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HomeMy WebLinkAbout0059 SEAPUIT ROAD - Health 59 SEAPUIT ROAD, OSTERVILLE A=118-124 LOT 6 �k e 1 i e A • -a ;, , COMMONWEALTH OF MASSACHLTSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL P CTI0�1 �3 - 17 'TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSIINE NTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A TIFICATION Property Address: Tci 7�e n3 Owner's Name: 7 f Owner's Address: rvi t= Date of Inspection: —11.1-WC C71 o` Name of Inspector.(please print)MATTwew L, c V Lit`3S Company Nance: IirlaWng Address:`i 2 . W. l�,c ,(a„ Telephone Number. rn CERTIFICATION STA I cat*that I have personally inspected the sewage disposal system at this address and that the information reported below is true,actuate and complete as of the time of tare inspection.The inspection was performed based on my tenoning and experience is the proper flmcdon anti maiatenaace of on site sewage disposal systems,I am a DEP approved system lnspector pursuant to Section 13.340 of Title 5(310 CIYIIt il000). The system: J�Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Falls Inspector's Slgnatnrey%� Date: ..5- 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 systan is a shared system or has a design flow of 10,000 gpd a greater,the iaspect�and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies.sent to the buyer,if applicable,and the approving authority. Notes and Comments ****Tbb 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 pave l Page 2 of 11 j . I OFFICIAL INSPECTION FORM-;-NOT FOR VOLUNTARY ASSESSMENTS . SUBSURFACE SEWAGE DISPOSAL SYSTEM INTSPEC 13ON FORM PART A CERTIFICATION(continued) Property Address:' owner. t je j<-ov! Date of Inspection: S 16 Inspection Snmmsry: Check A,&C,D or E/ALWAYS complete all of Section D A. System passes: `✓ I lisve not found any information which indicates that any of the failure criteria described in 310 CMR 13.303 or in 310 CMR 13.304 exist.Any failure criteria not evaluated are indicated below. Comments: f� B. System Conditionally Passes: One or more system components` as dmnbed in the"Conditional Pass"section need to be replaced or repaired.The system upon completion of the replacement or repair,as approved•by the Hoard of Health,will pass. Answer yes,no or not determined(YAND)in the for the following statements.If"not determined"please explain The septic tank is metal and over 20 years otd•or the septic tank(whether metal or not)is structtnally • unsound"exhibits substantial Mitrallon or mc8ltrad m or tank More is inunh mt System will pass inspection if the existing tank is replaced with a complying sepdc MR as approved by the Hoard of Health. 'A metal septic tank will pass inspection if it is st udurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less thaw 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipc(s)or due to a broken,settled at uneven distribution box.System will pass inspection if(with approval of Board of Health): broken pipes)=ieplsced obstruction isrmoved' disuffmdcn bm b leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipes).The system will pass inspection if(with approval of the Board of Heahhx broken pipe(s)are replaced obstruction is removed ND explain: r•. • Page 3 of l l OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CEATMCATION(contmted) Property Address: - S'4 Owner: c,o i rue,\�-z Date of Inspection: C. Farther Evaluation is Required by the Hoard of Health: Conditions exist which require Hurler evalnatim by the Board of Haft in order to determine if the syrtem is failing to protect public health,safety or the envkMjem, L System will pass-glens Board o(Hes ith determines in accordance with 310.0 sIR 1?j03(lxb)that the system b not functioning is a manner which will protect pablle heal*safety and the enviroamentt _ sspoo aa<p�nl pvy is within 50 Am ofa surAcs water C�p- vy U e 1 a within 30 Lett of a boftiog vegetated wetland or ai salt marsh ;. System will fag unless the Hoard of Health(and Public Water Sappller,If any)determines that the system Is ibnctioning to