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Home My WebLink About0009 NORTH BAY ROAD - Health 9 North Vay Road O terville A= 6� 7 No. 4210 1/3 BGR h ESSELTE 1 0% � O a 0 ��y\ � n � �c� �� C��u�� ° 4 ' COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A ' CERTIFICATION Property Address` i CZel ?GZL,EU �, Owner's Name: Owner's Address: s.��7�' Date of Inspection: Name of Inspect , please p int) i P0 �`(;)b' Of Company Name. ' Mailing Address: Telephone Number: 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 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 t Section 15.340 of Title 5(310 CMR 15.000). The system: Passes Conditionally Passes Nee Further Evaluation by the Local Approving Authority Pali s Inspector's Signature: Date: The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority: ._ v _Notes and Comments". . ... .__., �,.. .,..:.. �.��.,:. _.: ..... ..,.. : _ .. . _.... _,,, .z. � ... �..,�,..„. ......",,.. . . y' x.•s ""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 6/15/2000 page I Page 4.of I 1 OFFICIAL;INSPECTION FORM—.NOT FOR'VOLUNTARY ASSESSMENTS SUBSURFACE.SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART'A CERTIFICATION(continued) Property Address: h Owner: Date of Inspection: �(' D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No t� 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 J 'clogged SAS or cesspool °✓ Static liquid ldvel in the distribution box above outlet invert due to an overloaded:or clogged SAS or lcesspool Liquid depth in cesspool is less than 6"below invert or available volume is less than %z day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number Iof times pumped _ V 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. 4' 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 ofa.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 plum, 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 system the system must serve a facility with a design flow of 10;000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no the.system is.within 40.0 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. A Page 5 of 1 1 ` OFFICIAL INSPECTION FORM—.NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION TORM PART B CHECKLIST Property Address: AA Owner. I Date of Inspection: Check if the following have been done.You must indicate"yes" or"no".as to each of the following: Yes �o Pumping.information was provided by the owner,occupant,o-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 V Have large volumes of water been introduced to the system recently or as part of this inspection ? Were as built,plans of the system obtained and examined? (If'they were not available note as N/A) Was the facility or dwelling inspected for signs of sewage back up ? Was the site inspected for signs of,break out? _ Were all system components, excluding the SAS, located on site.? Were the septic tank manholes uncovered,opened, and the interior of the tank inspected for the condition _ P P I of t 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 j Existing information. For example,a plan at the Board of Health. (� Determined in the field(if any of the failure criteria'related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)J , 5 Page 6 of I 1 OFFICIAL INSPECTION.FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM,INFORMATION Property Address: C� Owner: Date of Inspection: FLOW CONDITIONS RESIDENTIAL Number of bedrooms(.design): Number of bedrooms(actual): DESIGN flow based on 310 C/MRR 15,203 (for example: 11.0 gpd x#of bedrooms): c i✓ Number of current residents: ifo Does residence have.a garbage grinder(yes or no): Is laundry on a separate sewage systejn,(ye :or no): .[if yes separate in&ion required] Laundry system inspected y s.or no); / Seasonal use. (yes or no): � v z€�Zfl �� Water meter readings, if a lable(last 2 years usage(gpd)): Joopo Sump pump (yes or no): Last date of occupancya4w4j COMMERCIAL/IND USTRIAL/\4 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 Source of information: Was system pumped as part of the inspection(yes or iio):'_ If yes; volume pumped: gallons-=How was quantity pumped determined? Reason for pumping: TYP OF SYSTEM T7 ptic tank,distribution box, soil absorption system _Single cesspool _Overflow cesspool _Privy _Shared system(yes or no)(if yes,attach previous inspection records; if any) _Innovative/Alternative technology.Attach a copy of the.current operation and maintenance contract(to be obtained from system owner) Tight tank _Attach a copy of the DEP approval Other(describe): (,(/,l,� %Q .� roxinlate gfall co t date installed(Awn a source of information Were sewage.odors.detected when arriving at the site(yes or no):-6 S 6 I Page 7:of 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: - ( f'y Owner: 6,_ 4 Date of spe BUILDING SEWER(locate on site plan)/ U 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.): i SEPTIC TANK:Zoocate on site plan:) Depth below grader of 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: Sludge depth: Distance from top of/sludge to bottom of outlet tee or baffle: 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: How were dimensions determined: ,P/rQ_ O AR" /,!d �(1 ,f Comments(on pumping recomme d is ons, inlet and outlet tee or baffle condition, structural integrity,liquid levels related to outlet invert evidence of leakage,et .)._ 0,/0 CUB ? 0..ry GREASE TRAPW (locate on site plan) Depth below grade:_ F 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) Property Address: 5&A Owner: I I v' (� Date of Inspection: :; I TIGHT or HOLDING TANK:/V( `tank must be at time of ins ection locate on.site plan) pumped P )( Depth below grade: Material of construction: concrete metal fiberglass, polyethylene otlier(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: t/ (if present must be opened)(locate on site-plan) Depth.of liquid level above outlet invert: .g� Comments(note if box is level and.distribution to outlet ual, any evidence of solids carryover.,any evidence of I akage into or out of box, e e , + 4-4 �117--eZ- l 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.):' R Page 9 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C . . 4 SYSTEM INFORMATION(continued) k Property Address:.J AwA 2�Q �O- Owner: Date of Inspection: SOIL ABSORPTION SYSTEM (SAS): - (locate on site plan,excavation not required) If SAS not located explain why: T/P , ching 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.): e ?a✓ 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: 3 Depth of scum layer:. Dimensions of cesspool: ' Materials of construction: 'j-_, Indication of.groundwater inflow:(yes or no)vJ Comments(note condition of soil signs of hydra lic failure, level of po ding cojidition ofvegetation,etc. PRIVY:/•l ) (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.): 9 Page 10 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY:ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Z �1 1JCt°; t U' Owner: fir? Date of Inspection: g� j SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent.reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. 5 0 1000 o(Q P 3e� a. ' Jt 7 in . Page 1 1 of I] OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: )Codel' Owner: „ �t Date of Inspection: SITE EXAM Slope Surface water Check cellar Shallow weiis J Estimated depth to ground water 11 C feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record -If checked, date of design plan reviewed: Observed site (abutting.property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with.local excavators, installers-(attach documentation) ✓Accessed USGS database-explain: You must describe how you established the high ground water elevation: 11 f Permit Number: 9 Date: Completed by: HIGH'GR ND-WATER LEVEL COMPUTATION _ OU Site Location: lJ�! / f ✓ r` Lot No. Owner: 2 /. Address: Contractor: AW /PA©,& l' _.iQW&59 Address: � 1 Notes: �✓jCr�uDl�'S �/7��5' STEP 1 Measure depth to water table s l to nearest 1/10 ft. ...................................................................... ........ Date month/day/year STEP 2 Using Water-Level Range Zone and Index Well Map locate . site and determine: r OAppropriate index well.........................................,......., ! OB Water-level range zone .........:....:...................................... STEP 3 Using monthly report "Current Water Resources Conditions" determine current depth to water level for index well .............:............. !•/ + month/year STEP 4 Using Table of Water-level Adjustments for index well (STEP 2A), current depth to water level for index well (STEP 3)', and water-level zone (STEP 2B) 1 determine water-level adjustment ................. r........:............................................................... r • STEP 5 Estimate depth to high water by subtracting the water level adjustment (STEP 4) from measured depth to water 1 ,z levelat site (STEP 1) :...............................................................................+............................ . s Figure 13.--Reproducible computation form. 15 t/ � l�p linx I...� © mil P IbO - - | - ^ ~ ' ^ � y 1 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM w PART CERTIFICATION ^ ^ ` / Property Address: Numn��Ownor . ' �. ' . . �� ) Date nfInspection: 7/31/00 � � ` Ad dress nfOwner: ' Name of | Edward P. Sjostedt ._--------------.-_^-_-.^-. |amuDEP approved Title 5(310 CMR15.000) -^�---'-----,------------' Company Name, K8uU�g�d�moxundTa�phona Number: ` ^ -----r'--- _ -�----- JEP£L-1uspmraboom]....Sarujcaa---------,-.`.----_=-.�_.--..�--__--^ ��5'@walJGatw-S1---_-----------.-.�---------____________._ Sailuwle,-NA....02D60...................................................... ----_-.