
.............. .................................................................. .......................................................................................... .. ................... ........................................
qDace
PermitNo. 5-7.............................. Issued ---------------------------------------------------------
Due
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
...................^.-...............n
----------------------------------------...... .......-.......................-.....
Gexttftottte of d-lempltttnre
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( � ) or Repaired ( )
by.............................................s.............-- .. ---------------- -----------............----------------.......----------...-----------------------------------------------------------......----------------------------
t, Insraller
at .........................................���.CAPQ r,j L I'N I�R� t.��}�......... .�.�--�/t.LC. ..
has been installed in accordance with the provisions of TITL 5 of The State Environmental Code as described in
the application for Disposal Works Construction Permit No. F6� .--3... .�------------------- dated ................................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS AMU A TEE THAT THE
SYSTEM WILL FUNCTION SATI FA O Y.
DATE......................... -�----- ..... Inspector --. ------------ = -------- --------------
...........
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH��
No'...�.. � ... FEp/�.0..............
Disposal Works k'alInstrudionfirrutit
Permissionis hereby granted.............................................................................................................................................. _.
to Construct O o Repair ( ) an Individual Sewage Dispo S stem .�
at No..._.... � Lt,� ; , 'v 1
-•-•----•-•-•-----------------------•---•---•-------•... ..............•-•-v....... ------- ------
as shown o a licat' or Di corks Construction erml r
PP Dat .........
....................... V-.....--•---
Board of Health
DATE.................................................................................
FORM 1255 HOBBS & WARREN, INC., PUBLISHERS
t
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M 53 MEADOW LARK
Property Address
PAUL H AUSTIN REV TRUST
Owner Owner's Name
information is required for OSTERVILLE MA - 8-12-13
,
every page. CityfTown 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: A. General Information
When filling out
forms on the .
computer,use 1. Inspector:
only the tab key
to move your DOUGLAS A BROWN
cursor-do not Name of Inspector
use the return
key. DOUGLAS ABROWN INC
Company Name
P.O. BOX 145
Company Address
CENTERVILLE MA 02632
City/Town State Zip Code
508-420-4534 S14297
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 15.000).The system:
Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
- 8-12-13
In ctor'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 buyer, 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.
t5ins-3/13 Title 5 official InspeVionubsurfac'e Sewage Disposal System-Page 1 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments .
G M 53 MEADOW LARK
s Property Address
PAUL H AUSTIN REV TRUST" w
Owner Owner's Name
information is required for OSTERVILLE y MA 8-12-13
every page. Citylrown State Zip Code ;,` Date of Inspection
B. Certification (Conti) -
Inspection Summary: Check AB CD of E/a/waYs complete
lete all of ection D
A) System Passes: t
® 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:
AT TIME OF INSPECTION SYSTEM MET ALL,PASSING REQUIREMENTS
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:
Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain. r
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. f
*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) .
Page 2 of 17
t5ins•3/13 s Title 5 Official Inspection Form:Subsurface Sewage Disposal System;
Commonwealth of Massachusetts '
Title 5 Official Inspection 'Form,
a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
, 53 MEADOWLARK
Property Address ,
PAUL H AUSTIN REV TRUST w
Owner Owner's Name
information is required for OSTERVILLE MA 8-12=13
-" � ,, - '
every page. City/Town State .. Zip Code Date of Inspection ection
B. Certification (cost.)
❑ Pump Chamber pumps/alarms not operational. System will`pass with Board of Health approval if
pumps/alarms are repaired. -
B) System Conditionally Passes (cont.):,h
❑ Observation of sewage backup or breakout 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 ❑'N ❑ ND(Explain below):
obstruction-is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or'replaced ' ❑.Y ❑;N ❑ ND (Explain below):
❑ 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):
El obstruction._is removed ❑TY ❑ N ❑ ND(Explain below):
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.
t
1. System will pass unless Board of Health determines iri 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:
F Y
❑. 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
t5ins•3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal_System•Page 3 of 17
Commonwealth of Massachusetts .
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
G1M , 53 MEADOW LARK
Property Address
PAUL H AUSTIN REV TRUST
Owner Owner's Name
information is 8-12-13
required for OSTERVILLE MA"- -
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
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 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:
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
❑ ® 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 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M '< 53 MEADOW LARK
Property Address
PAUL H AUSTIN REV TRUST
Owner Owner's Name
information is required for OSTERVILLE MA 8-12-13
every page. Cityfrown State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
Ej ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
Any portion of 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 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 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.