a manner that protects the public health,safely and eaviroamentt . . _ The system has a septic tank and soil absorption, (SAS)and the SAS is within 100&et of a s-dace water supply or tributdry to a aurffice WSW Supply. The system has a septic tank and SAS sad the SAS is within a zMe 1 of a public water supply. _ The system has a septic tank and SAS and the SAS is within 30 feet ota private water supply we1L The system has a septic tank and SAS and the SAS is,less thug 100 fat but S0 fcts oc more 5+cm a private water supply wen** Method used to de;eraiiae distance "This system passes if the well water aaalysb,performed at a DEP ce d'w laboratory,for coliforrm bacteria and volatile organic compounds indicate that the well is free$om pogution from that factflrty and the presence of ammonia nitrogen and nitrate nitrogen is&pW to or less than S ppm,provided that no other fat M criteria are tnUaod.A copy of the analysis must be attached to this form. 3. Other. r • Page 4 of l 1. OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSIVlEMS SURFACE SEWAGE DUPOSAL SYSTEM INSPECTION FORM PART A. CERTIFICATION(continued) ,. Ptoperty Address: =(Xi► 0""k_7LWe Owner: D=;�,1 k� Date of Inspection: <1 6-o tS' D. System Faflure Criteria applicable to all systems: . You 19'3!!indicate"yes"or"no*to each of the following for pjLhmpecdons: Yes No =/ Baclatp of sewage into facility or system component due to overloaded or clogged SAS or cesspool Disebecge or pcnding of e$baent to the suttee of the ground or siafltce waters due to an overloaded or clogged SAS or cesspool . d _ V. Static liquid level in the distribution boar above outlet invert due to an overloaded or clogged SAS or ,_ ✓ Liquid depth in cesspool is less than 6"below invert or available volume Is less than K day Boa► _.Ne Required more than 4 times in the last year I due to clogged or obstructed p4*sj Number pumpedOf times _W� Any portion of tie 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 waM'supply. ' Any pardon of a cesspool or privy is witMa a Zane 1 of a public well. _ Any portion of a cesspool or privy is within 30 fed of a private water supply well. , / Any portico of a cesspool or privy is lea than 100 Lea but greater than 30' M from a private water supply well with no acceptable water quality analysis.[The system passes it the well water..aaalysi4 performed at a DEP cerWed bibntogg for eolihm btreterb and volatile organic•compounds indicates that the well is free Soar pollution from that beWty and the presence of ammonia nitrogen and nitrate nitrogen Is equal to or lea than Sppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.) W (Yes/No)The system A.I have determined that one or mom of the above failure criteria racist 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: N�Ft To be considered a large system the system agnst serve a facility with a design new of 10,000 gpd to 1-4,000 You must indicate either"Yee or"ne to each of the following: (7U following criteria apply to large systems in addition to the criteria above) I yes no — •_ the system is within 400 fed of a surface drinking water supply the system is within 200 fed of a tributary to a surface drialdog water supply — _ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone U of a public water supply well If you have answered"fires"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 CUR 15.304.The system owner should contact the appropriate regional office of the Department. ` Page 3 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSES&WMS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORT PART B CHECKLIST Property Address: S9 kPyi - fzj . Owner.i-jP.lyczv4 at 1 _ Date of Inspection: . . _ Check if the f b1lowins have been done.You and indicate es"a"no"as to each of the ifollo . Yes No ✓ _ Pumping information was provided by the.owner.occupant,or Hoard of Hestth ✓ Were any of the system components pumped out in the previous two Weeks'? s _ Hato system received:normal flows in do previous two week period _ -k:::: 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?afthey 