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Home My WebLink About0140 SEAPUIT ROAD - Health 140 Seap uit Road Ostervine P A 09 .012001" V , 0 , Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 140 Seapuit Road Property Address Howard Padwee Owner Owner's Name information is required for every Osterville MA 02655 3/2 /2017 page. City/Town g State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A. General Information filling out forms �� on the computer, V # use only the tab 1. Inspector: key to move your cursor-do not James Ford key the return Name of Inspector Y Ford Septic Services, LLC U"t Company Name P.O. Box 49 Company Address Osterville MA 02655 City/Town State Zip Code 508-862-9400 S 12482 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: , ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further valuation by the Local Approving Authority 3/2/17 Insp is Signature Date The tem inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should'be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official. Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments ,M a 140 Seapuit Road Property Address Howard Padwee Owner Owner's Name information is required for every Osterville MA 02655 3/2/2017 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System•Passes: ® I.have not found any information which indicates that any of,the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired.The system, upon completion of the feplacement or repair, as approved by the Board.of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for-the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally.sound, not leaking and if a Certificate of Compliance indicating that ythe tank is less than 20 years old is available.,. 0. Y ❑ N ❑ ND (Explain below): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System.•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments '�M a 140 SeaP uit Road Property Address Howard Padwee Owner Owner's Name information is required for every Osterville MA 02655 3/2/2017 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): / ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 140 Seapuit Road Property Address Howard Padwee Owner Owner's Name information is required for every Osterville MA 02655 3/2/2017 page. CltyrTown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded for clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 1Y2 day flow t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 140 SeaN uit Road Property Address Howard Padwee Owner Owner's Name information is required for every Osterville MA 02655 3/2/2017 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® 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. ❑ ® An portion of y p a cesspool or privy Is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and.nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of'2000gpd- 10,000gpd. ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to.each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA)or a mapped Zone ll 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 an operator of large p Y 9 system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 • Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 140 Sea uit Road Property Address Howard Padwee Owner Owners Name information' s I a i required for,every Osterville MA 02655 3/2/2017 page. City/Town State Zi Code P Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been 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 of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ ® Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: i ` Number of bedrooms (design): 4 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 440 (Sins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 140 Seapuit Road Property Address Howard Padwee Owner Owner's Name information is Osterville required for every MA 02655 3/2/2017 page. City/Town State Zip Code Date of ins pection D. System Information Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection information in this report.) ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage(gpd)): Detail: unavailable Sump pump? ❑ Yes ® No Last date of occupancy: unknown Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ff., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ .Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: (Sins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwea lth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 140 Sea uit Road Property Address Howard Padwee Owner ' information is Owners Name required for every Osterville MA 02655 3/2/2017 page. City/Town State Code p Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: unknown Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): ^ t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °�M a 140 Seapuit Road Property Address Howard Padwee Owner Owner's Name information is required for every Osterville MA 02655 3/2/2017 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: system installed -5/20/1996- per asbuilt card Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: feet Material of construction: cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: 18 feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 & 1000 Sludge depth: 4 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 140 Seapuit Road Property Address Howard Padwee Owner Owner's Name isrequired for every Osterville MA 02655 3/2/2017 page. City/Town State Zip Code Date of Inspection D. System Information (Cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 29 Scum thickness 5 Distance from top of scum'to top of outlet tee or baffle 5 Distance from bottom of scum to bottom of outlet tee or baffle 10 How were dimensions determined? measure stick Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage, etc.): There is a 1500 septic tank and a 1000 settle tank. Tees were present Grease Trap (locate on site plan): Depth below grade: n/a feet 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: Date t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 140 Seapuit Road Property Address Howard Padwee Owner Owner's Name information is required for every Osterville MA, 02655 3/2/2017 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑,other(explain): N/a Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No . Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments A,•' 140 Seapuit Road Property Address Howard Padwee Owner Owner's Name information is required for every Osterville MA 02655 3/2/2017 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert even Comments (note if box is level and distribution to outlets equal; any evidence of solids carryover, any evidence of leakage into or out of box, etc.): The D-box was normal Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No' Alarms in working order: ❑ Yes ❑' No" Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 140 Seapuit Road Property Address Howard Padwee Owner Owner's Name information is required for every Osterville MA 02655 3/2/2017 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ® leaching trenches number, length: 2-75'x4'x2' per asbuilt card ❑ 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 pond ing, damp soil, condition of vegetation, etc.): The leach field was dry and there no sign of failure A camera was used to inspect • I Cesspools .(cesspool must be pumped as part of inspection) (locate on site plan). Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �,•y'•V 140 Seapuit Road Property Address Howard Padwee Owner Owner's Name information is required for every Osterville MA 02655 3/2/2017 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 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 of vegetation, etc.): N/a t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 L Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 140 Sea uit Road Property Address Howard Padwee Owner Owner's Name information is required for every Osterville MA 02655 3/2/2017 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately ` �ronT I A B a O _ 3 S Y a ay sy 3 as9 sy t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 • Commonwealth of Massachusetts W Title 5 Official Inspection For Subsurface Sewage Disposal System Form -Not for Voluntary Assessments e�. 140 Seapuit Road Property Address Howard Padwee Owner Owner's Name information is required for every Osterville MA 02655 3/2/2017 page. City/Town State Zip Code Date of Inspection D. System Information (Cont.) .Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 25'+/- feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: Topo and water contours map. ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: see above Before filing this Inspection Report, please see Report Completeness Checklist on next page. Mrs•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 • Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 140 Sea uit Road Property Address Howard Padwee Owner Owner's Name information is required for every Osterville MA 02655 3/2/2017 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist . ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed ® System Information— Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 .2� COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION RECEIVED APR 2 6 2005 TOWN OF BARNSTABLE HEALTH DEPT. TITLE.5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A' CERTIFICATION Property Address- 140 Seapuit Road • Osterville. Owner's Name: Donald Moran Owner's Address: Date of Inspection:- Name or Inspector:(please print) William _ Robinson . Sr.' Company Name: William E. Robinson Septic Service Mailing Address: P O Box 1089 Centerville, MA Telephone Number: (5081 775-8776 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 a9d maintenance of on site sewage disposal systems.I am a DEP approved system inspector pursuant;to:S ec on 15.340 o[Title 5(310 CI11R I5.000). The system: Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: 4 I — Date: �l�G—0 3 The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of HeaRhvr 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. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/152000 page 1 Page 2 of 11 e Y OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address:_ 140 Seapuit Road Osterville Owner: Dr)n a Date of Inspection: - —0 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. Syste Passes: I have not found any information which indicates that any of the failure criteria described in 310 CMR. 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B. Sys em Conditionally Passes: ne or more system components as described in the"Conditional Pass.'section need to be replaced or repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer y s,no or not determined(Y,N,ND)in the for the following statements.if"not determined"please explain. n septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound, ibits substantial infiltration or exfiltration or tank failure is imminent.System will pass inspection if the existing is replaced with a complying septic tank as approved by the Board of Health. •A metal ptic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating at the tank is less than 20 years old is available. ND expla' O servation of sewage backup or break out or high static water level in the distribution box due to-broken or _ obstruct pipe(s)or due to a broken,settled or uneven distribution box.System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND a lain: The system required pumping more than 4 times a year due to broken or obsmacted pipe(s).The system will pass ins ection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is rcmovcd ND expla n: s Page.3 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 140 Seapuit Road Ostervi e Owner: Donald Moran Date of Inspection: . 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 iling to protect public health,safety or the environment. I System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: _ Cesspool or privy is within 50 feet of a surface water — Cesspool or privy is within 50 feet of a bordering vegetated.wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. — The system has a septic tank and SAS and the SAS is within a Zone l of a public water supply. _ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more Goff a private water supply well•• Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is Gee from pollution from that facility and - the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. Other: r 3 Page-4 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Properly Address: 140 Seapuit Road Osterville Owner: Donald Moran Date of Inspection: D. S•stem Failure Criteria applicable to all systems: You nkast indicate"yes"or"no"to each of the following for all inspections: Yes o Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool Static liquid level in the distribution box above.outla invert due to an overloaded or clogged SAS or cesspool Liquid depth in cesspool is less than 6"below invert or available volume is less than Va day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped Any portion of the SAS,cesspool or privy is below high ground water elevation. Any portion of cesspool or privy is within I00.feet of a surface water supply or tributary to a surface Iwater supply. Any portion of a cesspool or privy is within a Zone I of a.public well. .Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 f ct from a private w-atrr supply well with no acceptable water quality analysis.(This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free.from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.l (Yes/No)The system fails.1 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. L rge Systems:To be nsidered a large system the system must serve a facility with a design now of 10,000 gpd to 15,000 gpd- You mu t indicate tither"yes"or"no"to each of the following: (71ue foil wing criteria apply to large systems in addition to the criteria above) yes no ie system is within 400 feet of a surface drinking water supply e system is within 200 feet of a tributary to a surface drinking water supply _ 1 e system is located in a nitrogen sensitive area(Interim We Protection Area—IWPA)or a mapped one 11 of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,ar answered "yes"in Se Lion D above the large system has failed.The uwner or operator of any large system considered a significant hreat under Section E or failed under Section-D shall upgrade the system in accordance with 310 CMR 15.304.Th system owner should contact the appropriate regional office of the Department. 4 Page S of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART.B CHECKLIST Property Address:_ 140 -Seapuit Road Osterville Owner: Donald Moran Date of Inspection: G S� Check if the following have been done.You must indicate'yes"or"no"as to each of the following: Yes No �/Pumping information was provided by the owner,occupant,or Board of Health _ 1 Wcre any of the system components pumped out in the previous two weeks? Has the system received normal flows in*the previous two week period? _ / Have large volumes of water been introduced to the system recently or as part of this inspection T. ✓ Were as built plans of the system obtained and examined?(If they were not available note as N/A) v Was the facility or dwelling inspected for signs of sewage backup? { 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 of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? -/ Was the facility owner(and occupants if different from owner)provided with information on the proper - maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined.based on: Yes, no 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)13 10 CMR 15.302(3)(b)j .. ... . - ..... .. ... a ;...... _. .,....: ..' . .. it 5 Page 6 of I I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 140 seapuit Road Os ervi e Owner: Donald Moran Date of Inspection: Z — —d FLOW CONDITIONS RESIDENTIAI. Number of bedrooms(design):. Number of bedrooms(actual): �/ r DESIGN flow based on 310 CMR t5.203(for example: 110 gpd x#of bedrooms):—4/ F'd Number of current residents: A/zi Does residence have a garbage Fmder(yes or no): A"! Is laundry on a separate sewage system(yes or no): [if yes separate inspection required] Laundry system inspected(yes or no):,,LO. Seasonal use:(yes or no): 6o Water meter readings,if available(last 2 years usage(gpd)): 2 0 0 4 — 9 7;0 0 0 _ Sump pump(yes or no):�� 2 0 0 3 — 81 , 000. Last date of occupancy: 6 COMMERCIA NDUSTRIAL Type of establis ent: Design flow(b ed on 310 CMR 15.203): gpd Basis of desi flow(seats/persons/sqft,etc.): Grease trap pr sent(yes or no):_ Industrial wa to holding tank present(yes or no):_ Non-sani waste discharged to the Title 5 system(yes or no):_ Water met readings,if available: Last date occupancy/use: OTHER describe): GENERAL INFORMATION Pumping Records Source of information: Was system pumped as part of the inspection(yes or no): ti ev If yes,volume pumped:_gallons--How was quantity pumped determined? Reason for pumping: r TYP OF SYSTEM Septic tank,distribution box,soil absorption system _Single cesspool Overflow cesspool —Privy _Shared system(yes or no)(if yes,attach previous inspection records,if any) _Innovative/Altemative 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 age of all components,datey' stalled(if known)and source of i formation: �J� 9S lsrIF Were sewage odors detected when arriving at the site(yes or no): - 6 Pagc 7 of OFFICIAL INSPECTION FOI0'1—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTENUNFOIi11'1AT10N(continued) Properly Address:140 Seapuit Road Ostervil e Owner: Donald Moran Date of Inspection: BUILD/loconstruction: VER(locate on site plan) Depth bc: Materia —castiron _40 PVC_other(explain): Distancvate water supply well orsuction lute:Commendition of ruins,venting,cvidcncc of leakage,etc.): SEPTIC TANK: _(locate on site