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HomeMy WebLinkAbout0121 SOUTH BAY ROAD - Health 121 South Bay Road, Osterville A t 'F u t 4 3 V 3 e F d V p +I la JUG s P BORTOI:O TIT1 ,CONSTRUC TI:ON, tls ro OP 4?000 45 INDUSTRY-ROAD,MARSTONS MILLS, MA 02648 508-771-9399 508-428-8926 FAX: 508-4 1.28-9399 v r y SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION�FORIVI PART A CERTIFICATION Property Address:- Date Of Inspection 6e 19 D C lnspe t r s Name: . Owner's Name and Address: CERTIFICATION STATEMENT: I Certify that have personally Inspected the Sewage Disposal System at this address and that the informa- tion reported below is true,accurate and complete as of the time of Inspection. The Inspection was perform- ed based on my Training and Experience in the Proper Function and Maintenance of On-Site Sewage Dis- posal Systems.Tjw system: Passes Conditionally sses Needs Fur le vatu, io i the Local, .APP, g rovin -Authority-Failur . . Inspector's Signature Date: 'The System Inspector shall submit a copy of this Inspection Report to the Approving Authority with Thirty (30) Days of completing this Inspection. If the System is a Shared System or has,a Design Flow of 10,000 gpd or greater,the Inspector and the System Owner shall submit the Report to the appropriate Regional Office of _ the Department of Environmental Protection. The Original should be sent to the System Owner and copies sent'to the !Buyer,if applicable and the Approving Authority: INSPECTION SUMMARY: A) SYSTE�d PASSES: 4 I have not found any Information which indicates that the System violates anyo_f the fail- ure criteria as defined in 310.CMR 15.303. Any Failure Criteria not evaluated are indi- cated below. B) SYSTEM CONDITIONALLY PASSES: One or more System Components need to be Replaced or Repaired_. The System,upon completion of the Replacement or Repair,Passes Inspection. Indicate j1cs,nor,or not determined(Y,N,OR ND). Describe bases of determination in all instances. lf."not determined",explain why not. µ„. The Septic Tank is Metal,Cracked,Structurally Unsound,shows Substantial Infiltration or exfil- tration,or Tank Failure is imminent: The System will Pass Inspection if Existing Septic Tank is Replaced with a conforming Septic Tank as Approved by the Board Of Health. 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): -1 - SUBSURFACE SEWAGE DISPOSAU SYSTEM 'INSPECTION FORM PART A CERTIFICATION (continued) Broken pipe(s)replaced Obstruction is removed Distribution Box is leveled or replaced The System required pumping more than four times a year due to broken or obstructed pipe(s). The System will pass inspection if(with approval of The Board Of.Health): Broken pipe(s)are replaced Obstruction is removed 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 . lie System is failing to protect the Public Health,Safety and the Environment. 1)SYSTEM WILL PASS UNLESS BOARD OF HELATH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or Privy is within 50 Feet of a Surface Water Cesspool or Privy is within 50 Feet of a bordering Vegetated Wetland or a Salt Marsh. 2)SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER,IF APPROPRIATE)DETERMINES THAT THE SYSTEMdS FUNCTION- ING IN A MANNER THAT PROTECTS TH&PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:` The system has`a Septic Tank"and'"SM Absorption'System and'is withiri;100 Feet to a Surface Water Supply or Tributary'to'a Surface Water S�ipply The System has.a Septic Tank and Soil Absorption System and is with a Zone 1'of a Public Water Supply Well. The System has a Septic Tank and Soil Absorption System and is within 50 Feet of a Private Water Supply.Well. The System has a Septic Tank and Soil Absorption System and is less than 100 Feet but 50 Feet or more from a Private Water Supply Well,unless a Well Water Analysis for coliform bacteria and volatile organic compounds indicates that the Well is from pollution from the facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. D)SYSTEM FAILSs have determined that the System violates one or more of the following Failure Criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Backup of sewage into facility or system component due to an overload or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged.SAS or cesspool. . Static liquid level in the distribution box above outlet invert due to`an overloaded or clog- 'ged SAS or cess ..pool.. Liquid`depth in cesspool is less than 6"`below invert or availabiewol'�I a is less`than 1/2 day flow r ,: :�-t sS"'.?, t ..FAT"r _ 'P,tt }..• ^Y;..:Vt. Required pumping more than 4 tim; es in'the last Year'NOT due to`clogged or obstructed pipe(s). Number of times pumped - 2 - E WAGE DISPOSA L S YSTEM INSPECTION ,FORM .SUBSURFACES ,I r�•r.x+. 9;!js. .� ��. 'PARTA ` t CERTIFICATION(continued) Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within160 Feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy.is within a Zone 1 of a Public Well. Any portion of a cesspool or privy is within 50 Feet of a private water supply well. Any.portion of a cesspool or privy is less than 100 Feet but greater than 50 Feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be.acceptable,attach copy of well water analysis for coliform bacteria,,volatfle organic - compounds,ammonia nitrogen and nitrate nitrogen. E) LARGE SYSTEM FAILS:, - . y ".The following criteria apply to a large system in addition to the'criteria above . . t The design flow of a system is 10,000 ggd 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 The system is-within 400 Feet of a surface drinking water supply ,T«: t, `.'The system is within-200 Feet of a tributary to.a surface drinking water supply r The system is located in a nitrogen sensitive area Interim Wellhead Protection Area .'