HomeMy WebLinkAbout0082 PINE LANE - Health 82 PINE LANE, OSTERVILI.E
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r P TOWN OF BARNSTABLE
LOCATION SEWAGE #
'i VILLAGE a ✓ , . • ___ ���
`'��Vi tf'L ASSESSOR'S MAP & LOT' "
INSTALLER'S NAME & PHONE,NO.9010-;;rA (50 ,I It
SEPTIC TANK CAPACITY
r
I, LEACHING FACILITY:(type) (size) -
NO. OF°BEDROOMS PRIVATE WELL O BLIC WATER
BUILDER OR WNER
,.
DATE PERMIT ISSUED: ��
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No J
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No....737.51;L j oy U / Fins ��®........
THE COMMONWEALTH OF MASSACHUSETTS
APPROVED BOARD OF HEALTH
[�tnsmblo Cort�caration D�yaR�'t
s .�... OWN OF BARNSTABLE.
AppliratiW-01 for Diripnnal Works Towitrur#inn ramit
Application is hereby made for a Permit to Construct ( ) or Repair k^-<) an Individual Sewage Disposal
System at:
pp-
Loca'm-:\ddress or Lot No.
WCG l� 0vJC�/Cl� ..............................................................
Installer Address
d Type of Building Size Lot.................... Sq. feet
U Dwelling— No. of Bedrooms------------------- --------------._.-_Expansion Attic ( ) Garbage Grinder ( )
04 Other—Type of Building ............................ No. of persons---------------------------- Showers ( ) — Cafeteria ( )
Other fixtures
W Design Flow..................
......................... per person per day. Total daily flow..__._...._...-? ................gallons.
04 W Septic Tank—Liquid capacito...gallons Length________________ Width.....----------- Diameter---............. Depth................
x Disposal Trench-- No. --------1_........ Width....... Total Lengtli_.d r.257Total leaching area....................sq. ft.
3 Seepage Pit No..................... Diameter._._______..._______ Depth below inlet.................... Total leaching area..................sq. 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........................
LT4 Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water........
04 ----------------------------------••----•------------------•-------......---•-•-•--••--•------•----................----.........._..........-•-•.............
0 Description of Soil.........................................--•---------------------------------------------------------------------------._...------------------•-------•-•----••••.---•-
x
W -•••••••••--•--------------------•-•---••----•--•--------•----......._..........._...._....-----------...-----..._...•---------•-------•------••---•-------•• ........................................
UNature of Repairs or Alterations—Answer when applicable._ A,l.. ........ Qlf e .=�4!� .�.�.e ...
----•----
Agreement.
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the.State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Compliance ha be iss d the and of. ealth. .
Signed - ...��........................ ................................ ............. ........ ...<..�`�/ --- --
Dare
Application Approved By --- C V I .. . . ....................................................................
Due
Application Disapproved for the following reafons: .... ..... ....................... ........................ . --- ...........................,
........ ............. .......................................................... _. . .............. ................................................................................. .............. . ....................
Date
PermitNo. ...... 7.3------.... ..j... ------------- Issued ....................................................... ......
Daze
1-" • ...--.....,. G.r v�r.,."r wVt.�'LJ`1u"•v�• :v..�,�'r�...,.v"!a-�' r-�..� ...�...�ry.p .. ...^vv v, t.-r --f r:.`tir o'w` ..y�>r-.y- .�: a,�
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
=�
� ,���1trtttinit fur �i5�lt�u1 �nrlt,� C�nit,��r�r�tnri prutt�
Application is hereby made for a Permit to Construct ( ) or Repair (>e,) an Individual Sewage Disposal
System at:
.......................•-----•---•-••--•.........--•--•---- -•--••---•-----•---•---••-•-•-..........--------------•-----------------------------------------••
Locatiin-Address or Lot No.