----------'-- , - . ^ CERTIFICATION STATEMENT / certify that / have personally inspected the sewerage system at this address and that theinformation- reported below ix true, accurate, and complete oucd the time ofinspection. The inspection was performed based onmy training and experience in the proper function and maintenance ofunon��o ° sewage disposal system. The system: x Pa0000 Conditionally Passes . Need Further Evaluation By the Local Approving Authority . . FuUu __-----_ . . . . . ` Inspector's Signature Data: � The System Inspector shall submit a copy of this inspection report to the Approving Authoritywidh'ndhirty (3O)'dayuofcompiehngtho inspection. If the system ioa shared system or has o design flow of1O.UUOgpdorgreater,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 tothe � system owner with copies sent to the buyer, if applicable and the approving authority. ^ NOTES AND COMMENTS . �� the ��gm�a��m�b�un�ro�m�� Thn�undry��o�m��woou» �� dh dunou\in1hp�u�ome/�andionc�h�ding �u�' (g�y�a»�ok � deck. The mm n e the basement . � d � dwa�ru�ou|adon\ndico�pit would be6J7'above the that point. �oxuminguS'xD' \aaohingpi��wouuoa groundwater groundwater table. ~ ' ` r---�-- ' ' ' ' ' nevised 9/2/98 i ` SUBSURFACE SEWAGE_ DISPOSAL SYSTEM INSPECTION FORM 2 of 11 PART A CERTIFICATION Property Address: 9 North Bay Rd,Oyster Harbors, MA Owner Peter Cook Date of Inspection: 7/31/00 INSPECTION SUMMARY: Check A,B,C, or D A) SYSTEM PASSES x I have not found.any information which indicates the system violates any of the failure criteria as described in CMR 15.303. 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 or 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 owner or operator has provided the system inspector with a copy of a Certificate of Compliance(attached) indicated that the tank was installed within(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 conforming septic tank as I approved by Board of Health. Sewerage 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). Describe observations: broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced The system required pumping more than four times a year due tobroken 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 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A 3 of 11 CERTIFICATION (continued) Property Address: 9 North Bay Rd,Oyster Harbors, MA Owner Peter Cook Date of Inspection: 7/31/00 C) FURTHER EVALUATION IS REQUIRED BY THE BOARD. OF HEALTH: Conditions exist which require further evaluationby the Board of Health in order to determine if the system is failing to protect the public health, safety and the environment. . 1. SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEMIS NOT FUNCTIONING IN A MATTER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2. SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER,IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system and SAS is within 100 feet to a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and SAS is within a Zone 1 of a public water supply well. The system has a septic tank and soil absorption system and SAS is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and 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 is not valid). 3. OTHER .. .................................................................................................................................................:..........................:...................:.............................:................... ............:......................:.......................:............................:................................................ revised 9/2/98 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM 4 of 11 PART A CERTIFICATION (continued) Property Address: 9 North Bay Rd,Oyster Harbors, MA Owner Peter Cook Date of Inspection: 7/31/00 D] SYSTEM FAILS: You must indicate either"Yes"or"No"to each of the following: NO I have determined that the system violates one or more of the following failure criteria as defined 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. no, Backup of sewage into the facility or system component due to an overloaded'or clogged SAS or cesspool. no Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. no Static liquid level in the distribution box above invert due to an overloaded or clogged SAS or cesspool. no Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow. no Required pumping more than 4 times in the last year not due to or more in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped. no Any portion of the SAS,cesspool or privy is below the high groundwater elevation no Any portion of a cesspool or privy is within•!00 feet of a surface water supply or tributary to a surface water supply. no Any portion of a cesspool or privy is within a Zone 1 of a public well? no Any portion of a cesspool or privy is within 50 feet of a private water supply well? no Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria,volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E] LARGE SYSTEM FAILS: You must indicate either"Yes'or"No"to each of the following: The following criteria apply to large system in addition to the criteria above: the design flow of the system is over 10,000 gpd or greater(large system)and the system is a significant threat to the public health and safety and the environment because one or more of the following conditions exist: the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection area(IWPA)or a mapped Zone 11 of a public water supply well. I The owner or operator of any such system shall bring the system facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. revised 9/2/98 I SUBSURFACE SEWAGE 'DISPOSAL SYSTEM INSPECTION FORM 5 of 11 PART B CHECKLIST Property Address: 9 North Bay Rd,Oyster Harbors, MA Owner Peter Cook " Date of Inspection: 7/31/00 Check if the following have been done:You must indicate"Yes"or"No"as to each of the following: y e s Pumping information was requested of the owner,occupant,and Board of Health. yes None of the systems 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. y e s As built plans have been obtained and examined. Note if they are not available with N/A. yes The facility or dwelling was inspected for signs of sewage back-up. yes The site was inspected for signs of breakout. no All system components, excluding the SAS, have been located on the site. yes The septic tank manholes were uncovered,opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions,depth of liquid, depth of sludge, depth of scum. The size and location of the SAS on the site has been determined based on: yes Existing information. (example plan on record at B.O.H.) yes 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)) yes The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of Sub-Surface Disposal system revised 9/2/98 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM 6 of 11 PART C r SYSTEM INFORMATION Property Address: 9 North Bay Rd,Oyster Harbors, MA Owner Peter Cook Date of Inspection: 7/31/00 FLOW CONDITIONS RESIDENTIAL: Design flow:6 6 0 g.p.d./bedroom. Number of bedrooms(design) 6 Number of bedrooms(actual): 6 Total DESIGN flow:660 Number of current residents 4 Garbage grinder(yes or no): Laundry (separate system) (yes or no) yes ; if yes, separate inspection required Laundry system inspected (yes or no):no Seasonal use, (yes or no) no Water meter readings, if available(last two year's usage(gpd)): town water Sump Pump(yes or no) in o Last date occupancy o c c. COMMERCIAL / INDUSTRIAL Type of establishment: Design flow gpd(Based on 15.203) Basis of design flow: Grease trap present: (yes or no) Industrial Waste Holding Tank present: (yes or no) Non-sanitary waste discharge to the Title 5 system(yes or no) Water meter readings, if avaiable Last date of occupancy OTHER: (describe) Last date of occupancy: GENERAL INFORMATION Pumping records and source of information: nane.........................................................................:........................................:::........................................ .. ........... .......... System pumped as part of inspection,yes or no: no If yes,volume pumped: gallons Reason for pumping ................................................................. .....................................:........................................................................ ...... Type of System .....: x Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy. no "Shared system (yes or no) (if yes, attach previous inspection records, if'any) I/A Technology etc: Copy of up to date contract? Tight Tank Copy of DEP Approval' Other Approximate age of all components. Date installed, if known. Source of information: 12/.8/.82:.......Source:Hoard...af...Healtkt...perrrxix..................................................:.................................................................................................... Sewage odors detected when arriving at the site, yes or no: no revised 9/2/98 i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM 7 of 11 PART C: SYSTEM INFORMATION (continued) a Property Address: 9 North Bay Rd,Oyster Harbors, MA Owner Peter Cook Date of Inspection: 7/31/00 BUILDING SEWER (Locate on site plan) b �. Depth below grade: 12" Material of construction: cast iron x sch40 pvc other Distance from private water supply or suction line:25'+ Diameter: 4" Comments:(condition of joints, venting, evidence of leakage, etc. gaad....cranditian.................................................................... ....................................................................................................................................................................... .......................................................................................................... .:....... ....... ..... ......... ......... ....................... .................................... SEPTIC TANK (locate on site plan): yes Depth below grade 16" & 29" Material of construction, Concrete x Metal FRP Polyethylene ` other(explain) .......................................... .............:.........................:.................................................................................. If tank is metal, list age Is age comfirmed by Certificate of Compliance(Yes/No) Dimensions: 8'6" x 5'6" Sludge depth 4" Distance from top of sludge to bottom of outlet tee of baffle 20" F Scum thickness 2" Distance from top of scum to top of tee or baffle 9 Distance from bottom of scum to bottom of tee or baffle 10"` How dimensions were determined: steel tape Comments: (recommendations 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.) .The...septir—Aaak-app.eared...to..be...structurally...sound-by...means.;.of...vismal...inspection...with...no...ev id P.a ce...ol..leakage. l e...li.quid-levels...were...carrent..and..fhe...lniel...and...outlet-lees..were...in...place............:.....::.............:..........................:............................... ...............................................................:................................................................................................................:............................................................................................... .....................................................................................:........................:...........................................:..................................................................................................................... 