plan) Depth below grade: Material of construction:_✓concrete metal fiberglass J,ulycdj;Iene _othcr(cxplain) — — If tank is metal list age._ Is age conftrmed•by a Certificate of Comjrliutce(yes or no):—(attach a copy uf? certificate) Dimensions: a ju)6 6d. 0. �Y �' �• Sludgedcpth: l to =-7 Distance from top of sludge to bottom of outlet Ice or bathe: 2 �/ Scum thickness: Distance from top of stunt to top of outlet tee or baffle: �+ Distance from bottom of scum to bottonn of outlet tee or baflle: /O l low were dimensions dctcnnincd: Comments(on pumping recommendations,inlet and ou(lct tee or battle condition,struuural integrity,liquid levels. as related to outlet invert,evidence of leakage,etc.): �s'G z � 16e sys 11L� GREASE TRAP:_(loc c on site plan) - Depth below grade: Material: eonstruetio :—concrete metal fiberglass_pol).ethylene—other (explain): — Dimensions: Scum thickness: Distance from to of scum to top of outlet tee or baffle: Distance front ottom of scum to bottom of outlet Ice or baffle: Date of last p roping: Cont.nents n pumping recoinnnendatiuns,inlet and outict tee or baffle condition,structural integrity,liquid levels as rclalcd( outict invert,cvidcncc of leakage,cic.): 7 Page 8 of OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFOR -IATION(continued) Properly Address: 140 Seapuit Road s ervi e Owner: Donald Moran Dttte or Inspection: TIGIIT or 1lOLD1N TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of eonst lion: concrete_metal fiberglass_polyClhylene othcr(explaut): Dimensions: Capacity: —gallons Design Flow. gallons/day Alarnt presc (yes or no): Alarm level Alann in working ordcr(yes or no):` Date of last pumping: Comrncnts(condition of alarm and float switches,ctc.): DISTI1lUUTION BOX: (if present must be opcncd)(locate on site plan) Depth of liquid level above outlet invert: O Conunents(note if box is level and distribution to oullets equal,any evidence of solids carryover,any evidence of leakage into or out of box,ctc.): f � ly PUMP CHAMBER: (local n site plan) Pumps in working order(yes r no):_ Alamis in working order( s or no): _ Comments(note eonditi of pump chamber,cundition of pumps and appurtenances,etc.): Page 9 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:- 140 Seapuit Road Osterville Owner: Donald Moran Date of Inspection: SOIL ABSORPTION SYSTEM(SAS): 2: {locate on site plan,excavation'not required) If SAS not located explain why: Type o- leaching pits,number:_ le ing chambers,number: aching galleries,number. leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number: innovative/altemative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): U A.04 CESSPOOLS: (ce spool must be pumped as part of inspection)(locate on site plan) , a Number and configur ton: _ Depth—top of liquid o inlet invert: Depth of solids Jaye Depth of scum lay : Dimensions of ce pool: Materials of con ction: Indication of gr undwater inflow(yes or no): Comments(no condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: (I ate on site plan) Materials of co struction: Dimensions: Depth of soli s: Comments ote condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): 9 Page 10 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE:DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 140 Seapuit Road Osterville Owner: Donald Mor n Date of Inspection: 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. A ja av 3 �. r ?� V 10 Page 11 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 140 Seapuit Road . Osterville Owner. Donald Moran Date of Inspection: /—/ --Q 5 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 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: pecked with local excavators,installers-(attach documentation) Accessed USGSdstabase-explain: You must describe how you established the high ground water elevation: I 11 YQAgiv OF BARNSTABLE SEWAGE ASSESSOR'S MAP & LOT®W'43's� :l: Tt.L:.);t.'S NAME&PHONE NCO. n�J SE?T'y TANK CAPAC.r',Y I '7 gyG Y LEACHI G FACR I"1'Y: (type)' �it9 (size) NO.OF BEDROOMS BUL.DER OR OWNER PERM'-TDATE: ' �10?— COMPLIANCE DATE-,"7 ''20,, Separation Distancz,Between the: MaxiMuni Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on Y-ite 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 Furnished by � �.