❑ ® 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. '
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
❑ ❑ 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
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.
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
53 MEADOW LARK
Property Address
PAUL H AUSTIN REV TRUST
Owner Owner's Name
information is required for OSTERVILLE MA 8-12-13
every 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 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 in 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?
❑ Z 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): 3 Number of bedrooms(actual): UNKNOWN
DESIGN flow based on 310 CMR 15.203 (for example: 110.gpd x#of bedrooms): 330
t5ins-3113 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M s 53 MEADOW LARK
Property Address
PAUL H AUSTIN REV TRUST
Owner Owner's Name
information is required for OSTERVILLE MA 8-12-13
every page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
ACCORDING TO AS-BUILT CARD SYSTEM CONSISTS OF A 1500 GALLON TANK D-BOX AND A
6X6 LEACH PIT 1000 GALLON WITH 3 FT OF STONE
Number of current residents: 0
Does residence have a garbage grinder? ❑ Yes ❑- No
Is laundry on a separate sewage system?(Include laundry system inspection El Yes ❑ No
information in this report.)
Laundry system inspected? . ❑ Yes ❑ No
Seasonaluse? ❑ Yes ® No
Water meter readings, if available(last 2 years usage(gpd)):
Detail:
2011-----105 2012----138 HOUSE HAS IRRIGATION SYSTEM HOUSE HAS BEEN OCCUPIED BY
ONE PERSON FOR THE PAST FEW YEARS AND 2 PEOPLE PRIOR TO THAT
Sump pump? ❑ Yes ❑ No
Last date of occupancy:• Date
Commercial/industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310'CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ 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:
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 53 MEADOW LARK
Property Address
PAUL H AUSTIN REV'TRUST
Owner Owner's Name
information is required for OSTERVILLE MA 8-12-13
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.),
Last date of occupancy/use: . Date
Other(describe below):
Genera_ 1 Information
Pumping Records: .
Source of information:
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):
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17
Commonwealth of Massachusetts
Title 5 Official- Inspection Form '
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 53 MEADOW LARK
Property Address
PAUL H AUSTIN REV TRUST
Owner Owner's Name
information is required for OSTERVILLE MA 8-U-13
every page. City/Town State. Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known)and source'of information:
1991 ACCORDING,TO,AS-BUILT
Were,sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: feet
Material of construction:
❑ cast iron ❑40 PVC ❑ other(explain):
Distance from private water supply well or suction line: feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
Septic Tank(locate on site plan):
Depth below grade: 2
feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 1500 PER AS-BUILT
Sludge depth: LIGHT
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of,17
Commonwealth of Massachusetts
Title 5 Official Inspection .Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 53 MEADOW LARK
Property Address
PAUL H AUSTIN REV TRUST
Owner Owner's Name
information is required for OSTERVILLE MA 8-12-13
every page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.) ,
Distance from top of sludge to bottom of outlet tee or baffle ,
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
How were dimensions determined? WOODEN POLE
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 LOOKED FINE AT TIME OF INSPECTION
Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction;
❑ concrete 0 metal ❑fiberglass "0 polyethylene 0 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 lasttpumping: - Date
t5ins•3/13 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
M 53 MEADOW LARK
Property Address
PAUL H AUSTIN REV TRUST
Owner Owner's Name
information is required for OSTERVILLE MA. 8-12-13
every page. Cityfrown 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.):
E
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:
Capacity:
gallons
Design Flow: . gallons per day
Alarm present: ❑ Yes ❑ 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•3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 11 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
53 MEADOW LARK
Property Address
PAUL H AUSTIN REV TRUST
Owner Owner's Name
information is required for OSTERVILLE MA 8-12-13
-
every page. Cityrrown State Zip Code Date of Inspection
D. System Information cont.
Y ( )
Distribution Box(if present must be opened) (locate on site plan):
Depth of.liquid level above outlet invert Oil
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.):
Pump Chamber(locate on site plan):
Pumps in working order. ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No*
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
t
* If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
r -
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M SVB,y 53 MEADOW LARK
Property Address
PAUL H AUSTIN REV TRUST
Owner n
Ow er's Name
information is wired for required OSTERVILLE MA 8-12-13
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont)
Type. '
z leaching pits number:
❑ leaching chambers . number:
❑ leaching galleries number:
❑ Teaching 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.):
PIT HAD AROUND 1 FT OF LIQUID AT TIME OF INSPECTION.
