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HomeMy WebLinkAbout0007 NECK POND ROAD - Health 7 Neck Pond ,Road Osterville P A = 140 092 TOWN OF BARNSTABLE LOCATION. eCV Pyp d Rd SEWAGE # VILLAGE C�)Sk0%-Vi1N IF-4 ASSESSOR'S MAP & LOT INSTALLER'S NAME & PHONE NO. SEPTIC TANK CAPACITY �"1•�S�1nq �`�SC �e LEACHING (size) NO. OF BEDROOMS, PRIVATE WELL O WATE BUILDER OR OWNER L-aSS DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANC ANTED: Yes No n�1 l r� o 4 'I^•9 l I \l �� I{s y • !� "' .'� '��._. V� �� COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS -DEPARTMENT. OF ENVIRONMENTAL PRO _CT ' — t - RECEIVED J U L 3 n 2003 aA1%-;TA6LE HEALTH DEM:) TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address:. (44 pro 0/ Owner's Name: Owner's Address: MAP Date of Inspection: PARCEL Name of Inspect%leaset) ACTCompany NameMailing Address Al/4 60( _,/E Telephone Number: [ . CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information r ported 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 pursuan7passes ection 15.340 of Title 5(310 CMR 15.000). The system: Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fai1_s,:. Inspector's Signature: Date: —11d 703 The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Heald 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 ofthe 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 ****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. Title 5 Inspection Form 6/1.5/2000 pace 1 i Page 2 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Owne _ Date of Inspection: Inspection Summary: Check A,B,C,D or E/'ALWAYS complete all of Section D A. System Passes: I have not found any information which.indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes, no or not determined(Y,N,ND)in the for the following statements. If"not determined"please explain. The septic tank is metal and over 20 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 ofsewaae 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: . 2 Page 3 of 1'1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART'A CERTIFICATION;(continued) Property Address: Jaf"� Owner' Date of Inspectio co C. Further Evaluation is equired 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 soii.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 l 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: 3 Page 4 of 1 I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: Owner: Date of Inspection: �P�c�'j 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 V Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or / cesspool _ V Liquid depth in.cesspool is less than 6"'below invert or available volume is less than '/2 day flow J� Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number ' / of times pumped 1VV 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. V 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 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.] (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.systemahe 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 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. 4 L Page 5 of 1.1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ` ., PART.B CHECKLIST Property Address: Owner: Date of Inspection: U Check.if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes �Io c/ Pumpins.information was provided by the owner,occupant,or Board of Health /Were,any of the system components pumped out in the previous two weeks Has the system received normal flows in the previous two week period? Have large.volumes of water been introduced to the system recently or as part of this inspection? Were as built plans of the system obtained and examined?(If they were not available note as N/A) _ Was the facility.or dwelling inspected for signs of sewage back up? Was the site inspected for signs of break out? V — 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: Yes no _DeteExisting information.For example,a plan.at the Board of Health. . rmined.in the field if any of the failure criteria related to Part C is at issue approximation of distance _ ( Y I is unacceptable) [310 CMR 15.302(3)(b)] 3 Page 6 of 1 l OFFICIAL,INSPECTION-FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C • - SYSTEMINFORIVIATION • Property Address: r • Owne . 12 Date of Inspection: FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):a Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203 for example: 11:0 op x#of bedrooms): Number of current reside n : Does residence have.a garbage grinder(yes or no Is laundry on a separate sewage system (yes or no [if yes separate inspection required) Laundry system inspected es or no Seasonal use:(yes or no: Water meter readings, if�illabllet 2 years usage(gpd).):QSump pump(yes or n Last date of occupa cy: ( COMMERCIAL/INDUSTRIAL Type of establishment: Design flow.