� ✓ N 70 135 �" , 13 73 �! n Fee v O THE COMMONWEALTH-OF MASSACH.USETTS . PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS ZlppltCatton for ;Di,5po9;a1 *pgtem Cow5trurtton Vermtt Application is hereby 6 yr for Permit to ( ")or Repair( )an On-site Sewage Disposal System at: Le Location Address or Lot No. Owner's Name,Address and Tel.No. LeT 147- 1 SEEEAPv rr Cm,' 0zX,e3zV I LA16 ai/iwj Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. x 11JyG I MC, Type of Building: Dwelling No.of Bedrooms Garbage Grinder Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flows gallons per day. Calculated daily flow gallons. Plan Date py 21 1Number v of sheets 2_ Revision Date Title C'�JT""I R Gdt f YL. h� t f•1 ��'Tt:-D��✓1 L416- 1/1/)� a YL` 'SI I.ei/i A- 1-�f U A- Description of Soil Q±:P6 96krzoIj 041 —8 ad?tJ Nature of Repairs or Alterations(Answer when applicable) Date last inspected: 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 Environmental de a d pla e he system in operation until a Certifi- cate of Compliance has been issued o d of H It Signed / Date 7� Application Approved ! ' Application Disapproved for the following reasons Permit No. Date Issued X• -� .`.+ >. r �{..�-.+ f _.^... `!� r.3- .4.y.-, u4�N -w Y`+ �—'�'�K,l :./may+J"�e'. -� �• � 0 > ." No. _ ,. -.. £ _ _. ) Fee THE COMMONWEAL O MASSAC+1 PUBLIC HEALTH-DIVISION - TOWN'- FBA STABLE MAS ACH nS application for Ztgpd!5aY *p�teM Construction Permit Application is hereby r Repair( )an On-site Sewage Disposal System at: Location Address or Lot No. Owner's Name,Address and Tel.No. 1477 Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. JType of Building: �'. . Dwelling No.of Bedrooms=� Garbage Grinder . { 1" Type g - _ ) Cafeteria( ) Othe�P �' T e of Building No.of Persons Showers "OtheU xtures' fir, , f , Design Flow A'y, �- J gallons per day. Calculated daily flow gallons. Plan Date 4f' 21 I N mber of sheets Revision Date Title C 2TI f=1 t=J') LLfMj 10 0sM-&'i_✓1 L,(,C WA-- EAt !�l t 0 A- 'f 5 LL A-- Description-of Soil. (` +-Q goll1-2.01j 0—o"t, ' �(O C . ppal f"L�tj 94f Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the of re described on-site"Sewage disposal system . in accordance with the provisions of Title 5 of the Environment G.de a pl th system in operation until a Certifi- cate of Compliance has been issnedby t 's-B d of It r.V Signed Date 2 ` Application Approved Applications 64sapproveds for the following reasons i i Permit No. Date Issued P-6— ___—_____-___-_______________�--—_=_--___ _----- _ THE`OMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE. MASSACHUSETTS Certificate of Compliance 14 THIS IS TO CERTIFY,that the'On-site Sewage Disposal System installed( or repaired/replaced( ')on't- �- 7 ? by �}� 7 ✓ V P t �, yzz for as h s b�;n constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit dated l49'. V-,19 S '{ Use of this system is conditioned on compliance with the provisions set forth l w: DESK+-� �l> TA �I►�IGLE FAmlu 4- PLA" ON BAGK. 4SIZFOF WiT14 6AI2 3AL1- 6414P 69— -PAA L. FLOW = 4 x I l o *so`I.7�o� L-oT l 4'1 Fu IT �D, 05Tiev IL_L�- Sw-T1G TANL • 6&0 ?Oo =132a GU- US� I Soo GAL. ' L GoMP. i PR�Ma2Y Jam' I,A641W, 5`{`T��K 17ES��1 T> ES E�CPA fJ5 fDrJ 2 TgAWC,(eS 2 XS X-is — -- — — — APpu GAilcW A¢EA 26Q'D. Appo"-noH AM DrN&W 5tt1=WALL 1 A=z<�sp�-A�L of LEAcAIu� Tzw-A 13DTrOM A ZPA ='Z X'S c2= 3Qo sF -TarAL AWA• 9co SF I. ot. Ao '~ 3' "'°'` PE=24OLAT10N t?dTE L r,Mlv�l � " �• OF A. &Ax R I T&=Z S �10=21 C`(c=� �• Tt~-325a I''' o tA�aal •i ialy 8` 1►J� � 2'7•0 loA►H� $AN7 LS.f141 "�E►JGH �tgor o IS•2 �K 8•d- e' " 1l0 o Si�pI1G f. TAw r FC � 2- .• Mrv, i SAND � �M(Jac�S�^Q 'VE FWF hb a T-F_1 30 /15 r S _C� R1 -::D PLOT PLAI1 • LnCATIo�I DsT�-v I c.tr� p 05,95 SD 'DATE go✓Z,pq= I G .Z11 r SAT T$4 E Dw g M& 15I-Mt4 PLAIN ZEFEZ -W-X_- �}E¢EoN czMpL-g5 vertu 1-14E SIT>E w4E AW LuT i 4-1 t.G S'12S 0wulE&MC 4,1 of 1-WG -mwN OF AiAP' Os PAOCZL tz (MZT� '$AT 41rA3 L9 P-m l S LLIGAT�D W I T'4 1 N A 5pw-caAL FLVOP HAZAJW ZONE. BAD A Nye IIJG I Cil Ct R e-(/t,- �wc> Qj&I WSW: aFF5eT^S �TzoM boIl.Dlt 66 490LNJ;l NOT' B6. QppUGAt•IT: Tb Gw T74BL j sq PRopEaTy LII e4. L�l 1 a `'�. SI L✓1Q , We— «+ OF w N OF A �_ �L tJov. 26,l995 � `moo 4A SULLIVAN r.ago NO.r::733 y CIV,L r o s Ass u 2Z \ \ IA Ic \ ter _ 4000 4 mat' THE FOLLOWING IS/ARE THE BEST IMAGES FROM POOR QUALITY ORIGINALS) I M -A � DATA `f Iqo APPLICATION FOR PERCOLATION TEST AND OBSERVATION A� S) LOCATION �EARJ lTT Kc�I4C7 VS7e C.L C=, OT'�- NO. Y SS03 VILLAGE DATE S-4-9 S APPLICANT_ �1�1 P L-D fi p�2,4T�, FEE IOU k ADDRE85_ �(c0 Cad RA-A 196 Kiv of y 100 17, TELEPHONE NO..NO. (Non-reftndabl ENGINEER I4xC�2.d k�C l:i c- T E Z 9 "S DATE SCHEDULED A60,jT (Applicant's signature . . • • . • . e o e o e e • o • • o n •o- e e . • • e e e • o e • • • • • o • • • • • • • • • • • • • e 0• • • • • • • • • • • •i • • • • i • • • • ASSESSOR'S b1AP 6 LOT'NU: yS / 1 Z U SOIL LOG (a SUB-DIVISION NAME DATE KA+ ��9 S TIME )000" EXPANSION A)tEA: YES NO �n,xm A My- �� ENGINEER:7( TOWN WATER�PRIVATE WELL BOARD OF HEAL Sf�oQ��N� coNgT'�L• EXCAVATOR SKETCH: (Street name,etc. ,dimensions of lot, exact location of test holes and percolation tests, locate. wetlarMs in proximity to test holes) NOTES: \�1 . E N1 1 4-.1 � -4 0 -N�,2 0 4�r-r.