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 in relation to outlet - invert, structural integrity, etc.) " ........................................................:..............:..........................................................................................................................................:.................:..........:....:........................... ...........................i:.......................................... .......... .. ..... .................................................................................. ...................................................................... ... revised 9/2/98 ` SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM 8 of 11 PART C:, SYSTEM INFORMATION (continued) Property Address 9 North Bay Rd,Oyster„Harbors, MA Owner Peter Cook Date of Inspection:7/31/00 TIGHT TANK (locate of site plan) (Tank must be,pumped prior to,or at time, of inspection) Depth below grade: Material of construction: concrete metal fiberglass polyethylene other: ............:......................:...............:.........................:...........................:...........:................:...:........:................................. Dimensions: Capacity: gallons Design flow: gallons/day Alarm present: Alarm level Alarm in working order: (yes or no) Date of previous pumping: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) .............................................................................................................................................:.....:.:.............................:....:....:.........:..........:........:.................................................... ...........................:.......................:....................................:................................................................:....:.................:...............:...........:..............:......:............................................. DISTRIBUTION BOX( locate on site plan): yes Depth of liquid level above outlet invert 0" - level with outlet pipe Comments: (note if level and distribution is equal,evidence of solids carryover, evidence of leakage into or out of box, etc.) l .Tbs...dlatrib:uli,art...box...appears-la-ba...structurally..saund.milti-ina...emirlence...of...leakaLge...ox...solids..cairry...over..................... ..................................................................................................................... . ..............................................................................................................................................:............:................:.....................................................:............................................. ..........................................................................................................................................................................................:.::.........:........:.:...............:.....................,....................... PUMP CHAMBER (locate on site plan): Pumps in working order: (yes or no). Alarms in working order: (yes or no) Comments:(note condition pump chamber,condition of pumps and appurtenances, etc.) revised 9/2/98 I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM 9 of 11 PART C: SYSTEM INFORMATION (continued) Property Address: 9 North Bay Rd,Oyster Harbors, MA Owner Peter Cook Date of Inspection: 7/31/00 SOIL ABSORPTION SYSTEM (SAS): yes . (Locate on site plan, if possible; excavation,not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: .leach..fit.systerzt...#.1...is.:&O.Q...gatlarx...uiih..2'+.stane............:.....:....:..::..:............:............................................................................................................. .................................................................................................................................................................................:.......................:........:.................::.......................................... Type 1- 6' x 6' as-built j Leaching pits and number Leaching chambers and number Leaching galleries and number Leaching trenches, number, length Leaching fields, number, dimensions Overflow cesspool, number Alternative system Name of Technology Comments: (Note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.) .Tbe...soil...absorptlaa..systerra...was...not..physically...I.orzated...ox...inspecl d...as...part...of..:xtiiaJ aspectio�n...as................... .deiirred...in...seatio n....15.,502...of..1hie...Mas sachusetxs....itie...5...Eavirnn rraeintal...Code........Tbe...sail...absorption.................. .systern...was...determined...to...he..iunctioniag...property...by...inspecling...the...liq.uid..ie.veL..of...the...distribution...hax,_ .However,..xa...determine..1be..aabual...slate...of..the..S.A,S,...a..more..intruslve...methad...waruld..be...need-la..be................... .employed,...w.Wctt...is...not..xequired..by...title...5...inspection....crireria.................................... ........................................................................ CESSPOOLS (locate on site plan): number and configuration depth-top of liquid to inlet invert depth of solids layer depth of scum layer dimensions of cesspool materials of construction indication of ground water inflow (cesspool must be pumped as part of inspection) Comments: (Note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) ................................................................................................................................................................................................................ ....................................... ........ ......... ......................... .................................................................... PRIVY (locate on site plan) materials of construction:. dimensions depth of solids Comments: (note condition of soil, signs of hydraulic failure, level of,ponding, condition vegetation, etc.) ..............................................................:......................................................................................................................................................................................:. ............................................................................................................................................................................................:..............................................:................ revised 9/2/98 i SUBSURFACE SEWAGE DISPOSAL. SYSTEM INSPECTION' FORM 10 of 11 PART C: SYSTEM INFORMATION (continued) Property Address: 9 North Bay Rd,Oyster Harbors, MA Owner Peter Cook Date of Inspection: 7/31/00 SKETCH OF SEWAGE DISPOSAL SYSTEM: Including ties to at least two references landmarks or, benchmarks, locate all wells within 100'. (Locate public water supply comes into house) A. �X�sT�>JcT Howl G.' 8 A 1� HLL� - s FD o L_ G V�) O 1 t L3' 59 o a 2 3 7 -2 ' J�. 13C„ Ll So' 1 4- ' y-? w , The laundry(System IM)was unable to be locate because the pipe is 8'below grade and possibly under concrete pool = deck. The line was snaked approx 90' from the clean out in the basement and is not holding water (gray water)at that point. Assuming a 6'x 8' leaching pit-was used groundwater calculation indicate pit would be 6.77'above the groundwater table. revised 9/2/98 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM 11 of 11 PART C: SYSTEM INFORMATION (continued) Property Address: 9 North Bay Rd,Oyster Harbors, MA Owner: Peter Cook Date of Inspection: 7/31/00 - N R C S Report name: Soil Type: Typical depth to groundwater: U S G S Date website visited: Observation Wells checked Groundwater depth: Shallow Moderate Deep SITE EXAM Slope Surface water Check Cellar Shallow Wells DEPTH TO GROUNDWATER Estimated Depth to groundwater 24.27' Please indicate all the methods used to determine High Groundwater.Elevation: x Obtained from Design Plans on record , x Observation of Site (Abutting property, observation hole,basement sump etc.) x Determined it from local conditions Check with local Board of Health Check FEMA Maps Check pumping records Check local excavators, installers Use USGS Data Describe in your own words how you established the High Groundwater Elevation.(Must be completed) .Hlgb...grnundwatex...was..deter.rained.by...hand...augaring..a..test.bole...to...a..depth...aLJ.0.'