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,excludingthe SAS,located on site ✓ Were the septic tank manholes uncovered,opened,and.the interior of the tank bapected for the condition of tine batHes or tees,material of construction,dimensions,depth of liquid,depth of sludge ad depth of scum? to,- _ Was the facility owner(and occupants if diffinm 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 ow Yes no G .v Existing information.For example,i plan at the Board of Health. v Detamined in the field(if any of the failure criteria related to part C is at issue approximation of distance is unacceptable)(310 CUR 15302(3)(b)l page 6 of 11 oyylCIAL ViSPECTION FORM—NOT FOR VOLUNTARY ASSESShMNTS SUBSURFACE SEWAG$:DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 5�l Owner: Date of Inspection: FLOW CONDITIONS RESIDNumber ofb6*E. Nmaber of bedrooms(a UMW. DESIGN flow based on 310 CUR 13.203(far acample: 110 gpd x*of bedrooms):—qqD WO Number of current residents* Q . Does residence Dave a garbage grinder(yes or nod La is laundry on-A separate sewage system(yea or no):jj�L [if yes separate inspection required] Laundry system:inspected(Yes a nox&n seaaanai use:(yes'ot nor Water meter readies6 if available(leaf?years usage(SA) Nl sump pump(yes at no): Last date doccupamy: Co D-139RCIALMDUSTRIAL Type oieatsblislime Design flow(based on 310 CUR 13.203): ®d Bask of design Sow(a eab/pelsasLtsllsgE.etc•Y• Graeae uv present(yes ornox— Industriel waste holding tank present(yes or no): Non-saniary/waste discharged in the Title S system(yes or no):_ Water meter reading%if available: Last date of occupancyluse: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: N I h Was system pumped as part of the inspection(yea or no):_ If yes,volume pumper melons—How was quantity pumped determined? Reason far pumping:. TYPE OF SYSTEMS -4ZSepole tank distribution box'soil absarptiaa system _Single cesspool _Ovaffow cesspool _" Shared system(yes or no)(if yes,attach previous inspection records,if any) lnaovative/Alternative technology.Attach a copy.of the current operation and maintenance contract(to be obtained from system owner) _Tight tank _Attach a copy of the DEP approval _Other(describe): -- Approximate a of all components,date installed(if known)and source of information: PPr tag ��54a1t2r� I`Iti�(tee dis��3wl �.s s cA,,*uj°ori 1- 46^3 Were sewage odors detected when arriving at the site(yes or no):M Page 7 of i l N OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM IlYSPECTION FORM PART C S YSTEM MORMATION(continued) Property Address: (Zd vi 1l ' Owner. e % Date of Inspection: BUUMING SEWER(locate an site plan) Depth below grade: 1 , r Materials of consmidom_cast irom _.::�40 PVC_otter(explain): Distance Elam private water supply well or suction lice: Comments(cin condition of joints,ventin&evidence of leakage,etc.): vl c�.rdJ 1-i1w.► . T—e t a✓ J?lc'ce C' - NnKr e-)C I`rvc . f r • SEPTIC TANK:Z(locate on sift plan) Depth below ice«- Material of construction:_!::�conceoe metal fiberglass_PohiftYlene cdur(acplain) If tank is metal list age:_ is age conl r_by a Certificate of Compliance(yes or no):_(attach a copy of ce:dficate) `-•~ Sludge depth: r Distance from top of sludge to bottom of outlet tee or baffle: "3, r Scam thiclmesa: e S r Distance from top of scum to top of outlet tee or baffiet o 41 Distance from bottom of scum to bottom of gullet tee or baffle: . m How were dimensions determined: S tvi.Q .i VI!4.9 Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity►,liquid levels as related to outlet invert;evidence of leakage,etc.): Z f� Mtx _,tA ec 4, 4,1- !`{ry k 61C I%fSPtc�°csw GREASE TRAP:Nitocate on site plan) V Depth below grader_ Material of construction:._concrete_metal_fiberglass_polyethylene_other (explain): - Dimensions: Scum thicimess:— 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 ptanping recommendations,islet and outlet tee or baffle condition,strucuual integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): • Page g of 1 I OFFICIAL IlVSPECTION FORM—,NOT FOR VOLUNTARY ASSESmS SUMURFACE SEWAGE DISPOSAL SYSTEM WSPEMON FORM PART C SYSTEM VMRMATION(continued) Property Address: ''q Q pu,�L ad i Owner. 