(based on 310 CMR.15.203): gpd Basis of design flow(•seats/persons/sgft,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 C Source of information: Was system pumped as part of thd inspection<yes or If yes,volume pumped: _ gallons--How was quantity pumped determined? Reason'for pumping; TYP OF SYSTEM _IZSeptic tank,distribution box,soff 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 DER approval Other(describe): Approximate age of allzomponents dat installed(if known)and source of information: Were:sewage odors•detected when arriving at the site.(yes or no): 6 Page 7 of i 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: —7 &o-4, Owner Date of Inspection: -Q3 BUILDING SEWER(locate on site plan)" Depth below grade: Materials of construction:_cast iron 40 PVC_other(explain):- Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage, etc.): SEPTIC TANK:Zlocate on site plan) Depth below grade: ijW Material of construction: ncrete_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: S X C P, K S Sludge depth: 7, 't 3 -. // Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: © 11 Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom f outlet tee or baffle: How were dimensions determined: &o Comments(on pumping recommendations,Inlet and outlet tee or baffle condition,structural integrity, liquid levels (nyelated to outlet invert evidence of leakage,et r J GREASE TR�(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.): 7 Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C. SYSTEM INFORMATION(continued) Property­Address: Owne - Date of Inspection: 3 TIGHT or HOLDING TAV�(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:- (if present must be opened)(locate on site plan) Depth of liquid level above-outlet invert: Comments(note,if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of kage into•or outof box, etc.)• - �� �, J PUMP CHAMBER: locate on site plan) Pumps in working.order(yes or no): Alarms in working order(yes or no).: t Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): 8 �e 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: OQC Owne Date of nspection: SOIL ABSORPTION SYST M (SAS): (locate on site plan,excavation not required) If SAS not located explain why: Type leaching.pits,number:_ 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.). 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 or no): ' Comments(note condition of soil,signs of hydraulic failure,-level of ponding,condition of vegetation,etc.): PRIVY. }—(locate on site plan) aterials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 9 Page 10 of l l OFFICIAL INSPECTION FORM=NOT FOR-VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:. 12etozA pad Owne Date of Inspection: C)W 2 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 I00 feet. Locate where public water supply enters the building. a V 1 Vo i9 %U 0 0 10 Pace 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: -7 1�tL IJ6-w,�Pna ILIA Owner. ^, � Date of Inspection: l� SITE EXAM Slope Surface water Check cellar Shallow wells i Estimated depth to around water feet Please indicate(check).all methods used to determine the high around 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) Accessed USGS database-explain: You must describe how you established the high ground water elevation: 11 Permit Number,* . Date. Completed by: NIGH GROUND-WATER LEVEL COMPUTATION Site Location: mot/�i C � � /�(�L i' ' �s6�L✓f�<�Lot No. Owner: 3 15e Address: Contractor: Address: &Lo— Notes: STEP 1 Measure depth to water*table to nearest 1/10 ft. ......................... Date t_L� month/day/Year STEP 2 Using Water-Level Range Zone and;Index Well'Map locate site and determine: A Appropriate index well............................l.C.�./..!� ........ �J�— OWater-level range zone.................................................:.:..... � STEP ; Using monthly report 'Current I Water Resources Conditions" �. determine current depth to �� /3 water level-for index well 60 I i month/year, STEP A Using Table of Water-level ,adjustments ;or index well (STEP 2A), cun.ent depth to water1e*vel for index.well (STEP 3)., -and water-level zone (STEP 26) determine water-level adjustment............... .............:.............................................................. ,�Z STEP 5 . ..Estimate depth to hi.gh'water by subtracting the water- - level adjustment (STEP 4) _ srom measured'depth. to water level at site (STEP 1)'.:.................'.................::.....•.:....