......................V� . f ..... ..................................... Z. � Lit _�/ (Z!�tar....--.............---
owner
/��/C`7�/�,L� CJ�12, sy J Zc s 17411 tj
...................................................• •-•-••------. ---..._----•--•----•-------•- .-• •••--------------••••---•-•.....--•-•-='---••-.....-•-- .............................
Installer Address
UType of Building Size Lot............................Sq. feet
Dwelling— No. of Bedrooms;FA...............: ---_---__-_--_-.-Expansion Attic ( ) Garbage Grinder ( )
04 04 Other—T e of Buildiu -----tea No. of persons---------------------------- Showers — Cafeteria
dOther fixtures --------------------------------------------------------------------------------------- ----•----•---•-----•-•-----•----.....-•-......_..............
W Design Flow.....................!.!5�...........gallons per person per day. Total daily flow.._........_.._2?.Q............_...gallons.
R: Septic Tank—Liquid capacity/. A..gallons Length---------------- Width---------------- Diameter................ Depth................
Disposal Trench--No. ......../........ Width.......7......... Total Length_. -? =_ Total leaching area....................sq. ft.
Seepage Pit No------------_------ Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................
G4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
0 Description of Soil..............................................................................................................................................................,._.......
x
U ..............•-••----...•--•••••---•--•---•-•-••-•-••--••--•---•._.......---•••-••---•-•----•--•-•---•----•-•-------•••-----•-••-•-•-----•-----•••-••--•--•••--..........--•------------........._•--••-
w
x •---------- ---------------•--........•-------•••------------.............----•------••--...-•••••----••-----------•---------------••••---•-------•-----......••••••••----•-•-----..............---••-
V Nature of Repairs or Alterations—Answer when applicable...� .......lr�l1 .... IST...
i
Agreement: ,
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to;place the
system in operation until a Certificate of Compliance has`be/'n iss ed b the board of health. !
Signed ......... i ........../. .. - - . _�............ ..... �: } ..
ApplicationApproved BY ----------- --- ....... .. .,,.� ,=.\./................................... ............................ ....... .r�Dae` .-.. ...'j
Application Disapproved for the following reasons: .... ....... .. .. ........................ . ...............................--.........
......... ..... .......................................................... . . . ... . ..........................................:................... ........................................
Date
PermitNo. ........7..3----------- -- ----.----- Issued ........................D..................................
ace
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Cfer#tf rate of 01omylianre
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
by ..... - .... ._............_... -......z.
lnsrallc
at ... ... .............................................<:� ...............�i-��-- -...-...LQ/V ..... = 5i... v/.../..... -
has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in
the application for Disposal Works Construction Permit No. ._...../.-3.--..5.1.�... dated ........................._...................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
1. Inspect( .........
..........._.... .. ....................................---------------------DATE_...... .....:. . 1........ . .._..
THE COMMONWEALTH OF MASSACHUSETTS /� �— 66
BOARD OF HEALTH
q TOWN OF BARNSTABLE
No.../._, _-:......... FEE. .` G..
Elispnoal Workii Tnriitru#inri firrutit /���
Permission is hereby granted---------_-------- ` GYL_i (&/ ' ..---
to Construct ( ) or Repair an Individual Sewage=�i
Systemat No----------------------------------------------------z'vT------ i ie�/E .........._-_- CJ,ST�t/t*1.. ..----....-------•--•--•----...
Street � p
as shown on the application for Disposal Works Construction Permit No._l-�C2.---- Dated...........................................
.................................. - --------------------------------------•---•------•--•--
rd of Health
DATE............... y._t- _ ............................
FORM 3e5oa HOBBS&WARREN.INC..PUBLISHERS
'rORM30 C&W HOBBS&WARREN TM THE COMMONWEALTH OF MASSACHUSETTS
BOARD,OF HEA T
CITY T WN
W
DEPARTMENT
ADDRESS
GSM 5v0 y`0� '
TELEPHONE
Address — Occupant
Floor Apartment No. No.of Occupants
No. of Habitable Rooms R9 No.Sleeping Rooms
No.dwelling or rooming units_ .Stories
Name and address of owner
Remarks Reg. Vio.