6k(SUw PA, 12 Date of Inspection: t 16-- of TIGHT or HOLDING TANK: ((tank must be pumped at time of inspectionXIocate on site plan) Depth below grade: Material of construction: concrete metal fiberglass_polyethylene odm(explai0 Dimensions: Capacity: sssllons Design Flow: aallons/dzy d Alarm present(yes or no): Alarm level• Alarm m working order(yes or no): Date of last pumping Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: '� (if present must be opened)Oocate an site plan) Depth of liquid level above outlet invert level Comments note if box is and distn'butioa to outlet( evidence of solids er, evidence of leakage into or out of box, etc.): ��'�Y �Yov ,any sieLx4vm I OF CW 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.): Page 9 of 11 OFFICIAL:INSPECTION FORM-=NOT FOR VOLUNTARY ASSESSMENTS / SUBSURFACE SEWAGE DISPOSAL SYSTEM IIVSPECTION FORM t PART C SYSTEM INFORMATION(contimsed) Property Address: d Owner: Ntk%w j ne,O-2. Date of Inspections !�;--c L--a�� SOII.ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits.numbech@zabom-._r.`�L� ' q leaching wenches,number,length: -7— _ =leaching fields,number,dimensions: ovezfiow cesspool,mnnber: innovativelalternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of pondin&damp soil,condition of vegetation, etc.): • 'l�acL. 1-,rc..r�,!-c s c,re tu�,rk,wc�- pan a-1 w Iwo st'14-�=S aI=-,t- �• f•=,.')�rr� . �.� ,�� CESSPOOLS: (cesspool must be pumped as part of iaspectionxlocate on site plan) Number and configuration: Depth—top of liquid to inlet invert: Depth of solids layer: Depth of scum layer. Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yea or no).* Comments(note condition of soil,signs of hydraulic failure,level of pondin&condition of vegetation.am.) PRIVY:V lg�,(locate on site plan) Materials of consnction: Dimensions: Depth of solids: Comments(note condition ofsoil,signs ofhydraulic failure,level of pondin&condition of vegetation,etc.): a Page 10 of I I OFFICIAL IlYSPXCTION FORM-NOT FOB VOLUNTARY ASSESSMENTS SIMSURFACE SEWAGE DISPOSAL.SYSTEM INSPEC71ON FORM PART,C. . .. SYSTEM ENFORMA71ON(continued) Property Address: c g"n ad. r,SS[ra11e_ Owner: Date of Inspectioiu SIzTCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal gstem including ties to at least two permanent re&ra=landmarks or benchmarks.Locate all wells within 100 feet Locate where public water supply enters the building. k I - i b� 0 o t 4Z -37' • Z O Page 11 of 1 :. •. OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) property Address: z , Owner: i►ir,9 SBr, Y3t I �-'� Date of Inspection: an zx4m Slope Surface water Check cellar Shallow wells Estimated depth to Srowd water12 feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained ftm system design plans on record-if checked,date of design plan reviewed: f= O site(wag property/obaervatton hole within 150 feat of SAS) ' Checked with local Hoard of Heahh-explain: Checked with local 03wavEmM mstalle»-(attach doa:mentadon) J�Accessed USGS database-axpla3a: You must describe how you established the b ground water elevation: t �a. t�-• D�� F%varr►• su c ,�+ COMMONWEALTH OF MASACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAI AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET BOSTON MA 02108(617)292-3500 TRUDY COXE Secretary ARGEO PAULCELLUCCI DAVID B.STRUHS Govemor ;:.. Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: 59 SEAPUIT RD. COTUIT, MA 02635 M118 P124 L6 �.� Name of Owner PETER BILODEAU Address of Owner. 