Cesspools (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 ❑ No
t5ins-3/13 Title 5 Official Inspection Forth:Subsurface SewageP Y
Disposal System-Page 13 of 17
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
53 MEADOW LARK
Property Address
P -
PAUL H AUSTIN REV TRUST
Owner Owner's Name
information is required for OSTERVILLE MA 8-12-13
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont:)A
Comments(note condition of soil, signs of hydraulic failure, level of ponding, conditionlof'vegetation,
etc.):
Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.): .
t5ins•3/13 Title 5 Official Inspection Form: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
GM , 53 MEADOW LARK
Property Address
PAUL H AUSTIN REV TRUST '
Owner Owner's Name
information is required for OSTERVILLE MA' 8-12-13
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
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 water supply enters the building. Check one of•the boxes below:
❑ hand-sketch in the area below {
® drawing attached separately -
r .
l5ins•3/13 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
M 53 MEADOW LARK
Property Address
PAUL H AUSTIN REV TRUST
Owner Owner's Name
information is required for OSTERVILLE MA 8-12-13
-
every page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
® Surface water
Check cellar
® Shallow wells
Estimated depth to high ground water: AT LEAST 5
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(abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health-explain:
• 1 •
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USES database-explain
You must describe how you established the high ground water elevation:
ABUTTING PROPERTY
y
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins-3/13 Title 5 Official Inspection Form:Subsurface 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 53 MEADOW LARK '
Property.Address
PAUL H AUSTIN REV TRUST
Owner Owner's Name
information is required for OSTERVILLE MA 8-12-13
every page. Cityrrown 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 System either drawn on page 15 or attached in separate file
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
f
Assessing As-Built Cards Page 2 of 3
- T-�
- TOWN OF $ARNSTABLE Ur J, -
LOCATION-°S3 . SEWAGE #
VILLAGE o ASSESSOR'S MAP& LOT
INSTALLER'S NAME PHONE NO.
� / pia• —S��o
SEPTIC TANK CAPACITY '/, -5-r27
LEACHING FACILITY:(type)_ t, 0 0 0 ` (size)
NO.OF BEDROOMS 3. PRIVATE WELL OR PUBLIC WATER
BUILDER OR OWNER
DATE PERMIT ISSUED: 5-
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No
r
a C
a
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http://www.town.bamstable.ma.us/Assessing/HMdisp'lay.asp?mappar=117028&seq=1 8/12/2013
COM11V'1ONWEEALTH"OF•MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
ONE WINTER STREET,BOSTON MA 02108-(617)292-5500
TRUDY COXE
- Secretary
ARGEO PAUL CELLUCCI DAVID B. STR UHS
Governor Commissioner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A t
LL CERTIFICATION Property Address: 3 / l�rGnuto �. rC�� Name of Owner ^ gr/��l
Nr mass /
Address of Owner: 5:3 dies ` - a p* R.1
Date of Inspection:
Name of Inspector:(Please Print) ff /7 c,
"Tam a DEP' owed system inspect to Section'15.340 of Title 5(310 CMR 15.000)
Company Name: ol,Nd for S�Yvl�o
Ma&v Address: W,/1s /t/Q
Telephone Number: g !6f-,20—v{�=6�5 9 C
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 tlme'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:
KPasses
_ Conditionally Passes
Needs Further Evaluation By.the Local Approving Authority
_ Fails w r
Gru s Sigrurture: C 'f� Date: ' r 00
Tbd,_System Inspecto 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 Environmental 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
Y2 0
3
104. -
Ft <0000
revised 9/2/98 Pagel of11
i�!Printed on Recycled Paper
F
y
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
:J, ::'. .:;.c�nFlcanoN(corttirxred)
PropertyAddre":,
Owner: er/ ,S's •tilead .•L.,.h �d::os/�Y.��71�, �, .
42r r M4 tS
Date of Inspection. g
S 3-
. INSPECTION SUMMARY: Check A, B, C, or D:
A. SYSTEM PASSES:
Y I 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: `
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 pipes)
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 2of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
f, PART A .
CER—TIFFIIC-ATION(continued)
Property Addres A4,e r j.,.r/I,*ek. Rd
Owner:
Date of 4upe�bo c.r IW4
CPO
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. I
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WfTH 310 CMR 15.303(1)(b)THAT THE SYSTEM
IS NOT FUNCTIONING W 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 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 W A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet 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
?�...'� PP Y Y � 9 P
'�;?':• 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
s
.. £
revised. 9/2/98 P2ge3of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Addres
Owner; 17--Zaeo. ^
tr
Date of Inspection: �`'�' SS r Cu
D. SYSTEM FAILS:
You must indicate either "Yes" or "No" to each of the following:
I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this
determination Is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure.