YARD Out Bld s.: Fences:
Garbage and Rubbish
Containers:
Drainage
Infestation Rats or other:
STRUCTURE EXT. Steps,Stairs, Porches:
Dual Egress:and Obst'n.:
❑ B ❑ F ❑ M Doors,Windows:
Roof
Gutters, Drains:
Walls:
Foundation:
Chimney: <
BASEMENT Gen.Sanitation: 01
Dampness:
Stairs:
Li htin :
STRUCTURE INT. Hall,Stairway:
Obst'n.:
Hall, Floor,Wall,Ceiling:
Hall Lighting:
Hall Windows:
HEATING Chimneys:
Central ❑ Y ❑ N Equip. Repair
TYPE: Stacks, Flues,Vents:
PLUMBING: Supply Line:
❑ MS ❑ ST ❑ P Waste Line:
H.W.Tanks Safety and Vent(s)
ELECTRICAL Panels, Meters,Cir.:
❑ 110 ❑ 220 Fusing,Grnd.:
AMP: Gen.Cond. Distrib. Box:
Gen.Basement Wiring:
DWELLING UNIT
Ventil. L to . Outlets Walls Ceils. Wind. Doors Floors Locks
Kitchen
Bathroom
Pantry
Den
Living Room
Bedroom 1 'O Et
Bedroom 2
Bedroom 3
Bedroom 4
Hot Water Facil. Sup.Ten.,Gas, Oil, Elect.:
ks, Flues,V. nts,Safeties:
Kitchen Facilities Sin
ve
Bathing,Toilet Facil. Vent., Plumb.,Sanit'n.:
Wash Basin,Shower or Tub:
Infestation Rats, Mice, Roaches or Other:
Egress Dual and Obst'n:
General Building Posted
Locks on Doors:
ONE OR MORE OF THE VIOLATIONS CHECKED ABOVE IS A CONDITION WHICH
MAY MATERIALLY IMPAIR THE HEALTH OR SAFETY AND WELL-BEING OF THE
OCCUPANT AS DETERMINED BY 105CMR 410.750 OF THE CODE OR THE
AUTHORIZED INSPECTOR.(See Over)
"THIS INSPECTION REP IS SIGNED AND CERTIFIED UNDERATHE PAINS AN
PENALTIEAD&RE A .'
INSPECTOR TITLE
� DATE � TIME
A.M.
THE NEXT SCHEDULED REINSPECTION P.M.
_
,
,
^
410.750: Conditions Deemed to Endanger or Impair Health or Safety
� The following conditions, when found Vz exist in residential premises, shall he deemed conditions which may endanger or
� impair the heaUh, or safety and well-being of person or persons occupying the premises.This listing is composed of those �
� items which are deemed to always have the potential to endanger or materially impair the health or safety, and well-being of the �
occupants or the public. Because Chapter ||. 105CMR410.1OO through 41O.620 state minimum requirements of fitness for �
human habitation, any other violation has the potential to fall within this category in any given specific situation but may not do so �
in every case and therefore is not included in this listing. Failure to include shall in no way be construed uoo determination that �
�
other violations orconditions may not be found to fall within this category. Nor shall failure to include affect the duty ofthe local �
health official to order repair or correction of such-violation(s) pursuant to 105 CIVIR 410.830 through 410.833 nor shall failure to
� include affect the legal obligation of the person to whom the order is issued to comply with such order.
� (A) Failure to provide a supply of water sufficient in quantity, pressure and temperature, both hot and cold, Vu meet the ordinary
i needs of the occupant in accordance with 105CIVIR410.18O and 410.10O for u period of24 hours orlonger.