69 SEAPUIT RD.COTUIT,MA 02635 - r� v Date of Inspection: 4/3/00 RECEIVED of Name of Inspector: JOHN GRACI APR 7 2000 - $ I am a DEP approved system inspector pursuant to Secdon 15.340 of Title 5(310 CMR 15.000) TOWN OF Mmsusa Company Name: SEPTIC INSPECTIONS HEALTH DEPT, Mailing Address: P.O.BOX 2119 TEATICKET,MA.02636 Telephone Number: 608-664-6813 FAX 608-664-7270 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: ' X Passes Conditionally Passes _ Needs Further Evaluati Byte Local Approving Authority Fails Inspector's Signature: Date:4/4/00 The System Inspector shall submi a copy of this inspection report to the Approving Authority(Board of Health or DEP)within thirty(30)days of completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. NOTES AND COMMENTS "The inspection is based on criteria defined in Title V code 310 CMR 15.303.My findings are of how the system is performing at the time of inspection.My inspection does not imply any warranty or guarantee of the longevity of the septic system and any of its component's useful life." THE SYSTEM PASSES TITLE V INSPECTION.RECOMMEND PUMPING THE SYSTEM EVERY TWO YEARS FOR PROPER MAINTENANCE. revised 9/2/98 Page 1 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 59 SEAPUIT RD. COTUIT, MA 02635 M118 P124 L6 Name of Owner PETER BILODEAU Date of Inspection: 4/3/00 INSPECTION SUMMARY: Check A, B, C, or D: A. SYSTEM PASSES: X I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist.Any failure criteria not evaluated are indicated below. 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. n1a, The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection;or the septic tank, whether or not metal,is cracked,structurally unsound,shows substantial infiltration or exfiltration,or tank failure is imminent.The system will pass inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. nta Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box.The system will pass inspection if(with approval of the Board of Health). broken pipe(s)are replaced _obstruction is removed _distribution box is levelled or replaced n1a The system required pumping more than four times a year due to broken or obstructed pipe(s).The system will pass inspection if (with approval of the Board of Health): _broken pipe(s)are replaced _obstruction is removed revised 9/2/98 Page 2 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 59 SEAPUIT RD. COTUIT, MA 02635 M118 P124 L6 Name of Owner PETER BILODEAU Date of Inspection: 4/3/00 D. SYSTEM FAILS: You must indicate either"Yes"or"No"to each of the following: I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303.The basis for this determination is identified below.The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No - X Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. - X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. - X Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow, - X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped Q. - X Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. - X Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. - X Any portion of a cesspool or privy is within a Zone I of a public well. X Any portion of a cesspool or privy is within 50 feet of a private water supply well, X Any portion of a cesspool or privy is less-than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis.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 systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No X the system is within 400 feet of a surface drinking water supply - X the system is within 200 feet of a tributary to a surface drinking water supply - X the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone II of a public water supply well) The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.30412).Please consult the local regional office of the Department for further information. N revised 912198 n` Page 4 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM IN''PECTION FORM PART B CHECKLIST Property Address: 59 SEAPUIT RD. COTUIT, MA 02635 M118 P124 L6 Name of Owner: PETER BILODEAU Date of Inspection: 4/3/00 " Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following: Yes No X _ Pumping information was provided by the owner,occupant,or Board of Health. • ' X _ 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. X _ As built plans have been obtained and examined.Note if they are not available with N/A. X _ The facility or dwelling was inspected for signs of sewage back-up. X _ The system does not receive non-sanitary or industrial waste flow. X _ The site was