•• �� rJfnlff�,i ,C (",`--Zr,'i 1 -, .
Yes No I+ , ; ::, .• er.
Backup of sewage into facility or system component due-to an overloaded or clogged SAS or cesspool.
Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or 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 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 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
ceptable water or privy is less than 100 feet but greater than 50 feet from a private water supply well with no
acr,quality analysis. If the well has been analyzed to be acceptable, attach co
coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. py of well water analysis for
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.
revised 9/2/98
Page 4 0(11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART 8
CHECKLIST..
Property Address: .7 3
Owner:
Arfikl�,. �tiss���fr
• Date of Inspection:
Check If the following have been done:You must indicate either "Yes" or"No" as to each of the`following:
Yeses No
1/ Pumping information was provided by the owner,occupant, or Board of Health.
None of the system components have been pumped for-at least two weeks and-the system has;been-receiving normal flow
rates during that period. Large volumes of water have not been Introduced into the system recently or as part of this
Inspection.
_ 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.
v _ The system does not receive non-sanitary or industrial waste flow.
_ The site was Inspected for signs of breakout.g
Y _ 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
Of teas,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.O.H.
�-•::_ Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable)
r,x ' 115.302(3)(b)]
_ The facility owner(and occupants,if different from owner) were provided with information on the proper maintenance of
SubSurface Disposal Systems.
revised 9•/2/98 page s of 11 ` ,
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property A ddress: 3 /y1�ta�aw�✓k 1po� CJS�//����� tea.
Owner:
Dots of Impaction:
Si S`i(�V FLOW CONDITIONS
RESIDENTIAL:
Design flow: /10 g.p.d.lbedroom.
Number of bedrooms(design): Number of bedrooms lactuaU:3
Total DESIGN flow 6A?
Number of current residents: I—L
Garbage grinder(yes or no): r!
Laundry(separate System) (yes or no): if yes,separate inspection required
Laundry system Inspected (yes or no) vi M h�� 40,L,.h
Seasonal use(yes.or no):_ Ad 9$: y-9' as�w,��N�
Water meter readings,if available(last two year's usage(gpd):
yQs >>59
Sump Pump(yes or no):, �o
Last data of occupancy:—ZE�-Vl`r
COMMERCIALIINDUSTRIAL:
Type of establishment: '
gad ( Based on 15.203)
Design flow:
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 motor readings,If available:
Last date of occupancy:_._..__
OTHER:(Describe)
Last date of occupancy:_ GENERAL INFORMATION
PUMPING RECORDS and source of information:
�ti.Ir.��a.•� �,QVlV H
System pumped as part of inspection:(yes or no)�
\ It yes,.volume pumped: _gallons , .}
Reason for pumping:
ins �� c'
TYPE 0 SYSTEM
Septic tankidistributlon boxisoil absorption system
Single cesspool
Overflow cesspool
_ Privy
Shared system(yes or not (if of ue attach
dateious inspection records,if operation and maintenance contract
_ I/A Technology etc.Attach copypy P
Tight Tank Copy of DEP Approval
Other
APPROXIMATE AGE of oil component ,date installed(if known)end source of information:
a$a�tl4 when arriving at the site:(yes or no) rYO
Pa§e 6 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
. PART C
F.. SYSTEM INFORMATION(continued)
Property Address: �a1k ks( 6?i;!I'V/f�4� Au
Owner: tvCA-Iry 10 40;e0 r-
Date of Inspection:
BUILDING SEWER:
(Locate on site plan)
'1
Depth below grade:ley,/
Material of construction:_cast iron__(4�PV� other(explain)
- ~Distance from private water supply well or suction line. ,.;..
Diameter ,. V r.. .. , ,
Comments:(condition of Joints,venting, evidence of leakage,-etc.)
.
SEPTIC TANK-._
(locate on site plan) .,
Depth below grade: /6
~Material of construction concrete metal_Fiberglass _Polyethylene_•other(expiain)
If tank is metal,list,age_.13.age_confirmed by,Certifcate_of Compliance (Yes/No)
Dimensions.