`......................... lz' ) Figure 11--Reproducible computation form. .r � ram•_s. E • Y y 1 } F R` • E 3 �q % f - � 4 _f •' 5 }' # 4 � s e • ii a i � • V% i j 1 5 } UD COMMOIv ALTH OF MASSACHUSETTS T EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL TROTECTION ONE WINTER STREET, BOSTON MA 02108 TRUDY COXE Secretary ARGEO PAUL CELLUCCI DAVID B. STRUHS Governor 1 :+:.'i P Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART A- )). ,.,_(.)_/��, CERTIFICATION . Property Address: 7 ry•�� P�"� /'� Name of Owner pv,//w All, Address of Owner: 7 wss0 Date of Inspection: 99 y.� ��11 Nam_a of Inspector:(Please Print)- Phh -17. AGt I am a DEP approved system i pect pu{suartt to.Soction•15.340 of Trtfe 5t(310;CMR,15.000) Company Name: . ' h /la It Iad, SeevrC� Marring Address: /$1 walma c i,S AiS ahs_ t/J�/i.: is E Telephone Number:, 57a2 —442 FLT9s CERTIFICATION STATEMENT .'- I certify that(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: asses Conditionally Passes,. _ Needs Further Evaluation By the Local Approving Authority F 'Is i p� Inspector's Signature: !/f Date: ,5 "t"�.i; TheS'ystem Inspector all 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 �1 1 NOV 2 1999 0' t e C> revised :9/2/98 Page l of tl ��! Printed on Recycled Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM + .. . .'. :. _. .. _ r PART A .... �. •.'.(j A p4; �— CERTIFICATION (continued) i Property Address: 7 Owner: ,�Y/GH 9LHH irrll�:. GSS, a Date of Inspection: INSPECTION SUMMARY: Check A B Cof A A. SYSTEM PASSES: 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: � k 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 replacemenYor.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 systern,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 spproved'by the Board of Health:`" 5 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 r 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 PART A �- CERTIFICATION(continued) � Property Address: -7 IV" A� R- o T_,-,-/l���• Owner: Date of Irupection: /— 4 9 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 IN ACCORDANCE WITH 310 CMR 15.303(1)(b)THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of surface water Cesspool or privy is within 50 feet of abordering vegetated wetland or a salt.marsh. t � it-.�• ... .4'%lwf '"T �."�3 L . it.. - 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 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 well is free from pollution from that facility and the'presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine distance (approximation not valid). 3) OTHER revised 9/2/98 , Page 3of11 r• SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART•A CERTIFICATION(continued) Property Address: t Owner: Date.of Inspection: s } D. SYSTEM FAILS: You must indicate.,either.."yes",or"No",to each of the following: J 1 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. Yes.., No. 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. Q• -_ ;Any portion of a cesspool or pnvy.is less-than 100 feet but greater than 50 feet from a private water supply well with no -y ti - acts table water quality analysis. If the well has been anal zed to be acceptable, attach co of well water analysis for : .,e4{;Y,. : ;,,,,,, P q Y. Y Y P PY Y U ;coliform bacteria,volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E. LARGE SYSTEM FAILS: following:each of the o"o You must indicate either "Yes".or"No" t , • 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 II 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 _, :Page4of11 • ,SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM 'PART B CHECKUST, " Property Address: 7 Al-'c P � RAP Owner: QQ 7pHH t Date of Inspection: , 11-1-99 Check if the following have been done:You must indicate either"Yes" or'"No":as to each of the following: Yes No r _ Pumping information was provided by the owner occupant or Board of Health. , t/ • _ None of the system components have been pumped for-at least two weeks and-the system has been receiving1tormal 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 NIA'.- The facility or dwelling was inspected for signs of sewage back-up. The system does not receive non-sanitary or industrial waste flow. ` Insp ected for signs of breakout* site was 9 The P All system components,excluding the Soil Absorption System,have been located on thesite. The septic tank manholes were uncovered,opened, and the interior of the septic tank was inspected for condition of baffles or tees,material of construction, dimensions,depth of liquid, depth of sludge, depth of scum. The of the oil AbsVvon Sys mon the site has been determined based on: s�Ni�r Qlaa o/s Y+li ll� � R O� (/ Existing information. For example, Plan at B.O.H. at Determined in the.field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable) , (15.302(3)(b)1 The facility owner land occupants,if different from owner) were provided with information on the proper maintenanceaf SubSurface Disposal Systems. _• ru �,: a. r ,hk} M1_ *+zt rdt7i�• ,•.97.. ';#.'