.Jn..the...area..raLth e...leaching....... .pit,...na...graundwater...obaerved..at..a..,dalatb...Cd..1.0'.......Alsa..p reuxaus...title...5.1aspection...has,..a...adjutstad..grauadwater..... .cal.culation...of...24.2.7'...bel ow...grade..based...an...tow.m...rasp...#0.7.2-.021....................................................... ....................................................... revised 9/2/98 � SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM \ / 1of11 ^ PART ' CERTIFICATION ^ Property Address: Name' - of ' - / ter k . . ' ` . - � Date of Inspection: 7/31/00 Address ofOwner: Named / Edward P. - � '___ � __ --''--- -------- |amoDEP OOO) upv,vv�umopoomrpumuan munonun �5U40��TlUo5(31OCK�R1�� -------c'--'--------'' ^ Company Name, MoU�gAdd�uoand Telephone Number: � ^-:-'-'----------.--'---.- pectia_ . ...��' ' ..... . ` ' ^ ` . ' . CERTIFICATION STATEMENT | certify that | have personally inspected the sewerage system at this 'address and'that thoinfonnaho'n reported below io true, accurate,and complete aao(the time of inspection. The inspection po�onnodbaoodonmy�a��gandoxpohanoaindhopmporhunnUonandm�nUe ' of an � aho sewage disposal system. The system: . . ' x Paaxoa ' _--_-__-_ Conditionally Passes . . Need Further Evaluation 8y the Looa - . R�� ` --_--__- |nxpoo�/sSiOnakum . .'D8�� ' The System Inspector shall submit a copy ofthis inspection report 0n the Approving^ Authority within thirty (30)days of completing the 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 with copies sent to the buyer,if applicable and the approving authority. NOTES AND COMMENTS The laundry(System-#3)was unable to be locate because the pipe is 8'below grade and possibly under concrete pool deck. The line was snaked approx 90' from the clean out in'the �a point. Aouum�gu�x8' �onhingphwau used gmundwa�/ calculnt ation ~ u'(gr"' ="=vm -- / momom pit would bo 577 ubuvoUm groundwater table. . ^ , revised 0/2/98 . ' . SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM 2 of 11 PART A CERTIFICATION Property Address: 9 North Bay Rd,Oyster Harbors, MA owner Peter Cook Date of Inspection: 7/31/00 INSPECTION SUMMARY: Check A,B,C, or D A) SYSTEM PASSES x I have not found any information which indicates the system violates any of the failure criteria as described in CMR 15.303. 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 or 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 owner or operator has provided the system inspector with a copy of a Certificate of Compliance (attached)indicated that the tank was installed within (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 conforming septic tank as . approved by Board of Health. Sewerage 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). Describe observations: broken pipe(s)are replaced obstruction is removed distribution box is leveled 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 N ' i SUBSURFACE SEWAGE 'DISPOSAL SYSTEM INSPECTION FORM 3 of 11 PART A CERTIFICATION (continued) . Property Address: 9 North Bay Rd,Oyster Harbors, MA Owner Peter Cook Date of Inspection: 7/31/00 - C) FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health, safety and the.environment. 1. SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MATTER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2. SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system and SAS is within 100 feet to a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and SAS is within a Zone 1 of a public water supply well. The system has a septic tank and soil absorption system and SAS is within 50 feet of a private water, supply well. The system has a septic tank and soil absorption system and 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 isfree 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 is not valid). 3. OTHER .................................................................................. ..........................................................................................................................................d.........................................................d............................................. revised 9/2/98 • SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION ,FORM 4 of 11 PART A CERTIFICATION (continued), Property Address: 9 North Bay Rd,Oyster Harbors, MA Owner Peter Cook Date of Inspection: 7/31/00 D] SYSTEM FAILS: You must indicate either"Yes"or"No"to each of the following: NO I have determined that the system violates one or more of the following failure criteria as defined 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. no Backup of sewage into the facility or system component due to,an overloaded or clogged SAS or,cesspool. no Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. no Static liquid level in the distribution box above invert due to an overloaded or clogged SAS or cesspool. no Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow. no Required pumping more than 4'times in'the last year not due to or more in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped. no Any portion of the SAS,cesspool or privy is below the high groundwater elevation no Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. no Any portion of a cesspool or privy is within a Zone 1 of a public well? no Any portion of a cesspool or privy is within 50 feet of a private water supply well? T no Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well.has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria,volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E] LARGE SYSTEM FAILS: You must indicate either"Yes'or"No"to each of the following: .' The following criteria apply to large system in addition to the-criteria above:' the design flow of the system is over 10,000 gpd or greater(large system)and the system is a significant threat to the public health and safety and the environment because one or more of the following conditions exist: the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection area(IWPA)or a mapped Zone II of a public water supply well. The owner or operator of any such system shall bring the system facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. . revised 9/2/98 SUBSURFACE. SEWAGE DISPOSAL SYSTEM INSPECTION; FORM 5 of 11 PART B w a CHECKLIST- Property Address: 9 North Bay Rd,Oyster Harbors,. MAi a Owner Peter Cook Date of Inspection: 7/31/00 ` Check if the following have been done:You must indicate,'Yes"or`'No"as to each of the following:- yes Pumping information was requested.of the owner,occupant,and Board of Health yes None of the systems 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. yes As built plans have been obtained and examined: Note if they are not available with N/A. yes The facility or dwelling was inspected for signs of sewage.back-up. r yes The site was inspected for signs of breakout. no All system components, excluding the`SAS,have been located on the site.' ° yes The septic tank manholes were uncovered,opened,and the interior of the septic tank was a inspected for condition of baffles or tees, material of construction',.dimensions, depth of liquid,," depth of sludge, depth of scum. The size and location of the SAS on the site has been determined based on: yes Existing information. (example plan on record at B.O.H.) yes Determined in the field(if any of the failure criteria related to part C is at issue,approximatioIn of distance is p unacceptable) (15.302(3)(b)) yes The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of Sub=Surface Disposal system ^'. revised 9/2/98 `> , SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM 6 of 11 PART C SYSTEM INFORMATION Property Address: 9 North Bay Rd,Oyster Harbors, MA Owner Peter Cook r Date of Inspection: 7/31/00 ' FLOW CONDITIONS RESIDENTIAL: Design flow:660 g.p.d./bedroom. Number of bedrooms(design) 6 Number of bedrooms(actual): 6 Total DESIGN flow:660 Number of current residents 4 Garbage grinder(yes or no): n o Laundry (separate system) (yes or no)yes ; if yes,separate inspection required Laundry system inspected (yes or no):no Seasonal use, (yes or no) no Water meter readings, if available(last two year's usage(gpd)): town water Sump Pump(yes or no) no Last date occupancy o c c COMMERCIAL / INDUSTRIAL Type of establishment: Design flow gpd(Based on 15.203) Basis of design flow: Grease trap present: (yes or no) Industrial Waste Holding Tank present: (yes or no) y Non-sanitary waste discharge to the Title 5 system (yes or no) Water meter readings,if avaiable r Last date of occupancy OTHER: (describe) Last date of occupancy: GENERAL INFORMATION k Pumping records and source of information: Wane.............................. . .....`................................ ......... .......... ......... ....................................................................... ................................................................................. ......... ........ ....................................... _ ...... ............................. ............ .. ..... ..,. ... System pumped as part of inspection,yes or no: no If yes,volume pumped: gallons. Reasonfor pumping: .........................................................:.......................................................................................................................................... Typeof System ............... .....................::................................................ ........ ........ ........ ;:................................................. Septic tank/distribution box/soil absorption system Single cesspool x Overflow cesspool Privy no Shared system (yes or no),(if yes, attach previous inspection redo_rds, if any) I/A Technology etc. Copy of up to date contract? Tight Tank Copy of DEP Approval Other Approximate age of all components. Date installed, if known. Source of information: .121BZ.....