(B) Failure to provide heat as required by 105 CIVIR 410.201 or improper venting or use ofaspace heater mwater heater as
prohibited by 1O5CIVIR4102OU(B)and 41O.2O2.
� (C) Shutoff a6d/or failure Vo restore electricity orgas. �
(D) Failure Vz provide the electrical facilities required by1O5CIVIR41O.25OB>. 41Ci251KQ. 41Ci253 and the lighting in com-
mon arearequired by 105CMR,410.254.
(E) Failure Vo provide a safe supply ofwater.
'
(F) Failure to provide a toilet and maintain a sewage disposal system in operable condition as required by 105CIVIR
410.15O(A)(1)and 41U.3OO.
(3) Failure to provide adequate exits, or the obstruction of any exit, passageway or common area caused by any object,
�
including garbage ortrash,which prevents ogeno in case ofun emergency 105 CIVIR 410i450 410.451 and 410.452. �
�
(H) Failure to comply with the security requirements of1O5CMR41O.48U(D).
(|) Failure ko comply with any provisions m1 CIVIR 410.600. 410.001 or410.0O2which results in any accumulation ofgm`
bage, mbbinh,filth or other causes of sickness which may provide afood source or harborage for mdontm, insects or other pests �
or otherwise contribute ko accidents orto the creation or spread ofdisease. �
(J) The presence of|oadbaood paint on adweUing or dwelling unit in violation of the Massachusetts Department of Public �
Health Regulations for Lead Poisoning Prevention and Control, 105CMR460.000. (See M.G.Lo. 111 @)@> 1QO through 1QQj
(K) Rmd,foundaUon, ur other structural defects that may expose the occupant oranyone else Vofire, bumu, ohook, accident or
other dangers nr impairment Vn health orsafety.
(L) Failure to install o|ootricu|, p|umbing, heating and gao'bumingfaoi|iVoo in accordance with accepted p|umbing, hooUing,
gas-fiffing and electrical wiring standards or failure to maintain such facilties as are required by 105 CMR 410.351 and41O.352.
so as to expose the occupant or anyone else to fire, burns, shock, accident or other danger or impairment to health orsafety.
(M) Any defect in asbestos material used as insulation or covering on u pipo, boiler or furnace which may result inthe ve|oano
of asbestos dust orwhich may result inthe release of powdorod, crumbled or pulverized asbestos material in violation of 105
CIVIR41O.353.
(N) Failure to provide a smoke detector required by 105 CIVIR 410.482.
(0) Any of the following conditions which remain uncorrected for a period of five or more days following the notice to or
knowledge nf the owner/d said condition orconditions:
(1) Lack of a kitchen sink of sufficient size and capacity for washing dishes and kitchen utensils or lack of a stove and oven
or any defect that renders either inoperable.
(2) Failure to provide a washbasin and shower or bathtub as required in 105 CMR 410.150(A)(2)and 410.150(A)(3)or any
defect which renders them inoperable.
(3) Any defect in the electrical, plumbing or heating system which makes such system or any part thereof in violation of
generally accepted p|umbing, hmating, gasfitting, or electrical wiring standards that do not create an immediate hazard.
(4) Failure to maintain aoufo handrail or protective railing for every stairway, porch ba|cony, roof o,similar place as
required by 105CIVIR410.5O3(A)and 410.503(B).
(5) Failure toeliminate mdomo, 000knoaohen, insect infestations and other pests as required by 105 CIVIR 410.550.
(P) Any other violation of 105 CIVIR 410.000 not enumerated in 105 CIVIR 410750(A)\hmugh <O>ohu|| be deemed to boacon-
dition which may endanger o/materially impair the health or safety and well-being of an occupant upon the failure of the owner
to remedy said condition within the time 000rdered by the Board of Health.