. #Sr' .:'#. . i 't-_. ,. .. �`� . .. , revised '9/2/98 Pages of11 ' i iSURSURFACE SEWAGE DISPOSAGSYSTEJM INSPECTION FORM 1PART C SYSTEM INFORMATION 7 AWC, Po l.of Rol ©s Property Address: . /� � •..( ,., F Owner: �- 4 �/�H/TPI- last Data of hu on: l 9 FLOW CONDITIONS RESIDENTIAL: Design flow:310 g.p.d./bedroom. Number of bedrooms(design): ';Number of bedrooms(actual): 3 Total DESIGN flow :1�10 : Number of current residents: 4 Garbage grinder(yes or no):_&p o : :. V.: a :.•.r. } Laundry(separate system) (yes or no)* If yes, separate inspection required Laundry system inspected .(yes or no) t': Seasonal use(yes or no):--A�P,l ., : • r. i ,, _ p Water meter readings,If available(last two year's usage.(gpd): 97= i0y006 9�= 9p �1Dp Sump Pump(yes or no):_I& r1 / Last date of occupancy:_Q,g"�4ey r .. COMM ERCIAUINDUSTRIAL: Type of establishment: Design flow: oad ( Based on 15.203) :. . . Basis of design flow Grease trap present: (yes or no)_ �•y•,Y, Industrial Waste Holding Tank present: (yes or no)_ Non sanitary waste discharged to the Title 5 system:.(yes or.no)_ x • Water meter readings,if available: Last date.of occupancy: =iw ..{,;,, OTHER:(Describe) Last date of occupancy: GENERAL INFORMATION PUMPINPvRECORDS and source of information: . ;System pumped as part of inspection: (yes or no) ,a °''yes, volume pumped: gallons> .r;7 . •u 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) I/A Technology etc.Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other APPROXIMATE AGE of all components, date installed(if known) and source of information: Sewage odors detected when arriving at the site: (yes or no) 1 revised 9/2/98 Page 6of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM .. ':.PART C .> SYSTEM INFORMATION(continued) Property Address. ' ech 1004 Owner: Date of Ins on: .. BUILDING SEWER: (Locate on site plan) ; Depth below grade: Material of construction:_cast iron_40 PVC' other,(explain) Distance from private water supply well or suction line Diameter 9' a Comments: (condition of Joints, venting, evidence of leakage,etc.) SEPTIC TANK: (locate on site plan) Depth below grade: /y�r Material of construction: concrete metal_Fiberglass _Polyethylene._other(explain) It tank is metal, list age_ Is:age confirmed by Certificate of Compliance_(Yes/No). Dimensions: Sludge depth: • Distance from top of sludge to bottom of outlet tee or baffle: ?;F Scum thickness: Distance from top of scum to top of outlet tee or baffle: 1!� ,. i n ,0 sta ce from bottom of scum to bottom of outlet tea or baffle: l9 How dimensions were determined:_ /"644r % MaG'suri�� Rss� Comments: W r« t ;:,;; lrec9timgtendaLon for pumping;,conditior�of inlet and outlettees or baffles, depth of liquid,Iwel in'relatiori to outlet invert;`structural integrity, evtaience of I kage, etc T n/� 7`r+h cfiD�iia� }it3��'gclor�T GREASE TRAP: ^ - (locate on site plan) Depth below grade_ Material of construction:_concrete_metal_Fiberglass _Polyethylene_other(explain) Dimensions Scum thickness: Distance from top of scum to top of outlet tee.or baffle: Distance from-bottom of scum to bottom of outlet tee or baffle: , Date of last pumping: Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage,etc.) revised •9/2/98 Page7of11 T r t SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM s PART C SYSTEM INFORMATION(continued) Property Address: .f 1t ch(rAhJ �j� ©s v/`��� /Y/�i.` t Owner: )/<.•� Gr- NniI� 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) i Depth of liquid level above outlet invert: Comments: (not, jf.level and distribution is equal evideJn�ce ppf sQpI'd carryover, evidence of leakage into or out�Q/f box, etc.) - ''+ —/3L7J[ drS/ribu LJ2alvS7F" L�Gk[a / unitZaf G K 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 8of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM .�.. _ PART Cl'•: / SYSTEM INFORMATION(continued) Property Address: Owner: �Y/aN :?.- Date of Inspection: 99 t SOIL ABSORPTION SYSTEM(SAS):_ (locate on site plan,if possible;excavation not required,location may be approximated by non-intrusive methods) If not located, explaip: LoCrcoh o� 7�2/d C/Ohe G✓/�7i� �/-ob .� Y.Or/, QS �arIt��A�s Type: leaching pits,number:_ leaching chambers,number:_ ' leaching galleries,number:_ leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number:_ Alternative system: �, ,q P//rmiZ t Name of Technology: a,l:�/xa m.