� 1 c. • HcG,lo►.� : -5.'s. -MP hot-- LOT2 1+-� p c-oi o M sit->J o �X1r� �4 J,. c •t-fa2 ,�. � I . aff p�Ta-ro S,�y, He r/ + ' 370 \ PERCOLATION RATE: tf Z+ TEST HOLE NO: ELEVATION: TEST "fiOLE`NO: w,., FELEVATION3 2 •sue P�-4� f% 3 H-'f� o✓�. 3 t 15E�►1-� 4 ¢► 5' 6 y 7 .. 1 y r 9 } 4 ; 10 to . a. :t A ? 1x„ ` •,° q.+':�, �tw'", •'i fi, ,y.�. ._� 'k ° r r ry r ri �F '♦ r+' u�v�.�i 3 ll a t,"t,, 12 �, P • g .;,.E •, tr��•;:f r x 1� e4 `,X t zh 14 i y- ' idr ti a _ Ky1 7 # � .. is !. A 4' .� ,f � i �t, •��` 1'�y,y r in - ,•1� .•" y 5. cr• 'g.�x'• %��Z. r F ",k•'ttarY"Fa t'car-` ° .. .,, er 6 tt f rxA,S7,.i16ti '' �r '—..r'"G ? Iffil{ SUxTABLE FORUB--SURFACESSEWAGE: °LF�ACHINO: FIELD LEACHING'PITS ? K; LEA , :° � HINQ T y.N'CH-E ' - 's« RZ, ' MNSULTABLE,,T0R&S 1a z3URFA &,SEWAC3E N,XETd��f.�7 erc'Otc 1M�'. Y ;.",, ai J+f �,�. _ + 3 �'r., �r, c�, :.9 .•d Y3r, < �r 4� J• �, - - ,_a a�. vp, NOTE > NGIN E'R NG PI�ANS�UST' ,SHOW N,U,MB ASSI¢�1FDr..ON .PERCH ..TEST.�APPLICA`,TION;,S. �RxG 4�f•M! " ��C yM -M �r �51h* a 1 i "P°+rc�N �?:4fi4 F Y. k;i_t 904� - '. ., r , �'< 4"o13 Appendix 4 Page I ?Titlt S: Draft Priattd September 20, 1993 Date No. Commonwealth of Massachusetts Massachusetts • • • • • • • te Certificadon Number: ►�oT �:IL , �••� . ��.. .»F.:....»r»��..». N 6 F (�PcQNSTf4'hLE PeTfOrinedBy ..... H EA LT v4 I w S P E CTPC-Q- TaW ................................................................................. ,v, By: ........ ...» ELt-lS L„NA-A•Irk. ., ''y ...a... .1..�...........»..» ......... al5 SvP+Ol.hs.lc� of ►2 QwMPo Nanw.Address (11z� - 355- 5553 {.oestion Address or Lot No. / L G T . 4 F ( - s�,tPu 1T Q-orr� O SieQ��! LE, MPmF -T-rlB AAA�cA> (� 1 00 1 9 - Coo 13 SEA Ou IT Q.o A� � 400� E•A•ST eF �.1EW yCQK-� 1'-•�• 1 11-1'�L-g E�•'T O�-1 f�J1•.+ILt:'R- Yh l-L p-o�'0 . New Construction Repair ❑ Affice Review • No ❑ Yes Published Soil Survey Avg ilable• C-rt L2�S�5�1 V FJ- .. 4G-r•"�2'I�Sc�+nL OE'�eSOit Ma. Unit Publication S. ale oo v.0 ad.�.U �c.T Year Published _ Fee W000 1FI: �OP E � a. awkv'H......• 1 Cr=¢M Drainage Class 0e�"��° Soil Lim lions ,gyp H ................. • � W of sep'Ilc. s•ti�i•'E Yes Surficial Geologic Report Available:Publication Scale I - Year.. Published .I -1 s Pub v P M A.S A+ Eo P 1� c. ...... rial lMap Unit) �•m -Ceolopic Mate GAL o�T .6..... 'LandYorm +... Flood Insurance,Rate Map: Yes Abase 500 year flood boundary No ❑ No Yes Within 500 year flood boundary ❑ Yes Within 100 year flood boundary No Wetland Area: ................................. Map (map unit) .....u�*...A�A,.�.�r�.. .... National Wetland Inventory Wetlands Conservancy Program Map map unit) • t q Month Current Water,Resource Conditions (USGS): Normal ❑ Below Normal Range : Above Normal ❑ ....................... Other References Reviewed: v s s.. .�-►,-,1T.. �k oN 1o1-Ie Li►..lc.... 3 /G 2�-F : '/C!M �vJ•-•'L9 .� Appendix 4 Page 2 Me S: Drgft Printed September 20, 1993 an-site b ew i 30. 5E-0vI Weather P,eo L�O NIu T/AA I Lb /T 5 zSho TOau: (AAA) Deep Hole Number ,-. T 0�1 �ILLe 4'?- i 3"p- ,f E/tST l ««..:.�.. � Location lider►tifY Site plan 3 8'10 ce Stones �:is�o Surfs . Land Use uyR E!�veu./. Q -° Slope lXil a F !►-R A P- Vspetetion P ire+ P,1-'E �`^'rnr�:;PLandfi�,2 onr ouTwA, PcA��-+ PcRcA oc S ON 6�rc.�� L TEO Position on landscape (Sketch On the back) ..��....�. •• •• P`� DPr o S Distances from: "3 feet.. ®pen Water Body i3 ? fat OraMaOpwaY ... Possible WetAna 3a' feetPropertv'. prinking Water Well o fat Other 0 DEEP OBSERVATION HOLE LOG SM cam so o oa+K path han Surhw flag Nofson flea Tame Iswowh.Stenos.aougao - 1 •- /L � Q _. 1�1 o r.+S u ow7F� N Lc— I 4 � � Q - L.oAM-I 1 I ic+-G VLR�I FRAfiLE Si�c.� - ..� A458 .. ...,.. �0►-8 PT•,c 2 �7o G2n�ieL QL o gI.a„ C . o U - parent Material (geologic) ��,,� A�...p�yr�,,,gs..l -(I«•.��-� o��,, Depth to Bedrock: nPath to Grote Standing Water in the Hole: Wpeping from Pit Face: Estimated Seasonal High Ground Water: 7 l o F-2--r=T L aN Pa i u r os--. Ldw E L =