inspected for signs of breakout. X _ All system components,excluding the Soil Absorption System,have been located on the site. X _ The septic tank manholes were uncovered,opened,and the interior of the 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: X _ Existing information,For example,Plan at B4O,H, X _ Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable)1.5.302(3)(b)) X _ The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of SubSurface Disposal Systems. revised 9/2/96 Page 5 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 59 SEAPUIT RD. COTUIT, MA 02635 M118 P124 L6 Name of Owner PETER BILODEAU Date of Inspection: 4/3100 FLOW CONDITIONS RESIDENTIAL: Design flow: 110 g.p.d./bedroom Number of bedrooms(design): 4 Number of bedrooms(actual): Total DESIGN flow: 440 gpd Number of current residents:4 Garbage grinder(yes or no):NO Laundry(separate system)(yes or no): NO 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): n/a gpd Sump Pump(yes or no): NO Last date of occupancy: n/a': CO M M ERC IAUINDUSTRI AL Type of establishment: n/a Design flow: n/a gpd(Based on 15.203) Basis of design flow:n/a Grease trap present:(yes or no): NO Industrial Waste Holding Tank present:(yes or no): NO Non-sanitary waste discharged to the Title 5 system:(yes or no):NO Water meter readings.if available: n/a Last date of occupancy:n/a Ili - OTHER: (Describe) n/a GENERAL INFORMATION PUMPING RECORDS and source of information: n/a System pumped as part of inspection:(yes or no):NO If yes,volume pumped n/a gallons Reason for pumping:n/a TYPE OF SYSTEM X Septic tank/distribution box/soil absorption system _ Single cesspool _ Overflow cesspool _ Privy _ Shared system(yes or no)(if yes.attach previous inspection records,if any) _ I/A Technology etc.Attach copy of up to date operation and maintenance contract _ Tight Tank Copy of DEP Approval Other:n/a APPROXIMATE AGE of all components,date installed(if known)and source of information: 1998 PERMIT 97463 Sewage odors detected when arriving at the site:(yes or no): N0 ` revised 9/2198 Page 6 of 11 L _ SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 59 SEAPUIT RD. COTUIT, MA 02635 M118 P124 L6 Name of Owner PETER BILODEAU Date of Inspection: 413100 BUILDING SEWER:X (Locate on site plan) Depth below grade: 18" Material of construction: _ cast iron X 40 Pvc _ other(explain) Distance from private water supply well or suction line: n/a Diameter: 4" Comments: (condition of joints,venting,evidence of leakage,etc.) THE SYSTEM HAS TOWN WATER. SEPTIC TANK: X (locate on site plan) Depth below grade: 12" Material of construction: X concrete_ metal_ Fiberglass_ Polyethylene_ other explain: n/a If tank is metal,list age Is age confirmed by Certificate of Compliance(Yes/No): NO 4 Age: n/a Dimensions: 1600G L 10'6"H 6'6"W 6'8 Sludge depth: 1" Distance from top of sludge to bottom of outlet tee or baffle: 33" Scum thickness: 1" Distance from top of scum to top of outlet tee or baffle: 6" Distance from bottom of scum to bottom of outlet tee or baffle: n/a How dimensions were determined: MEASURED 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.) THE SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND.RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFULL LIFE. GREASE TRAP: _ (locate on site plan) Depth below grade: n/a ' Material of construction: _concrete_ metal_ Fiberglass _ Polyethylene_other Explain: n/a Dimensions:n/a Scum thickness: n/a Distance from top of scum to top of outlet tee or baffle: n/a Distance from bottom of scum to bottom of outlet tee or baffle n/a Date of last pumping: n/a 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.) n/a revised 9/2/98 Page 7 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 59 SEAPUIT RD. COTUIT, MA 02636 M118 P124 L6 Name of Owner PETER BILODEAU Date of Inspection: 4/3/00 TIGHT OR HOLDING TANK: _. (Tank must be pumped prior to,or at time of,inspection) , (locate on site plan) Depth below grade: n/a Material of construction: _concrete_ metal_Fiberglass _Polyethylene _other u Explain: n/a Dimensions: n/a Capacity: n/a gallons Design flow: n/a gallonstday Alarm present: NO Alarm level:N/A Alarm in working order:NO Date of previous pumping: n/a Comments: (condition of inlet tee,condition of alarm and float switches,etc.) n/a DISTRIBUTION BOX:X (locate on site plan) Depth of liquid level above outlet invert: LEVEL WITH BOTTOM OF PIPE Comments: (note if level and distribution Is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.) THE DISTRIBUTION BOX IS STRUCTURALLY SOUND. PUMP CHAMBER: _ (locate on site plan) Pumps in working order:(Yes or No): NO Alarms in working order(Yes or Noy NO Comments: (note condition of pump chamber,condition of pumps and appurtenances.etc.) n/a revised 9/2/98 Page 8 of t t SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 59 SEAPUIT RD. COTUIT, MA 02635 M118 P124 L6 Name of Owner PETER BILODEAU Date of Inspection: 413100 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,if possible;excavation not required,location may be approximated by non-intrusive methods) If not located,explain: n/a Type: leaching pits,number:(n/a)n/a leaching chambers,number: (n/a)n/a leaching galleries,number: (n/a)n/a leaching trenches,number,length: (2)47 leaching fields,number,dimensions: (n/a)n/a overflow cesspool,number: (n/a)n/a Alternative system: nla Name of Technology: Na Comments: (note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.) THE LEACH TRENCHES ARE FUNCTIONING PROPERLY.THEY ARE 47'X 4'X 2';SOIL PROBED DRY IN LEACH AREA. CESSPOOLS: _ (locate on site plan) Number and configuration: n/a . Depth-top of liquid to inlet invert: n/a a Depth of solids layer: n/a Depth of scum layer. n/a Dimensions of cesspool: n/a Materials of construction: n/a Indication of groundwater: n/a inflow(cesspool must be pumped as part of inspection)NO Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) . n/a PRIVY: (locate on site plan) Materials of construction: n/a Dimensions: n/a Depth of solids: n/a Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) n/a revised 9/2/99 Page 9 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 59 SEAPUIT RD. COTUIT, MA 02635 M118 P124 L6 Name of Owner PETER BILODEAU Date of Inspection: 413/00 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100'(Locate where public water supply comes into house) I� 16e Page 10 of 11 revised 9/2/98 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 59$EAPUIT RD. COTUIT, MA 02635 M118 P124 L6 P Y Name of Owner PETER BILODEAU Date of Inspection: 413/00 NRCS Report name: n/a Soil Type: n/a Typical depth to groundwater: n/a r USGS Date website visited: n/a Observation Wells checked: NO Groundwater depth: Shallow_ Moderate_ Deep_ SITE EXAM _ Slope _ Surface water _ Check Cellar _ Shallow wells Estimated Depth to Groundwater 12 Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observed Site(Abutting property,observation hole,basement sump etc.) Determined from local conditions _ Checked with local Board of health Checked FEMA Maps _ Checked pumping records _ Checked local excavators,installers X Used USGS Data Describe how you established the High Groundwater Elevation.(Mu'st be completed) UGSS MAPS AND CHARTS-12+FEET revised 9/2/98 Page 11 of 11 N if X7 No. .J ��� -' Fee THE COMMONWEALTH OF MASS CHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF B STABLES MASSACHUSETTS 0pprication for Migaal 6, tem Construction Permit Application for a Permit to Construct Repair( )Upgra e( )Abandon( ) Complete System ❑Individual Components Location Address or Lot No. J1 S G% QU 1 t R (D5-t—. Owner's Name,Address angel.No. — r� �q'76 Assessor'sMap/Par 1�IU ",'�� 2-S� P21►�l ry) v2 ST- 0 M S f l Installer's Name,Address,and Tel.No. G tJ Designer's Name,Address and Tel.No. _ -:�- 9 Type of Building: Dwelling No.of Bedrooms 60 J� Lot Size - sq.ft. Garbage-Grinder( � Other Tvve of Buildings '.A PG- No. of Persons_ Sho ers Other.Fixtures-6 -tL��". uj a. r)E5 t" -3 Design Flow � T gallons per day. Calculated daily flow gallons.. Plan Date S Number of sheets Revision Date kknts ,cF Title Size of Septic Tank (,5�0 Type of S.A.S. � Description of Soil I V n 1 C--r ) Nature of Repairs or Alterations(Answer when applicable) Date last inspected: !V O UC—_ Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environm n Code to place the system in operation until a Certifi- cate of Compliance has b sue ss Board of e t:, Signed ® Date Application Approved by Date Application Disapproved for the following reason Permit No. 9 Date Issued '- 40. � - sz�....