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SENDER: COMPLETEtTHISSFCTIOff •MPLETE:THIS SECTION ON DELIVERY
® Complete items 1,2,and 3.Also complete A. ignature
item 4 if Restricted Delivery is desired. ❑Agent
■ Print your name and address on fhe reverse X ❑Addressee
so that we can return the card to you. Ived by(Prl ted Name) C. ate of Delivery
■ Attach this card to the back of the mailpiece, n/l-�
or on the front if space permits.
I! !Z'
1. Article Addressed to: D. Is delivery address diffe Rem 1? ❑Yes
CC If YES,enter delivery ad eiow: ❑No
_ 3. Service Type
D e��V V�2-� ��} (j� (e.S, U Certified Mail ❑Express Mail
w<��q�, �,•� „� ❑Registered IS Return Receipt for Merchandise
va•, xx= ai "''~ ❑Insured Mail ❑C.O.D.
❑Yes
Roll
gnu � �.WrFt''�'�;@$4yta�� ,a,'�x Yp�� •� ,� a{
PS Form 38ff,"IftVuary eipt 10259<2=ivt-1540
UNrFn $ First-Class Mail
Postage&Fees Paid
USPS
Permit No.G-10
l • Sender: Please print your name, address, and ZIP+41n this box • i
I
°' Town of Barnstable
Health Division
%
� Jf 200 Main Street , �..�
Hyannis,MA 02601
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iiii=.==,i= i =itiii,=.:iliiiiiil=.iiiiiit =1ii11ii11ii=. 1iii1
FINE T°k j
Townf of Barnstable Barnstable
P� q'
Regulatory Services Department Ce
CH
i BARN.WABLE.
"A9-1639- Public Health Division
ArfD MAC" 200 Main Street, Hyannis MA 02601 2 07
Office: 508-862-4644 Thomas F.Geiler,Director
FAX: 508-790-6304 Thomas A.McKean,CHO
S. SQ IV.
a�
October 15, 2007 �
Susan Bright
82 Pine Lane
Osterville, MA 02655
Re: 82 Pine Lane and Chapter 170—Rental Properties
CY
Dear Susan,
I am writing in regards to the new rental ordinance for the Town of Barnstable,
where all rental properties are to be registered and inspected by the Town of Barnstable
Health Department. We received an application to register the above-referenced rental
property in accordance with Chapter 170-Rental Properties of the Town of Barnstable
Code; the next step would be to schedule an inspection. Please contact me at your
earliest convenience to discuss and schedule this inspection.
Thank you in advance for your cooperation.
Respectfully, \01123
Caitie Barrett
Rental Program-Coordinator
Health Division
Direct#508-862-4072
CERTIFIED MAIL# 7006 0810 0000 3525 0847
J:\Letter to Occupant.doc
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[SEND6: CO-MPLETE-THIS SECTION COMPLETE THIS,SECTION ON DELIVERY
■ Complete items 1,2,and 3.Also pomplete A. Si nature
Item 4 if Restricted Delivery is desired. ❑Agent
a Print your name and address on the reverse X & j/J - . ❑Addressee
so that we can return the card to you. B. Received y(Printed Name) C. Date of Delivery
to Attach this card to the back of the mailpiece, ; rc
I or on the front if space permits.
D. Is delive address diffe t from item 1? ❑Yes
I 1. Article Addressed to: If YES,enter delivery address below: ❑No
I
3. Service Type
I V� •�n t� M A d 1�t Z 0 ®certified Mail ❑ Fress Mail
❑Registered I h
❑Insured Mail C.O.D.