�c w/�L .67oy♦�r�k Comments: � (note 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 Dimensions of cesspool: Materials of construction: InOiSatlon of groundwater: x 4 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 site plan), Materials of construction: ) i Dimensions: Depth of solids: Comments: (note condition of soil,signs of hydraulic failure,level of ponding, condition of vegetation, etc.) revised 9/2/98 P2ge9of11 SUBSURFACE SEWAGEDISPOSAL SYSTEM INSPECTION FORM 0 �S-YSTEM/INFORMATION(continued) Property Address: i Owner: Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: Include ties to at least`two permanent.,ref erence.landmarks or,benchmarks ,.,.;�� locate ail wells'withiri 100"(Locate where public water supply comes into house) 0 (vVlr �:1 8 u r 176 �3 II revised -9/2/98 Page 10of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 7 Allec h / ,P-4 el RAQ/ ©ile (/,/14. Ida, Owner: ar7ak7 9F- T-enklo7-ev Z s s Date of Inspection: NRCS Report name Soil Type_ Typical depth to groundwater USGS Date website visited Observation Wells checked Groundwater depth: Shallow Moderate Deep SITE EXAM Slope Surface water Check Cellar Shallow wells Estimated Depth to Groundwater 30 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 '(,hacked pumping records /x­lChecked local excavators, installers Used USGS Data Describe how you established the High Groundwater Elevation. (Must be completed) dj 9YvuA®Cla�GlGv � 7 ; s 4h C. 5 revised -9/2/98 Page 11of11 TOWN OF BARNSTABLE 1.6CA404 gC e ,yd /R SEWAGE # 3 VILLAGE _ -r J2(�i ASSESSOR'S MAP & LO'T� INSTALLER'S NAME & PHONE NO. aeumlL5, (� SEPTIC TANK CAPACITY LEACHING FACILiTY:(type) -//p/ ;// ,Q �,I" (size) NO. OF BEDROOMS _PRIVATE WELL OR PUIC WATER BUILDER OR OWNER &/A)0 DATE PERMIT ISSUED: ,i!E: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No C� M 1 ,3 C� z Z � � tw a � vl w 1 I Lf 0 , bG No... S v � F.�$..... .. .... THE COMMONWEALTH OF MASSACHUSETTS . Bar' - BOARD OF HEALTH ?TOWN OF BARNSTABLE s1--ei Applir Nt fur Diripniial Wurk,i Tomitrnrtinn 1hrmit Application he ��de fps a Permit o Construct O or Repair ( ) an Individual Sewage Disposal System at: • .......... ......... y --•--- 4 Location-Address — or Lot No. FL1..A 5-------------------------••--•••••••--------•-•--•..... -... -1_�n'.A'1-----�1 6�------�5_ d"��?t_t'1 ,..... - owner A ess a nstaller Address UType of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms------Y-----------------------------------Expansion Attic ( ) Garbage Grinder ( ) p•, Other—Type of Building ............................ No. of persons---------.---------_----- Showers ( ) Cafeteria ( ) a' Other fixtures ------------------------------- - - W Design Flow............................................gallons per person per day. Total daily flow.................._.........................gallons. WSeptic Tank—Liquid capacity���d..gallons Length................ Width....-..-:-.----. Diameter---.------------ Depth................ x Disposal Trench--No. .................... Width.................... Total Length.................--- Total leaching area....................sq. ft. Seepage Pit No--------------------- Diameter.---------_-_---- Depth below inlet..--................ Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) a Percolation Test Results Performed by----------------------•-......-••-•------------------ -•••----•••-----••.. 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.------.-.-------.-. Depth to ground water........................ P4 ........................................0............... y' 0 Description of Soil...........-.................. -A !d.l. .. ' J 1��,� -•••-•......•. ...........................•----•--••--•-•......--------•-- ...------••... ••-••--•----.......------. -•--•••........ ••.. .... .............--•-•- ----- - ------ ----- U Nature of Repairs or Alterations—Answer when applicable------ OW------- j.....-S .a I.S,.....l.N. .... .-•.---••--_------- 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 Compli ce has been iss by the board of health. Signed . .. ............... ............ ...............:......................... Dace Application Approved By -----------. - .. �.�-•-"""� = e 3 Application Disapproved for the following reasons: ..... ........ ... ..... ................. ........ . ..... . .............................. ........... ....................... ........ ........ ............................................................ ............ ... ....... ................. Permit No. .........�� .. .... .5..... .... Issued .......................................................�[e..... Dace �,X..- �.��-+�...L,._�%''�, ,'....-�„}- ...... -...:..;�a.,..,r.��.u.: �..+v7,:.•:...'S}':`.f'L�r.V��au�L..e:.:,'.1:..`�,,.�Lis .- ' aiv;,:-.-r..: .. � K...-_..-..•,_..