-- � j�/f`Y// �,•r"�- Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS— Application for Mfi6paar *patent Con.5truction_ Permit Application for a Permit to Construct )Repair( )Upgr de( )Abandon( ) 4co mplete System El Individual Components Location Address or Lot No. >g :!z,c—AP, I f Owner's Name,Address angel.No. a 2 8 n �� s Assessor's Map/Paz r dC a 7 P1Z-1 hJC� A�� " l " Insta�ller�'s/Name,Address,and Tel.No. L eJ Designer's Name,Address and Tel.No. € / A rJ D A C,( lS j Type of Building: r Dwelling No.of Bedrooms Lot Size sq.ft. Gail( � Other Type of Building 1--4 PE No.of Persons Sho ers(3) Gaf 4- r Other Fixtures �A� D021 . _3 EjV ' Design Flow �J�'L/ gallons per day. Calculated daily flow gallons. Plan,D(ate _ I - Q7 Number of sheets Revision Date iUnJ6F— Title i nJ Size of Septic_Taan/k� 1,��000 '��n/�� tom., Type of S.A.S. X l �Q n_.Qllon Description'of Soil 1 Y t 1::!5A tj 1� Nature of Repairs or Alterations(Answer when applicable) 1\ � II,, Date last inspected: N C)�� Agreement: r The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environm nt YCode a. o place the system in operation until a Certifi- cate of Compliance has b ssue s Bo d of V e t Signe d Date G Application Approved by / Date Application Disapproved for the.following reason Permit No. n� Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed(XRepaired( )UpgradedAbandoned( )by at 'T 6:-A Pr b 7T r _ constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. dated Installer S�'FT- _Tj A i ' Designer The issuance of this permit shall not be construed as a guarantee that the system willfunction as designed. Date Inspector J f --r—� -- ---------------------- ------- No. . Fee r-- THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS Migpogal bpMem Con0truction j3ermit Permission is hereby granted to Construct(XRepair( )Upgrade( )Abandon( ) System located at /_oT -55,t,1 Pv) r R_. ©5T-4-qR C► ►l .4 and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his er duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be co eted within three years of the date oft Date: Approved by � °v � V F TOWN OF BARNSTABLE LOCATION L� ti i l SEWAGE# P II.LAGE CIS sV U ASSESSORS MAP &LOTfI� ,,INSTALLER'S NAME&PHONE NO. �adan%S•` cprJ �ff�'-��`� SEPTIC TANK CAPACITY S07E> BLEACHING FACILITY: (type) �� � (size) .NO .OF BEDROOMS S -BE7ILDER OR OWNER � � 6C�:�o d'Q4w PERMITDATE: -7 •�I COMPLIANCE DATE: Separation Distance Between the: Max mime Adjusted Groundwater Table and,Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furaished.by q. 1 ` If F 1 4 �. APPLICATION FOR PERCOLATION TEST AND OBSERVATION PITS LOCATION 1''�� 9�� � '�•� _ NO. - ^� VILLAGE �J/�� U/� _ DATES 7 APPLICANT FEES lz� ADDRESS TELEPHONE NO d (Non-refundable) ENGINEER � �G� Z /�� '�-.'��C TELEPHONE NO..3 Z^�'_ DATE SCHEDULED — T_ (Applicant' s signature) t1SSES96A'S*b1AP6i LOT NO� !�� /�y. z.). . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . OIL LOG SUB-DIVISION NAME DATE TIME EXPANSION AREAWRIVATE YES N0G ��. ENGINEER TOWN WATER WELL . BOARD OF HEALTH ,✓ c%tJ� EXCAVATOR_ SKETCH: (Street name,etc. ,dimensions of lot, exact location of test holes and percolation tests, .locate wetlands in proximity to test holes) NOTES: 83 PERCOLATION RATE: TEST HOLE NO: ELEVATION: TEST HOLE NO: ELEVATION: z y 6> 2 3 � �� 4 4 6 E2 7 7 s - 8 9 9 10 s� 1�� 10 12 12 13 13 14 14 4; 15 � e9?�i2 15 16 16 SUITABLE FOR SUB-SURFACE SEWAGE: LEACHING FIELD LEACHING PITS LEACHING TRENCHESe----' UNSUITABLE FOR SUB-SURFACE SEWAGE. REASONS: NOTE: ENGINEERING PLANS MUST SHOW NUMBER ASSIGNED ON PERC TEST APPLICATION ORIGINAL: COMPLETED IN ENTIRETY BY P. E. AND RETURNED TO BOARD OF HEALTH COPY: RETAINED BY APPLICANT