4. Restricted Delivery?(Extra Fee) ❑Yes
2. Article Number " - F
(Transfer from servicelaW 7003 1680 0004 5458 4845
PS Form 3811,February 2004 t 1 !Domestic Return Receipt 102595-02-M-1540 i
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UNITED STATES POSTAL SERVICE: .f 4. '` First-Class Mail
.Postage&Fees;Paid I
USPS
Permit.No.G-10
• Sender:Please print yourna .e, address,a IP+4.in this box•
I
fownofBarnstable
Q � Health Division
200 Main Street
Hyannis,MA 02601
I
III,sit,
�sT Town of Barnstable
ti
Regulatory Services Department
BARNSTABLE,
9�A MASS. r Public Health Division
rfb" A 200 Main Street, Hyannis MA 02601
Office: 508-862-4644
FAX: 508-790-6304 Thomas A.McKean,CHO
July 5, 2007
Mary Mannix
679 High Rock Road
Fitchburg, MA 01420
Dear Mary,
I am writing in regards to the rental ordinance for the Town of Barnstable. We
would like to inspect the rental unit you own at 82 Pine Lane Osterville. I have left a
few messages with you, as well as having sent you a letter dated June 19, 2007, but have
yet to hear from you. At your earliest convenience,please contact me to schedule this
inspection.
Any comments or questions,please do not hesitate to contact the Health
Department. Thank you in advance for your assistance and cooperation.
Respectfully,
Caitie Barrett
Health Division
Rental Program Coordinator
#508-862-4072 Direct Line
CERTIFIED MAIL# 7003 1680 0004 5458 4845
s • • fff j
♦ 4 4
• • 0
°PIKE Tp Town of Barnstable
P
Regulatory Services Department
f
� IIARNSTABLE, '
MASS.39. Public Health Division
�p i63q. ��
ATFD MAC a' 200 Main Street, Hyannis MA 02601
Office: 508-862-4644
FAX: 508-790-6304 Thomas A.McKean,CHO
June 19, 2007
Mary Mannix
679 High Rock Road
Fitchburg, MA 01420
Dear Mary,
I am writing in regards to the new rental ordinance. We would like to conduct an
inspection of the property you own at 82 Pine Lane, Osterville. I have left a couple of
messages with you since April,but have yet to hear back. Please do give me a call when
you have time so we can schedule an inspection that is convenient with your schedule.
Thank you for your assistance and cooperation, it is truly appreciated.
Respectfully,
Caitie Barrett
Health Division Assistant
Rental Program Coordinator
#508-862-4072 Direct Line
f
tF;
BOR:TOLOT.TFCONSTRUCTION INC..
�BD8BOR1'J►CL 'SEX7�C3E•• DZBPO.SAL SYST ZNBPECTION PORT!
Addr4s,8 ,ofapropert'y
OvizeYts ?1i�bie, --._ ..
Gate' ot�2ispaction501 1.4 - -
PART .a
CHECKLIST
Checkk11 f the Zcl-lovinq. ..have been done:,
7tumpinq information ti,►a's .raqupsted:. of the owner, occupant , and
ti Nona o= the system components have been. for at least too
and the system has' be'en receiv ngnormal flow rates during that
pariad. Large vol,uwaa ot::water have:
.not been introduced into thy.
�syst�m racerttly or: par.t of:",this.< inspection.
i- ...Az built plans haye.•b.een obtained and examined . .
..a Note if they r
ava bl.. :with N/1►',`.
This facility 'or dvell'.ing.•vas inspected f signs of sewage heel:
; The efts wet :`inspected for: signs . of ha.° b
J111 system componets , ; excluding the, S-;A ;ve been located
n •
The aepti�c tank manholes w c�
were uncovers;-v ooened , and the inter
the septic. tank vaa: inspected. for cond +_; of baffles or t o s ,
iaateriah of construCtion.,'edi,m.ensi'on;s c 2;,"a of liquid , depth o
sludgo, d.apth
_ 1_ The size and hocation- of the .SAS ,on the site has been deteLmined
qr� existing information or ,approximated by non-intrusive method. .
The f:acil�ay owner (and occupants, ,if . different from owner] w� r •
provided .with Ynformation on the proper maintenance of SSns .
SUBSURFACE ,:S:EWAGE ,DISPOSAL SYSTEM INSPECTION FO"
...PART B
SYSTEM INFORMATION
FLOW';,CONDITIONS
It residential
:`nuatiber of bedrooms
aaai_.number o2 current residents
O garbage grinder, yes or no
ye S laundry connected to system, yes. or no
! .seasonal 'use, ; yes ;or_;°no.