Sludge depth:
• outlet tee or baffler
Distance from top of sludge to bottom of
Scum thickness: 5rr y
Distance from top-of scum to top of outlet.tee or baffler_
Distance from bottom of scum to bottom of outlet tee or baffle: 2/
How dimensions were determined: A4214S6160.0, JPc
Comments:
`irecommendation for pumping;'condition of inlet and outlet tees or baJfl , depth of,liquid level in relation to outlet invert,structural integrity,
�;�v�dence of leakage,etc.).... Re don+ hrp�+c� "/JNr'✓Jr" {"/twos D""C
GREASE TRAP:
(locate on site plan)
Depth below grade:_
Material of construction: concrete_metal '_Fiberglass _Polyethylene_other(explain)
Dimensions
- Scum thickness: .. w
_..Distance from top of scum to top of outlet tee or.baffle:
_Distance.from bottom"ofrscum to bottom of outlet tee or baffle:
of last pumping
Comments:
(recommendation for pumping,condition of inlet and outlet toes or baffles,depth of liquid level in relation to outlet invert, structural integrity,
evidence of leakage,etc.)
revised 9/2/98 Page7orll
'.,,,,SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEMININFORMATION(continued)
Property Address: .,f"3�Yleavlo�v�r'l�' Iler
Owner: �j- j�yj /fifi►fs� Co
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.)
DISTRIBUTION BOX:_
(locate on site plan)
Depth of liquid level above outlet invert: 49 rr
Comments:
(poia.if level annd_distribution Isbbe ual, evidence of solids carryover evi e�n�a of leakage a into or out of box, etc.)
. ,,fi•,4. ... .�-L� ..-�,n Q., So�."sl i
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 8ofll
'.A'-HSUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORM
NFOR 7IO�N(corfmod)
Property Address: �3 �4td.,4&A �� 4• rv�''" /„�%`
Owner:
Data 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: /
�P4c� .dI/ /S GJH�Iy ,OAyed. pYrlit I.I/�y c8-�IG QCJytrn /p 91Y.��
Type:
leaching pits,number: %
leaching chambers,number:
leaching galleries,number:_
leaching trenches,number,length:
leaching fields,number, dimensions:
overflow cesspool,number:_
Alternative system:
Name of Technology:
Comments:
Inote condition.of soil, signs of hydraulic failure,level of ponding, damp soil, condition of vegetation; etc.) :
. CESSPOOLS _
(locate on site plan)
Number and configuration:
Depth-top of liquid to Inlet invert:
Depth of solids layer.
Depth,of scum layer:
Diftlfrns)ons of cesspool•
Matouals of construction:
Indication of groundwater.
inflow (cesspool must be pumped as part of inspection)
Comments: .
(note'condition of$oil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.)
PRIVY:
(locate on site plan) r�
Materials of construction: G. Dimensions':
Depth of solids:
Comments:
(note condition of$oil, signs of hydraulic failure,level of ponding, condition of vegetatlon, etc.)
revised 9/2/98 Page 9eru
,SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART.C
/ L p„>;SYSTEM.WFORMATION(continued)
Property Address:
Owner: �ysrf4Sf�CDI/
Date of Inspection:
s-s=oa
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)
8't
2�6,, �16
FL
4 ,•To
V�7
7o Gow 4#r
Ll
revised, 9/2/98 Page 10of11
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TOWN OF BARNSTABLE
LOCATION Zdr- SEWAGE # 71— 3 S7
VILLAGE L ' ASSESSOR'S MAP & LOT 612
INSTALLER'S NAME & PHONE NO.
SEPTIC TANK CAPACITY Pr S'b rs_4
LEACHING FACILITY:(type)f,o a e 3 14;tFY1A (size) A b
NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER
BUILDER OR OWNER ten/' cC.w
t{7 3-- tie 413
DATE PERMIT ISSUED: q�"/ ^Q 3ir3'- a 5,5'7
DATE COMPLIANCE ISSUED; D-- 3
VARIANCE GRANTED: Yes' v No
cQ �
a
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
/ SYSTEM INFORMATION(continued)
Property Address: f3 /fiJ epo�vry �� /Q�Q e9ske`41%71Q IYu.
Owner:
NY
Date of Inspection: �aSS/Co
S=0a
NRCS Report name
Soil Type_
Typical depth to groundwater
USGS Date website visited
Observation Wells checked
Groundwater depth: Shallow Moderate Deep
SITE EXAM Slope
Surface water
Check Cellar
Shallow wells
Estimated Depth to Groundwater `1 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.)
Determined from local conditions
Checked with local Board of health
Checked FEMA Maps
_T Checked pumping records
Checked local excavators, installers
P
IL Used USGS Data
Describe how you established the High Groundwater Elevation. (Must be completed)
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