-Source:8aard...af...Healft..parmil..l...systam...handles...wasle...from..2.5...laalbs...and.1hie...pool...house........... Sewage odors detected when arriving at the site, yes or no: no revised 9/2/98 • SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM 7 of 11 PART C: SYSTEM INFORMATION (continued) Property Address: 9 North Bay Rd,Oyster"Harbors, MA Owner Peter Cook Date of Inspection: 7/31/00 BUILDING SEWER (Locate on site plan) Depth below grade: 12" Material of construction: cast iron sch40 pvc other schedule 20 pvc Distance from private water supply or suction line:l5'+ Diameter: 4" Comments:(condition of joints, venting, evidence of leakage, etc. .goad....condition.............................................................................. "...................:.......:..................................................:.............................:.................:............................. ....................................................................... ........................ ......... ......... ...... ....................................................... SEPTIC TANK (locate on site plan). cesspool utilized as septic tank (see cesspool section of report) Depth below grade Material of construction, Concrete Metal 'FRP- Polyethylene other(explain) ..................... If tank is metal, list age Is age comfirmed by Certificate of Compliance(Yes/No) Dimensions: Sludge depth Distance from top of sludge to bottom of outlet tee of baffle a Scum thickness Distance from top of scum to top of tee or baffle Distance from bottom of scum to bottom of tee or baffle How dimensions were determined: Comments: (recommendations 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.) ................................................................................................................................................................................................................................................................................ ................................................................................................................................................................................................................................................................................ GREASE TRAP(Locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass - polyethylene other(explain) ............................................................................................................................................................................... .................................t..................... ,'.................... ........ ..............,...........::.............................. 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 in relation to outlet` invert, structural integrity, etc.) .................................................................................:.............................................................................................................................................................................................. ............................................................................................................................................................................................................................................................................... revised 9/2/98 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM 8 of 11 PART C: SYSTEM INFORMATION (continued) Property Address 9 North Bay Rd,Oyster Harbors, MA Owner Peter Cook Date of Inspection:7/31/00 TIGHT TANK (locate of site plan) (Tank must be pumped prior to,or at time,of inspection) Depth below grade: Material of construction: concrete metal fiberglass polyethylene other: ...................................................................................................................................::........................:........................................... .......................................................................................................................................................................................................... Dimensions: Capacity: gallons Design flow: gallons/day Alarm present: Alarm level Alarm in working order: (yes or 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 Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) ' t .............................................................................:............................................................................:........................................:............................................................................ ................................................................................................................................................................................................................................................................................ ....................................................................................:..................................................................................:.............................................................:......................................... ................................................................................................................................................................................................................................................................................ PUMP CHAMBER (locate on site plan): Pumps in working order: (yes or no). Alarms in working order:(yes or no) Comments: (note condition pump chamber, condition of pumps and appurtenances, etc.) ................................................................................................................................................................................................................................................................................. revised 9/2/98 SUBSURFACE SEWAGE S G DISPOSAL 'SYSTEM INSPECTION. ,FQRM • 9 of 11 PART C: SYSTEM INFORMATION (continued) Property Address: 9 North Bay Rd,Oyster Harbors, MA Owner Peter Cook Date of Inspection: 7/31/00 SOIL ABSORPTION SYSTEM (SAS): (Locate on site plan, if possible;excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: ......................................... Type Leaching pits and number ' Leaching chambers and number Leaching galleries and number Leaching trenches, number, length Leaching fields, number,dimensions Overflow cesspool, number Alternative system Name of Technology Comments: (Note condition of soil, signs of hydraulic failure, level of'ponding, condition of vegetation, etc.) ..................................................................................................................................:...............................................................:............................................................... .................................................................................................................................................................................................................................................................. ..........................................................................................................................................................................................:....................................................................... .................................................................................................................................................................................................................................................................. ............................................................................................................................................................. CESSPOOLS (locate on site plan): yes / two in series number and configuration #1 utilized as septic tank / #2 overflow cesspool depth-top of liquid to inlet invert 12" 60" depth of solids layer 2" 0" depth of scum layer 1" 0" , dimensions of cesspool 6' x 6' 6' x 6' materials of construction block precast (hexagon) indication of ground water inflow none none (cesspool must be pumped as part of inspection) . Comments: (Note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.) .c,asspoml...#.1...had..Iw.o...inlef..pipns...4on,e...fram-he..hausn..and...one..from-pooLi...ho:use)...and...one...ouflet...pipe.......... .Liquid..leuel...was..at..th,e...outlet..pipe..,ele.v.axi,an.......Cesspool..#2..has...s�edn-some...uvaste...bul..v as...dry...at...tb e......... .time...of...inspecxion...with...no...signs...of..gr auadwatsx...inflow....................................................................................................................... ..................................................................................... ...........:............................................................ ........ ...... ....................................................... 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 vegetation, etc.) ............................................................................................................................................................................................................................................................ revised 9/2/98 f ' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM 10 of 11 PART C: SYSTEM INFORMATION (continued) Property Address: 9 North Bay Rd,Oyster Harbors, MA Owner Peter Cook Date of Inspection: 7/31/00 SKETCH OF SEWAGE DISPOSAL SYSTEM: Includingties to at least w references I r t o landmarks or benchmarks, locate all wells within 100'. (Locate public water supply comes into house) 9-0 CT- 2 'Poo I-- G :: ... 