Z_f nonresidential, Icalculated. .flow:
Water meter readin`s
g ,. •if ..available:
( 9 y Last date ;of- occu an
P cy
GENERAL, INFORMATION
-:Pumping records and source of information:
�Vb_ System pumped as , art of inspection, yes or no
if yes, volume_,.pumped
Reason'. for =pumpin'q: .
Type .of, system
Septic tank/distriburi'on box/soil absorption system
,� Single, cesspool
Overfaw ocesspool
Privy;`.
Shared system.;: (yes or no, (if yes, attach previous inspection.
records,;.if any)
Approximate, age; of all components. Date
inf installed, if known . source o`
orma`tion`•
1�CZ Sewage odors detected when arriving at - the site, es or n
Y o
BUBSURFACE ':BEWAGE DISPOSAL SYSTEM INSPECTION FORM
, ..
PART` B'
SYSTEH ;INPORHATION. continued
SEPTIC
(locate onit se .plan)
deptti below grade.
iaate.rial :;'of „construction t/concrete:. _ <_metal FRP other explain)
:.
aluage depth
aifi.ig` i ou,..,t p. cf �.Iudge . to bottom„of outlet tee or baffle
'scums' thickness
, mt t baffledistance f
d.is ance; from. .bottom.. of scum' -to bottom of outlet tee or baffle
Comments
(recommendation, for pumping, '-condition of inlet and outlet tees or baffle-.
al inte rit
depth of , l.iqu d.. level-., in .relation to outlet. invert, structur q y
evidence::of leakage:,`, recommendations for 're airs,, etc . )
)
c . �. yee4 ,
i l Cti�'•.
(11
DISTRIBUTION' BOX.
(locate on iite plan,)
depth of- liquid , level'. .ab.ove outlet invert
:Comments_..
(note (''level and distribution is equal evidence of solids carryover ,
evidence,.,of 1`eakage ,"Into .or 'out of box, recommendation for repairs , etc , )
D- �' ,1
PUMP`< CHAMBER
(locate on side plan)'
pumps in: :workng order, yes . or-'no
Commentsz
:`,(note condit `on :of pump chamber, condition - of pumps and appurtenances ,
recommendit 6nS; for mal 1niaenanCe Or repa"irs, etc. )
E. SgWAGE ;DI
soesoRpAc.
BPOSP►L SYSTEM INSPECTION FORM
PART..B
SYSTEM INpORXATION . continued
SOM ABSORPTION SYSTEM (SAS).: .
(hocate on site plan'",; if.,.possible; . excavation not required , but may be
approximated by non-intrusive methods)
If aot. determined to tie present, explain:
TYPe
leac3ain ` p. s .sz d sum6er
leaching. chaidibers and number
1"eachinq,gallet. es and number
Ieachir�q" tenches., number., :length
leaching= fie Ids,, ;number, 'dimensions
--
overtlow cesspool, number
Comments:
(note condition -of soil , signs of hydraulic failure, level of ponding ,
condition Ot >vegetatiOn, ..recommend t' ns for maintenance or repairs , etc . ;
C ps Q �•� �i4e tin lontcp; yern h cj�)>L h a�� rhr�nh iE -
CESS.POOIS (locate on site pl"an) : � .
number and don iqurition
pth-top ot':>Iiquid to nlet rove
de rt
depth of solids Payer, .
depth of -scum layer ---.
dimensions= o! cesspool,
materials of :!construction
dcation o;t groundwater,
inflow (cesspool` must, be :pumped as
part of :inspection,)
Comments
(note condition:`of so-il, signs of hydraulic failure , level of ponding ,
condition of-.vegetation,_. recommendations for maintenance or repairs , etc . ;
PRIVY: ��-
locate :6n site _ ----
::-(. plan) :
r materials of,--c ruction
dimensions
--
depth otl'.. o1id5 — --
,:Comments:
note condition of soil, signs of hydraulic failure, level of ponding ,
condition' of .vegetat `on, re.:commendatons for maintenance or repairs , etc .