=`(IWPA),or''a mapped,Zone 11 of a public,,watersupPly well r The owner or operator of any such system shall bring the system,and,facility into full compliance with the groundwater treatment program requirements of 315 CMR 5.00 and.6.00.`Please consult the local regional office of the Department for further information. . _ f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM . PART B CHECKLIST , Check if the following have been done: umping information was requested of the owner,occupant;and:Board of Health. one of the system components have been pumped for atleast two weeks and the system has been receiving normal flow rates during that period. Large volumes of water:have not been a introduced into the system recently or as part of this inspection. V As-built plans have been obtained and examined. Note if they are not available with N/A. The facility or dwelling was.inspected for signs of sewage back-up. The'system does not receive non-sanitary or industrial.waste flow. __/The site was inspected for signs of breakout. All system components,excluding the Soil Absorption System,have been located on.site _ 'IThe septic tank manholes were uncovered,opened,and the interior of ttie septic.tank was ui-; �spected for;condition of,battles or tees,material of construction,dimensi,ons,,depth of liquid, . a r„ .a..•a,� .d#n,E. -- depth of sludge,depth of scum. The size and location of.the SWAbsorption System on the site t as`been determined based on ' ..; °t`n.';;s,„ ... ., ,. . a ..,. •.. .: rr • � ";' P7 q '';', Fr �^..y. •.. existing information or approximated by non-intrusive methods - 3 a v� �k � ,•. °ts> �Y`` fir. SUBSURFA'CE�SEWAGE IDISROSAL�SYSTEM' INSPECTION FORM, PART B CHECKLIST(continued) - __1Zf►e facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of Subsurface Disposal System. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION FLOW CONDITIONS F RESIDEN_ fJAL: 'Design Flow: t� gallons Number of Bedrooms:'7 Number of Current Residents:&kuu Garbage Grinder: Laundry Connected To System:( Seasonal Use Water Meter Readi gs,if ailable: 7U7� Last Date of Occupanc CO MER I I./IND 1 T i L: 12j 5- Type of Establishment: J �w } Design Flow. . ..__ ga.l.lons/day Grease Trap Present:.(Yes or no) Industrial Waste Holding Tank Present:.. _ ...." NowSanitary Waste.,Discharged To..The Title.V,System: Water Meter Readings,.If Available:.. . _ Last Date of Occupancy: OTHER: (Describe) Last Date of Occupancy: GENERAL FORMATION PUMPING RECORDS any source of information: System Pumped as part of inspection:. jr`}---. I yes,v me pumped: gallons Reason for Pumping: TYP�,OF SYSTEM: _/Septic Tank/Distribution Box/Soil Absorption System Single Cesspool Overflow Cesspool Privy Shared System(If yes,attach previous inspection records,.if any) Other(explain): ROXIMATE'AGE of all,c mponents,;date.installed.(if.known).and..solurce of information., .,. :e. „y .�. /,�: .� Sii'YC � ...=5i, .3� .*, "i' t"• t. ... r!rnj .a�ii+'e J<?, ,r.s„q ewage odors.detected.when arriving at the site. -4- SUBSURFACE SEWAGE,`DISPOSAL'SYSTEM INSPECTION FORM =a:: PART C GENERAL. INFORMATION.(continued) SEP'I.1( I ANK l✓ r i Depth below grade: Material of Construction: <�concrete ._ metal . . FRP., ' Other (explain) Dimensions:ep 0 X67SIudge Depth:— C2U_, Scum Thickness: rX Distance from top of sludge to bottom of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Comments: (recommendation for pumping,conditioin of inlet and outlet to s or baffles,depth of liquid lev 1 in relatiol too ' vert,structural integrity,evidence o leakage, GREASE TRAP: r' Depth,Relow.Gradc:' • :. Material of Construction: concrete metal FRP Other (explain): , Dimensions: Scum Thickness: Distance from top of scum to top of outlet tee or baffle: ' Comments: (recommendation yfor pumping;condition of inlet and outlet tees or baffles;depth of liquid.level . in relation to outlet invert,structural integrity,evidence,of leakage;;.etc.)_',,' TIGHT OR HOLDING TANK,/ * . Depth Below Grade:! Material of Construction: concrete metal FRP Other (explain): Dimensions: Capacity: gallons• Design Flow: gallons/day' Alarm Level: Continents: (condition of inlet tee,condition of alarm and float switches,etc.) DISTRIBUTION BOX: �/ Depth of liquid level above outlet invert: Comments: (not Ylevel and distribution is equal,evidence solids carryover,evidence of leakage into or out of N ,etc. A, 6912a "PUMP CHAMBER " Punip is m workmg.'order: Comments:(note condition'of pump chamber,condition'of pumps and appurtenances;etc r-L .r - 5 - K. •tii.I VI SUBSU rDISPOSAL SYSTEM INSPECTION FORM .; PART C SYSTEM INFORMATION(continued) SOIL ABSORPTION SYSTEM(SAS): (Locate on site plan,if possible;excavation not required,but may be approximately by non-intrusive. methods) If not determined to be present,explain: Type: Leaching pits,number: Leaching chambers,number: Leaching galleries,number: Leacahing trenches,number,length:- Leaching Gelds,number,dimensions: Overflow cesspool,number: uments: (note conidtion of soil,signs of hydraulic failure lev I of ponding,condition of vegetation,etc.)