-.. _ .... - THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH _2_ ,g3TOWN OF BARNSTABLE ,C Allp iratinit for Diripw3al lVnrk,i Tonfitrnrtion Prrmit Application 7s hereby made fo ajPermit to Construct (>() or Repair ( ) an Individual Sewage Disposal System at: ......................................................; Location-:\d iress -� — or ,No.Lot 1 >..A�:_._._.�./a�f----.---•------•-------------------------------------- ,.� ------C�: �s � �./4........------ O�r Owner �� A�1 dress ./ W /� /V Installer Address Type of Building Size Lot............................Sq. feet .� Dwelling—No. of Bedrooms.....X-----------------------------------Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building --------------------- ------ No. of persons.----_-----------..-------- Showers ( ) Cafeteria ( ) d Other fixtures ------------------------------------ ---------- W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity/DO0-.gallons Length................ Width....-..--------- Diameter................ Depth................ x Disposal Trench No. ................ Width-------------------- Total Length...............----- Total leaching area....................sq. ft. Seepage Pit No..................... Diameter.----_--.--------- Depth below inlet.................... Total leaching area..................sq. ft. z Other Distribution box ( ) Dosing tank ( ) , : . Percolation Test Results_ Performed by----------------------- .................................................. Date Date.-------------------••••---••--••---•-- ,� Test Pit No. I................minutes per inch Depth of Test Pit.....-------------------- Depth to ground water........................ L74 Test Pit No. 2................minutes per inch Depth of Test Pit..............--.... Depth to ground water........................ 9 ......•......................................................... I........................................................................................... D Description of Soil f- v-------------x U ---••---•--••.....•----•••••---------------•---............--------•-------•-• =--------.........•---••---- ............................ W x ---------------------------•----------------...•-•-----------------------------..........------------ ••--•-------------------------•-----••------•-•----------•--- U Nature of Repairs or Altteradons—Answer when applicable......,aw........ . . ..... 5/� 1.-'c ...7A..h-k.................. e. ------•-------------------------••-••----- --•-------------------....---••----•---------------••-•---•---••-------•----•---................ 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 Complia ce has been isspc by the board of health. Signed .:- ---- --- -- C �M.�-Y'�- --------------------------- ----6..........>.. .�� Dace ApplicationApproved By --_-------- ..e. ...... .... ...c"` .............................................................................. ..----G....: Application Disapproved for the following reasons: .. .................. .............. ............ . ....................................... .... ................. . ... ....... .......................................................... .................................... . .................................................. ........................................ _ Dace Permit No. ......... ..-.....� .,_�.....!�.............. Issued Dare ---------_____--.__ l.___—_....____.__.__.__._.—_.__.______.__ - THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Cer#ifi ate of Complianre THI)IS TO CERTI,�X, That the Individual Sewage Disposal System constructed ( ) or Repaired n,wuer / --..O.S. fi ---------------------------------------------.....------------------- at ..... ... ... .. .. .... ! �L../`'....- ..... �. `ll �. .... has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in the application for Disposal Works Construction Permit No. ----..73 R... fated .._._.. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE.... -- ........... �-- Inspec ..............._.. ....._ ------------------------------------------------------------------------ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH qq v TOWN OF BARNSTABLE N0.... FEE_3��.....- Dispoli Workii Tonot ton rrmit Permission is hereby granted---•• a �NYI".,/ -------- ---------------------------------------------- 1 to Construct ( ) or Repair ( ) an Individual Sewag�isposal Sys�temo atNo. r '�P-� ---•--.. ....------.... ��- A1--------------------------------- ----------------------•--.......-- ' Street �. as shown on the application for Disposal Works Construction Permit No./'3_.23...KDated........................................... ............................ ^' ...----------•-.... DATE------------------- ...............-.......... / Brd of Health FORM 36508 HOBBS&WARREN.INC..PUBLISHERS