1
BDBBIIRFACE..: SEWAGE :.DZS.POSAL , BYBTEM INSPECTION FORM
PART B k`,
SYSTEM INFORHATION``continued
SKETCH OF,;,:SEWAGE. D.I$POSAL .SYS.TEM:
include; ties to at. least two ;.permanent references landmarks or benchmark:
iocate all wel:ls .within`' 10o'
a
q'
DEPTH -TO' GROUNDWATER
depth to groundwater
method of. .determination or approximation:
h o B l4 S�rwt� O r // y�o B ----
---
SUBSURFACE ...SEWAGE DISP08AL.: SYSTE2i INSPECTION FORM
PART C ..
FAILURE;-CRITERIA
indicate yes,,. no,. or .not_ determined (Y, _14, or ND) . Describe basis of
.;determination in all instances. Zf "_not determined" , explain why not)
: Backup o! sewage into.: facility?
Discharge or ponding of effluent to the . surface of the ground or
surface`_waters?
: Str�.tic .?iuuid lfveI it .the distribution .box, above outlet invert?
Liquid depth in cesspool <6" below invert or available volume< 1/ 1 -Jt .
flow?
Required pumping 4 times or more in the last year?
number: of times pumped
Septic tank is metal? .cracked? structurally unsound? substantial
infiltrations substantial. exfiltraton? tank - failure imminent?
Is any portion of the SAS, ce.sspo:ol or privy:
be 6V the high :groundwater elevation?
N within 50, feet of a surface water.?
within 100 :'feet of a surface. .water supply or tributary to a surface
water supply?:
within .a :Zone I `of a public well?
within 50 feet of ..a bordering vegetated wetland or salt marsh
(cesspools and;.priv es,' on y;. the SAS) ?
A . Within 50 .feet-..of a private .water supply well?
less thsn 100 feet but greater than 50 feet from a private water
er
supply w.el.I with no acceptable water quality analysis? If the well
has beet analyzed to.'be ''acceptable attach copy of well water analys
to'r ;coli'form'`bacteriavolat, e'.organic compounds, ammonia nitrogen
and :nit'rate nitrogen:.
V B ti
7 .f}
SUBSURPl10E `BENAGE D'I8PO8J�L BYSTE?t: INSPECTION FOR
�. PfiRT D
CERTTYZCxtION
ULA
` Cr✓(:UZ W��
Name of Inspector
Company. Nama,&40
Com a n Ad 5 .- Coca c�
P Y ` dress `7LoS, rnA v� �
:<:�Certificati'on "statement
I ceYtif� tat 1--. ha 3 p`ersii,):na1..y; irispe6=ted the sewage dispc;sal system at
this address: that the inforzaation reported is true, accurate and
complete as `of the time `of ;.inspection. r The inspection was performed and
any recommendations regarding upgrade;. maintenance and repair are
consistent w th ;.my trainingand exper:fence in the: proper function and
man te . tms.
Chec one
I have not found any information which indicates that the system fai ;
to :`ads=quately .pro,t:ect; ,public h'e. lth :,or the environment as defined if
310' CMR= 15 .303. A y f;aiAvre criteria not -evaluated are as stated ir,
the P1IILORE CRS'TERTA section. of. "this form.
L,?have determined that the;isystem fails to protect public health an:i
the` environment. as .defned in 3'10 . CMR 15 . 303 . The basis for this.
determination `isli, .pr,ovaded, 'in :the Y ILURE CRITERIA section of this
form
Inspector_'S Signature.
Date
original ',to system owner
Copies to;.
Buyer, (af appiicable)
Approving authority t,