3 -7 -Air 2 y The laundry(System 113)was unable to be locate because the pipe is 8'below grade and possibly under concrete pool deck. The line was snaked a r pp ox 90' from the clean out.in the basement and is not holding water. g (gray water)at that point. Assuming a 6'x 8' leaching pit-was used groundwater calculation indicate pit would be 6.77'..above the groundwater table. revised 9/2/98 v SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM 11 of 11 PART C: SYSTEM INFORMATION (continued) Property Address: 9 North Bay Rd,Oyster Harbors, MA Owner: Peter Cook Date of Inspection: 7/31/00 NRCS Report name: Soil Type: Typical depth to groundwater: U S G S Date website visited: Observation Wells checked Groundwater depth: Shallow Moderate Deep SITE EXAM Slope Surface water r` Check Cellar Shallow Wells DEPTH TO GROUNDWATER Estimated Depth to groundwater 24.27' Please indicate all the methods used to determine High Groundwater Elevation: x Obtained from Design Plans on record x Observation of Site (Abutting property, observation hole, basement sump etc.) x Determined it from local conditions Check with local Board of Health Check FEMA Maps Check pumping records Check local excavators, installers Use USGS Data Describe in your own words how you established the High Groundwater Elevation.(Must be completed) .High...gro�undwaiex...was..datermiined:.by...hand...augering..a..last..bole...to...a..depth... L1.0.'.Jri:.xhe...axaa..af...the...lanhiing....... .pif,...no...groundwatar.... bsexved..at..a...depth...af.,:1.0'.......Alsa..pxauious...title...b..inspection...haas...a...adjusted-groundwater.... .cal:culation...of...24.2.7'...bal aw...grade...based...on...tow.m...reap...#.0.7.2-.021..........................................:.................:.............:...:................................... revised 9/2/98 f 0 a 8 COMMONWEALTH OF MASSACHUSETTS ^ fp 61� EXECUTIVE OFFICE OF ENVIRONMENT FF A�END �✓ DEPARTMENT OF ENVIRONMENTA ROT 'IION ddJ N 2 , 1997 ONE WINTER STREET. BOSTON. NIA 02108 617 .�-55 � M TOWN OF BARNSTABLE N WILLIAM F.WELD � A � TRUDY CORE Govemo: Secretary . ' E ARGEO PAUL CELLUCCI DAVID B.STRUHS Lt.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Commissioner PART A -� CERTIFICATION Property Address: 9 A/or ► (307 t vyst� �`rrdv�s Address of Owner: Date of Inspection: (If different) Name of Inspector: I PAJ. a I am a DEP approved, system-ins ector pursuant to Section 15.340 of Title 5 (310 CMR 15.000) Company Name: Jolrr. }t;./�vc/i'4o2 S1ryiG> Mailing Address: /SU u/GImA,� , /Ylr3r.,.g 1 ��i. o:se fF Telephone Number: CERTIFICATION STATEMENT ' I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: Passes Conditionally Passes Needs Further Evaluation By the Local Approving Authority _ Fails ' Inspector's Signature: Date: S' Z 9—97 The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(30) days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. INSPECTION SUMMARY: Check A, B,, C, or D: ' A] S�YSTT PASSES: V I have not found an information which indicates that the system violates an of the failure criteria as.defined in 310 CMR 15.303. Y Y Y 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 conforming septic tank as approved by the Board of Health. '(zwi..d 04/25/97) Page 1 of 10 , DEP on the World Wide Web: http:/twww.magnet.state.ma.us/dep _ Printed on RecvrJed Pacer i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM •�' NO, PART A CERTIFICATION (continued) p roper y Address:{ 9 Moray Rd ays- ✓ H/Crl�ho✓� Owner: �5dA/,;,vd G% LIFT•-�/lam/v� Dat ,o Inspection:, BJ SYSTEM_ CONDITIONALLY PASSES (continued) = 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. Thisystem will pass inspection if(with approval of the Board of Health). Describe observations: , 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 remqved C) FURTHER EVALUATION IS REQUIRED BY THE BOARDIOF H LTH: Conditions exist which require further evaluation by t�e oar of Health in order to determine if the system is failing to protect the public health, safety and the environment. ET 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH g ERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH A ,D SAI'ETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of a urface wat' Cesspool or privy is within 50 feet of bordering ve �VBLIC etated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD O HEALTH (AND WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MAI ER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: \ The system has a septic tank a9d soil absorption system (SAS and the SAS is within 100 feet to a surface water supply or tributary to a surface water supply. The system has a septic tank;ind soil absorption system and t e SAS is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and th SAS is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and theeSAS 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 prgsence\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 04/25/97) Page 2 of 10 I SUBSURFACE SEWAGE DISPOSAL SYSTEM'INSPECTION FORM. + ' PART A CERTIFICATION (continued) Property Address: C/ Owner: ,�olwa�/ C */a 4-e,r� / Date of Inspection: - `;, D) SYSTEM FAILS: ' You must indicate either "Yes" or"No"as to each of the following: I have deter fined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determ' anon 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 erloaded or clogged•SAS or cesspool. Discharge or orcling of effluent to the surface of the grou or surface waters due to an overloaded or CIMed SAS or- cesspool. w , Static liquid level in i e distribution box.above outle invert due to an overloaded or clogged SAS or cesspool. � s F - Liquid depth in cesspooNs less than 6" below in ert or available volume is less than 1/2 day'flow. Required pumping more tha� 4 times in the I st year EM due to clogged or obstructed,pipe(s). . Number of times pumped . +r Any portion of the Soil Absorptlpn Syste , cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy,is ithin 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 pr vy is w�jhin 50 feet of a private water supply well. Any portion of a cesspool o privy is less``than 100 feet but greater than 50 feet from a private water suppiv well with no, acceptable water quality a alysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatil organic compounn s, ammonia nitrogen and nitrate nitrogen. E) LARGE SYSTEM FAILS: t i You must indicate either "Yes" or "No' as to each of the following:\' The following criteria appl}/to large systems in addition to`the criteria above a 3 The system serves a facili�, with a design flow of 10,000 g t or greater (Large System) and the system is a significam 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 A ir 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 operatorof any such system shall bring the system and facility into full compliance with the groundwater treaumnt program y6' '• 7 ' requirements of 314 AMR 5.00 and 6.00. Please consult the local regional office of the.Department forfurther information.' x B. (,zwi,id 04/25/97) # ?age 3 of 10 � � SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 9 � 'A Owner: Gi�pI�R 1. IYA ,' Date of Inspection: Check if the following have been done: You must indicate either "Yes" or"No" as to each of the following: Yes No Pumping information was provided by the owner, occupant, or Board of Health. 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. i✓ _ The system does not receive non-sanitary or industrial waste flow. V w inspected for signs of breakout. The site as e Pe 8 All system components, excluding the Soil Absorption System, have been located on the site. The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid; depth of sludge, depth of scum. The size and location of the Soil Absorption System on the site has been determined based on: _✓ _ The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of Sub-Surface Disposal System. ✓ _ Existing information. Ex. 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) (15.302(3)(b)) (revised 04/25/97) Page 4 of 10 r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM, PART C SYSTEM INFORMATION Property Address: 9 /Yo/,,�4 /Ay Rd 0�5�1r �r��o�� Owner: Wut� //'/�f Lido Date of Inspection: - S-29f 97 FLOW CONDITIONS RESIDENTIAL: Design flow: L 6 4 s P.d./bedroom for S.A.S. Number of bedrooms: hf Number of current residents: Garbage gr,r.der (yes or no):_ Laundry connected to system (yes or no):, ' PS Seasonal use (yes or no):- Water meter readings, if available (last two (2) year usage (gpd): / 9S ��S vd0 �q�d = 19S Sump Pump (yes or no): 4/0 Last date of occupancy: COMMERCI.AUINDUSTRIAL: R Type of establishment: ` Design flow: Qallons/day Grease trap present: (yes or no)_ Industrial Waste Holding Tank present: Ives o no)T Non-sanitary waste discharged to the Title 5 syst `. (yes or no)_ Water meter readings, if available Last date of occupancy: OTHER: (Describe) / \ Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: System pumped as part of inspection: (yes or no)-1-1-9 If yes, volume pumped: gallons Reason for pumping- TYPE OF SYSTEM - f/ Septic tank/distribution box/soil absorption system Single cesspool -7 Overflow cesspool Privy Shared system (yes or no) (if yes, attach previous inspection records, if any) I/A Technology etc. Copy of up to date contract Other APPROXIMATE AGE of all components, date installed (if known) and source of information: 2 (/j— Sewage odors detected when arriving at the site: (yes or no) (revised 04/25/97) Pays 5 of 20 SUBSURFACE SEWAGE'DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: /�/ �.`� /Qq✓ P�ysr /Y�✓��ys Owner: v Date of Inspection: '97 BUILDING SEWER: (Locate on site plan) s Depth below grade: Material of construction: _cast iron _ 40 PV _other (expl ' ) Distance from private water supply well suction line � Diameter Comments: (condition of joints, ve ing, evidence of leakage, etc.) SEPTIC TANK:_ (locate on site plan) Depth below grade: �r a �y�r Material of construction: Zconcrete _metal _Fiberglass _Polyethylene _other(explain) If tank is metal, list age _ Is age confirmed by Certificate of Compliance _(Yes/No) Dimensions: S i( y Sludge depth: 3" Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: 2 rr Distance from top of scum to top of outlet tee or baffle: !7 Distance from bottom of scum'to bottom of outlet to or baffler How dimensions were determined: . 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.) GREASE TRAP: (locate on site plan) Depth below grade: Material of construction: concrete _metal _Fiber ss _Polyethylene _other(explain) Dimensions: Scum thickness: .Distance from top of scum to top of outlet tee or baffler Distance from bottom of scum to bottom of outle)/tee or baffle: Date of last pumping: Comments: (recommendation for pumping, Condit} n of inlet and outlet tees or baffles, depth liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) - (revised 04/25/97) Page 6 of-10 I II V SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOR_M PART C SYSTEM INFORMATION.(coritinued) r Property Address: 9 444' Owner: Date of Inspection: 5-�9-97 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 _me I Fiberglass —PolyethyleneZother(explain) Dimensions: Capacity gallons Design now: gallons/da% Alarm level: Alarm in working order .. ' Yes; No Date of previous pumping: Comments: « (condition of inlet tee, condition of alal{n•and float switches, etc.) DISTRIBUTION BOX:_ (locate on site plan) Depth of liquid level above outlet invert: Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) //Ox Llvtl) �5�� gPI4'i� CfvRdt . No t�lsil U �/.�i[TNl>s PUMP CHAMBER:_ ` (locate on site plan). t Pumps in working order: (Yes or No) Alarms in working order (Yes or No) , Comments: _ (note condition of pump chamber, condition of pumps and appurte/ nces, etc.) r (r.vi,.d 04/25/97) Page 7 of 10 . - t - SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: / �Yv✓�� 7 Rd (5 ..AerA,lat Owner: ,",-6 Date of Inspection: SOIL ABSORPTION SYSTEM (SAS):_ (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, expjain: , __'4 /f 6W 9u� ry -t7ree t he Pe Type. leaching pits, number: I Syb�j' leaching chambers, number:__ leaching galleries, number: leaching trenches, number,length: leaching fields, number, dimensions: overflow cesspool, number: Alternative system: Name of Technology: Comments: (note condition of)oil, signs of hydraulic failure, level of ponding, condition, of vegetation, etc.) / r� 57 CESSPOOLS: _ (locate on site plan) s74� Acz / cesb w/OL�lr /opt/ Number and configuration: 3�y ,!'� oJ Depth-top of liquid to inlet invert: S" Depth of solids layer: Depth of scum layer: _ Dimensions of cesspool: ` c _ s s-flr Pt 2 Materials of construction: cnMcl 1 8/ /y o f�aC�^ of c�f�a'L y Indication of groundwater: /Ve Div,pKnoewJ�tr w;74�M inflow (cesspool must be pumped as part of inspection) Comments: (note condition of soil, si s of hydrauli failure, level of ponding, condition of vegetation, etc.) V ;1.eaP1 S-er A,'4 at 1, 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.) (revised 04/25/97) Page 8 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C _ SYST.E.1M_ INFORMATION (continued) Property Address:. 9 Owner: /�/1t�✓A/�GI C /Y�G��r -- �aYv h ��/uGl.�r ' Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) 4 r l oo i 1 0f11 f' CrHa � v j0 2y u � � D� y C'p�icv.0�� ,�pavL. �lfk � 6 cj� ,s g' sr, M�tl n� jr� �r1 > Red v ��- %-1N o� 3 �� 62 a /A i pSSN,r+� pr $ r vp ;7? Ac,,afi,�Cu�as OdJN stea�l!/t�t, (revised '04/25/97) Page 9 of 10 i SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Addreesss, Owner: G�►bf/Al�p C /Y�AI�I�" /�lq a'� //�lra��v ' Date of Inspection: Depth to Groundwater:29 Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observation of Site (Abutting property, observation hole, basement sump etc.) ('Determine it from local conditions Check with local Board of health Check FEMA Maps Check pumping records Check local excavators, installers Use USGS Data Describe in your own words how you established the High Groundwater Elevation. Must be completed) i0l � f f d70 I/ �+ / �r/N y� ' �'��R f�'C� '�«7�l �rQ N v►!/�W IO/+� fi7/, yo H nd t.Vfw f y Pe :s4o c. U L! ee t i 1?-7/ be�04 / 9f 4'Glv/e (revised 04/25/97) Page 10 01 10 >: :•:. SEWAGE PERMIT N0. L p C.A.T ION vILlAGE lER'S NAME i ADDRESS ; U'11. D E R OR OWNER /��S DA:T:',E P E R M I T ISSUED a DA�T. E COMPLIANC E I S U E D • - - -. . 1. , . hS s pe e i LOC A T ION/ SEWAGE PERMIT NO. d /� 6?0 - Wit L A G E :Des 7ZT72 i/~Ors I.R.:ST�LLER-S NAME i ADDRESS . - � —a6 :U It D E R OR OWN ER DA;T, E PERMIT. ISSUED -�- DA,T'.E COMPLIANCE ISSUED /y. �,/ i I - I c • Q d 0CAT-. '6 `" SEWAGE PERMIT NO. Z, cop k / VILL-.AGE INST LER'S NAME i ADDRESS X�t 6 6-59-or e IA46 t,e UILDER OR OWNER GATE PERMIT ISSUED DATE COMPLIANCE ISSUED ��s/J/� a ��T .. a�` s��- �y �� 0 CAT-IOi ..p � SEWAGE PERMIT NO. G2 _ 74-1 VILL'3GE hs ► .1 I N STA LLER'S NAME i ADDRESS 69,61iz 66 /&c BUILDER , OR OWNER DATE PERMIT ISSUED DATE COMPLIANCE ISSUED /�, � � � _ 1 -� , � �� . �� J � �,, �- . y. �� .. i rr-�� V .... ....................... THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH ........... --------------or.............. 5 . Appliration for Dispagal Workii Tomitrurtion Vamit Application is hereby�/made for a ermit to Construct ( ) or Repair (X) an Individual Sewage Disposal System at: F /" (2 6 / 2- S .............. _........ L tS..... . !rI!�Q$!�i_._ L .... ............................................................................... Location-Address ....... :..... � or Lo& `1�! �I0. -- r. . � ..•-•---...--•--- wner -Address Installer Address PQ d Type of Building Size Lot...................:........Sq. feet U Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) W`k Other—T e of Building _..... No. of Other—Type g ----=-•--------------• persons............................ Showers ( ) — Cafeteria ( ) Otherfixtures .----•-•--------_----------------------•---------........----------------•--------------•-----•--................................................. W Design Flow.............9 ........................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity_.15"ogallons Length................ Width................ Diameter..........._--- Depth................. x Disposal Trench—No. .................... Width.................... Total Length.................... Total.leaching area............ _sq. ft. Seepage Pit No......(.............. Diameter...../_P........_ Depth below inlet................ Total leaching area.... q. ft. Z Other Distribution box ( I ) Dosing tank ( ) . Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1...........:....minutes per inch Depth of Test Pit.................... Depth to ground water........................ Gi, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ GG -----------------•-_--•-•-......................................................... 0 Description of Soil......................................................................................................................................................................... x U W x ----•---•••---- .....................................................................--•------------------ -----•-•-•--....•---•----•--•---••--•---•----•---•--•---•--- ------...................... U Nature of Repairs or Alterations—Answer when applicable.I&L5 -----14g1g----!�!-_______- ............. Agreement: The undersigned agrees to install the afored c bed Indiv idual ewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary o e—The under d ful- Zer agrees not to place the system in operation until a Certificate of Compliance has bee issued b the ar of health. ---1 A Application Approved B �L /Date PPPP y-•-•--•--••-•-- =------- . .. .•.•--.....--••--------- .l .f .' Date Application.Disapproved for the following reasons:............................................................................................................... --.....---•---•-----•.............•--•---....._.........------•----------------•--------.......---------'-------------------------••------••---------------•---•--••••-----•--••--•' --••---------- Date PermitNo......................................................... Issued_....................................................... Date a.c ` No.. FIzs.... .......... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ........... ...... OF...........................:_............... Appliration for Dispnsal Works Tutuitxnrtion Vamit Application is hereby made for a Permit to Construct ( ) or Repair (;�� an Individual Sewage Disposal System at: ................__ --_--__------__-_. ................................= -•---••----•................... _.....----......._..---••••-•---•-•••-----••-•••-..__.....--•--_:__------------•-......----•...--- Location-€1 Address or Lot o.F...f_. �.................................................................7,3 �r Address t... Installer Address UType of Building Size Lot............................Sq. feet �-, Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building No. of persons............................ Showers a YP g ------•-•----•-•----•-----•• P ( ) — Cafeteria ( ) Other �yu es -------------------------------------------------------•----------------------------------------------------------------.....-----------.........---- W Design Flow...........................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity..i....'?'gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area___________.___._..sq. ft. Seepage Pit No..................... Diameter.__._ .0......... Depth below inlet................ Total leaching area........_O`Lsq. ft. Z Other Distribution box ( ► ) Dosing tank ( ) Percolation Test Results Performed by.................................... ••---------------•---- •-••-•......• Date........................................ a Test Pit No. I................minutes per inch Depth of Test Pit___.__....._...:::_• Depth to ground water........................ Test Pit No. 2................minutes per inch Depth of Test Pit..................... Depth to ground water........................ ----•---------------------------------------------------------------`------•--.....----•--••-------------.......---.........--------------•-••----•---....•. ODescription of Soil........................................................................................................................................................................ w UNature of Repairs or Alterations—Answer when applicable._-•"'"•��!_A L`•:..__...�_�-t'�i-?....1 51)�___.__c's.t:=_._130 x,............. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITALE 5 of the State Sanitary Code— The undersfgnd further agrees not to place the system in operation until a Certificate of Compliance has beedissued b the 1}oar�.'Of health. Signed. :;.x'. .•GC ''�% '�%.._.._ •---•• -•---••-••..... 7 1 Date Application Approved By................................. J h ................... ----------------------------••---•--•--- Application Disapproved for the following reasons:................. ............................................................. .............. ..............•------------....------•--...----------------....--•--------•------•---------•--------•-•------------------------------------•---....-----------------------------------•••...•----------- Date PermitNo......................................................... Issued_....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................OF............................................................................ ....... Tntif iratr of Tuntpliaanrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) by......................... -....................................................................................................................................... Installer F has been install i�d in ordance with the provisions of TITLE 5 of The State Sanitary Code as described in the application:for Disposal Works Construction Permit No...............................�`�V ;........................... THE ISSUANCE OF THIS CERTIFICATE SHAL(ft0?B CONSTR E AS A GUARANTEE THAT THE SYSTtM WIL CTION SATISFACTORY. / f DATE........1.�'.�. ............:....-•--------------------------•-----...---.. Inspector..... ... ......................................................................... THE,COMMONWEALTH OF MASSACHUSETTS - B6ARD OF HEALTH ...........................................OF..................................................................................... N ,... FEE .......... Disposal Works Tuanstrurtiott ptrMit Permission_is hereby granted.---•-, - ............................•--.--.............-------•--------------------......---------........-----...............-•---•--- to Construct ( ) or.Repair ( ) a1r1!ndMdual Sewage Disposal System atNo............ --•-••. C/V� j. ,y,�y�s Street ' : as shown on the application for Disposal Works Construction Permit No..................... Dated.......................................... -------••--•-•••--•-------;/-------------------•----------••------•-•-----•-----_----•- A i 9�� rd Health DATE............................................................................... /A FORM 1255 A. M. SULKIN, INC., BOSTON . A, AsBuilt Page 1 of 1 LOCAT SEWAGE PERMIT NO. 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Eli-, 124 I c I I :d' - - F,:u, cH -s 1, _<,i• Ih -. _ 1 fe: 'I GRAWL ' ALL 4 L V I k . .. 9D . T I Z? U I iX ( ;.a )•9 A:i•.I Ao i _ O O to C. =3 (If: C L oN � a m 2) o Q� mCa cu oa r--c c N - �. l --- a -- z U- aU '� I • i lob no.: date draw 119 tev. nev. Amii 1 n 0 � ;oit tF j i ` ISSUED FOR:PERMIT sid .I of i2 1 HALL '[ LE. rlr r L nvTEi ;I rCA,E L L 1 > 11T, LL_ n TEr.<-'Tp oc i[ v,vp=O-R, ti EC f t. ,L, IJ I{1 i _ I : ,wnL s vlrH Mc'I.Er ocoas to ec E T : O c../ _ fA -N1. G..C.FEL A AQ H r 61L5 �LA kF O)ELEJATOn FOR `r E P C .. E 0 5 REF R TO EC'.1TIo Ok .npOYl L S'n"o-GA 1i r w L-5 CR DOO i- TES LO SE LC RPYDIE[:A4C VAl/hCJ.A - .•� II Y ca.. KIYGHEN it rCL'p OR R_F'AO[ 1trl:D: R_yre/?LLE ATED ED m. . FIELr Y o N N O,'OR5 1 Ne,,CASep m J W 5TO—TGH LVST. - pp 1 r 6 c I _ ! I c _E_FVCuIT, ' I I 1 {AT M FA - i I _ rt+ _ WV:... r�.. CL':I: I t 4 �. I .. s. � ..FAMILY V Sd yLAUNDRY/- LIVING- ..I OIL WIG I PAS NTRY IE,T f •W F G P TAV'n _ BEDROOM 3 s I .._-4,5T, w, EthT.CFENINS� .. RO:•:i-93/4X 45.3/4 `.I G I Irk r I _ OIL I'' FOYER'. -I PDR $ATH 3 ..., _ LN: -11sT..,F�_Tn;-' Ro::40:3w X ash' Ili — I 7i La. I +n114 1 10'i V i .._...__.. - _ f' !"!ALL I'. . �' J I �i;; — IV pN j-- �' .BEDROOM 2. .. _. .. _. 1 I JCNTE IN .l':iAl']Is3 ._.: Z,� - - —.___ �:'•• G.I_..OFEH:\5. RO.•. 5-4 �_� I TN 4 19iNJN �� 1 e / _ 1 L V 1 _..I l' tt ..;,sue I NMI - I.I I I RA IJ5341 9' L�.YfF.N.WII 1: >-o =S 3,14 X 5'3!4X 5W4 l �N BAT H.2 z-� JJAME T"E 4__ FY$R.IN _ ..A5..p1 2H53 l II � 211 OI'cY'4 T,WIn .. NFN FI'tTLFES .I %S...PEI✓\5 40 3.53/4%4531+ � 2 PVI Er'IE.C- I ^:v, i i _L _^,-- .Iv L J. bb a:. HIS I.� ,�: tI ,I r« O' i` -- BATH —o- ..— i _�' LL y jV1 I j a:(n 3>i I _ c r 5.r I sw 'C�o'. (a.t N J E c� rL l �, oI F 7 Z_�—o&iF LL...:�L f_nI .. ' I i MASTER ! , YG._9 I r¢In BEDROOM_, 1 HERS.._ 1E\v+lv+ .rti.rIN:r.r i _ .___ -�: I WIG.. ;Y FIRn R.c: P job n0 %J I4 _ .. date 4.1.aY G014 i scale !f drawn:: �Lw fit 7 &.2 4t of I2 sht 2_. . .. . ISSUED FDR PERMIT -- - r- _---- --- e s - - - MALL D t IJ L-_ ENP _ ._ _. ^ I ♦:L NPLL TO BE 2%45 a IB' p •IO .. tGTED.OrNEQYV=E,? Uf ---- 15 E% T:HS'WALL>TO u> A RiL t1:::' -'—.__. R=NAIN.. ✓L4''-LS WIHPr.G1:ET.COOR5:T0 __ __-. _- - .. v�..DONSTO EE FELLA AROITEGT BE A� RIE91h VCR ELMPi—FGR Wiv YlALLS �I.F ._T_ •—_: ;! I 7G,10 AOTG'c' WIND R �^ AD--c WEPLOOR -_ 1I I T\Q A51 DWI OW5 WW:-i:5 E:ER To C/A.GN'FOR S', GHEO A5 Y W (Q '� 1 -f.CCDEO OR REPL4 EP r n„TD: ALL E T—W L'BAT406 rAEMI D - FLATI,�tA rIfLD$ CAT EDiE v-. I Y L , I , I. 1 I. I I , BATH 4 , BEDROOM 5 , I FFIGE. I. r BEDROON 4AR : , I _ _ , r - BATH 5 h i ` CJr 4 P : ll I t I: �,:� I r --- ----- 11 r _1__ .. : >b ��Je i i I--'!,!a� jiul : I 0U) Ca U zr E r; La. I - " ' O L :O :WC cc vo Caa� o 7 c_ C.-0 N U �. U U Fr, f L <� I I -� -U^` 1 TCi,i LJ\fi:iR_ ZN, �, W U N i i Q� rno. Job no date scale. A5 R EO, drawn JLuA �.�«7- FP tr r}- - —: rev. StR lr TI R!rl_ rev.A-3 . n. �f r a Ty r1 IMED,mk PERMIT slit 5 Of 12 N Q -7 - (� ku 1 R . L U k 1 �c — 0 di n O t J W � �C7jrSt�rl^1�limt� ' �� • wl � in r o PROPOSED PROP05ED 0 ADDITION ADDITION lopo o - O TJ , 1"OF G9.4' _--- - ► ��0 LOT 1 5 R W. � NO. 79f y 40009. 15.F. R= 1 5.00' A= 1 8.71 I 3 l POOL ' T= 10.79' ` AtUWD AREA 1 4- 1 1 BUILDING. LOCATION PLAN o� FOR \ 0 9 NORTH BAY ROAD 05TERVILLE, MA PREPARED FOR DAVID TAMMY MGLEAN 232-0/ ` • /^ SCALE: DATE: DRAWN BY; Ili 30' 05-30-201'4 TMW ` JOB NUMBER: REV1510N: 5HEET NUMBER: 14-O 18 CPP- I ' WELLE R * A550C I ATE5 I G45 FALMOLITH RD.. SUITE 1`9 P.O. BOX 4 1 7 CENTERVILLE, MA 02G32 TELEPHONE: (508) 328-4G92 EMAIL: tri5wcller@cjmaii.com REGISTERED LAND 5URVEYOR5 ENVIRONMENTAL CONSULTANTS Traverse PC c u O V C O N +O. o � � o O C t N fO la. u G.7 v c O co Y ca E9 (C Fri a H � E O • It •• LUVJ Y 1 V O �1 s0 V °1IIIIfi = w 0 b a � w 5ELO ttPE G eILKHEAp �/Q •� � BELOW � L g SITTING ca 4 q AREA q - I _ 15'-5"X 13'-e 1/2" 71 npo cN • BVILT-ZJ BtiILT-IN NEW----L.O. WATER O NEW OPENIN6� HEATER :• ' `• PDR. LIVING ROOM r CHN6,, SEPT --------------- _ __ Room rFid�atmda�o„m0 o ds om= — W cc O� L B A 5 E M E N T P L A N F L O O D P L A N O ` O (13 W SCALE 1/4' I'-O" SCALE 114 1 -O ^` ^(nu) 1 c m cu aZS °n Cc C o co t— N0 � E Z ' (n U�0 m job no.: Ie25 date 16 PEeR—y eon style : A5 NOTED drawn: MM rev. rev. a: A- 1 0 ISSUED FOR REVIEW Sbt I of Y id �'' `ad 5.:& ,^t `E,:3» h �' ., «w - ; w €;,. Legend ft ir:. }a:'€':. t ", ;K" xa c $ , l Parcels a , .. ,_ u � . Y 5 :.�.; +a $33a ql +;.ti• 'n;m...'r'• „v . ..,, x:: .....� .m 1' .- -ate > Town Boundary 9 s Railroad Tracks �; ,;� 4 Buildings `� ,2 Painted Lines e jg Parking Lots a r . Paved • _ : i < i a rh ':;,3, ....UnpaveeR �0 Driveways e - � c - Paved x Unpav .4 L 0za2. r: Roads n j . `' ZS u• " '� � . Bridges 20 b P i i -. 5 ._?. .. �,Z,� Unpav doROads .kr' i � .Es v, "a .Stfean'1S .: r $ } S� d k ,� , Marsh ' '_ ` a; a a - ..- F v ; 'Water BO ies g X w $ � f .. l�� d i Z '' ib"'�1 Kf' d.: .,..":...- ,. ... .... .. �. . ., m,.... :.,.,,.. ... 1" .,,"i.. ..... .. I. :...,.i....r .: / , ,: ! ; + . .: — „-,, c ✓ d 4 { .. ..... :::, l tF 't, £ d .. ¢�. ` .. „ , .. .. R 8 . '� ,1v s 7, J d .,+y.''y' .I £are €r f x �' _ • r 9� ,$ � W,� � � �r� IM - a .� k a : i s r: \ s' :: n 11 r 3 7 f �I.11:.,.,i,.L.�4�:._,� .. I: # ._1,A..,..:I..;...:,-,;.tA,'�...-..:�Z.1,,,,.�.4A�,,1�,�111:...:.�.�,�,-.�11�::'11;..,1.�,�'�l-��,��".I:;.1�,�]",'.,';-;.!,.:.s�1�.:,�',�` V .1�:1':,I�-.1,�,_,%:.:.......-1 I.,,..,_-.I.I,�.1,.�-�1;,..,I:�':,,,-I1,...:'��:�,1.,�,__:-',� :.,,,��;7K!,;,.;:-.,,, ._,_.1 Y # ��' "t v=`'(': : V �� " ms , -- � — w 4 ZkL t i A'' ` v F* �� 1 �has.. "fit}�� "g Y is �tY �/ � `ram '" 1, l °ti02.;54tvF€. £ .,.. (V �1 /' Paz Y r A-4 )''1 " -< t �* s, I Parcel lines shown on this map are a only graphic representations of ' rt - , Assessor's tax parcels.They are not k�-.,,,� � % h , r true property boundaries and do not ""'r. Jl � 1' �� represent accurate relationships to 1-','S_,:: 3 -. physical objects on the map such as ' Y r, '1, building locations. AE F ;� This map is for illustration purposes z x, z only.It is not adequate for legal boundary determination or ,' - $- at Y einterretation. is map regul Th YE ;` does no pres tan on-the-ground •. ? smve .It may be eneralized,may not reflect current conditions,and may contain cartographic errors or ,' omissions. _ . :. t) i +°j x T mt own of Barnstable GIS U r i s a 367 Main Street,Hyannis,MA 02601 8-86 - 6 2 50 4 24 gis@town.baznstable.ma.us .. 4 ';:. .. Z.. :.. :. N Feet ,J - t] ' Q Foy 0. Approx.Scale: i Inch= 42 feet _ \ " a. a, t ' Map prin a on. 3/6/2017 M d