_ i� 95, CESSPOOLS:� — Number and c ntigd uration: Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of Cesspool: Materials of construction: R ',�I'ndication,of groundwater, Inflow(cesspool must be pumped as part of inspection) Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation, etc.) PRIVYMateri s of construction: Dimensions: ' Depth of Solids: Comments: (note condition of soil,•sigris of hyddraulic failure,level of ponding,condition of vegetation, etc.) r, ......___.� .. 't _x., � 5. ..... ' ''. �� a.. ` *. � `. 1,-:._ - y. � '•.y. :; 4� 3. •(. 4 rv:. �. F f t�� + ii ..�ti...��.�«. ..»...._......�........e..��.,.e...».�.:_._....ter._�.....� _ �....r......._i�...r......-.. ........ .. .. -..TV...»..,.....e 4w ...f......-+.. .. _..,..... . _ 6 _ SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION_FORM ART..0 SYSTEM INFORMATION (continued) SKETCH OF SEWAGE DISPOSAL SYSTEM: Include ties to atleast two permanent references,landmarks or benchmarks. Locate all wells within 100 Feet. .. ,.•-� , ��tFP 4 % ;,'^ad. � zrt�r t �,` tt F�'S � T '..p�� - - }33 >e :A /��i.\ _ ,✓L+ t t1 6� y E 1.•1 4 sl"' .i Lo DEPTH TO GROUNDWATER: Depth to groundwater: Feet Metho of Determination or A r xi ma ion: J^ s 7 - ' V COMMONWEALTH OF MASSACHL:SETTS � ¢ _ EXECUTIVE OFFICE OF ENVIRONNENT.4L AFFAIR AUG fCfIVEt 40 DEPARTMENT OF EVIRO'�?�IEITAL PROTEC j 3 1997 lift 'W ONE WINTER STREET. BOSTON. NIA 02105 61717-292.5500 64 ter. A WILLI.AM F.R'ELD. E �l C0XI Govemc• e,retan ARGEO PAUL CELLUCCI D.AVID B.STRUHS Lt.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Commissions, PART A �,�J CERTIFICATION Property Address: v( Y /G�1-O�vtI�®ddress of Owner: �`� Date of Inspection: O l��i�`l (If different) / CGa K� Name of Inspector: I �e��o �f r 1,4 „ 1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000) T Company Name:A±1L a,4-r,c E,i v^r'r+,,,p #"P 0 2�- Mailing Address: R O -Aenx 2_3719 Cf H AgaeeL2- H -09-© e-C4-c' Telephone Number: r Cf $ti— /4L Zy 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 comolete as of the time of inspec o7.. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sev,age disposa; systems. The system: Passes t _ Cono!tionam Passes tieeas Further Evaluation By the Local Approving Authority _ LInspector's Signatur Date: The Systerr Inspector shal' submit a Copy of this inspection report to the Approving Authority within thirty (30) days of completing this inspection. If the system is a shared system o, has a design flow of 10,000 god 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 authorih.' INSPECTION SUMMARY: Check A, B, C, or D: AI SYSTEM PASSES: I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. COMMENTS: BI SYSTEM CONDITIONALLY PASSES: One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement�or repair, as approved by the Board of Health, will pass. Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain why not. The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection; or the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 04/25/97) Page 1 of 10 DEP on ttie Worid Woe Weo http ti~magnet state ma.usioec if PnnteC on Recwcied Pacer r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A ► ��� CERTIFICATION continued Property Address: / �j J O ucz /3cec/ Own�;i.nx`� ;of16. t nspection:,A- f DA� BJ SYSTEM COhDITIO ALLY PASSES tcontinued _ Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipets) or due to a broken,.settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health). Describe observations: broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four times a year due to broken or obstructed pipe(s).,The system will pass inspection if (with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed C] FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health, safe(,-and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER ., WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or prn, is within 50 feet of a surface water Cesspool or pro.) is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet to a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and the SAS is within a Zone 1 of a public water supniv well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine distance (approximation not valid). 3) OTHER (revised 04/25/97) Page 2 of 10 f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTIO's FORM PART A CERTIFICATION (continued) Propert. Address: —WaCvP So v a ��1 •L� - Owner: � r©� Date of ns� pection: (l DJ SYSTEM FAILS: You mutt indicate either "Yes- or "No' as to each of the following: I have determined that the system violates one or more of the following failure criteria as defined to 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 Backgp of sewage into facile or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. Static liquid level in the distribution bore above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flov;. Required pumping more than 4 times in the last year NOT due to clogged or obstructeo pipe's:. Number of times pumped _. Anv pomon of the Soil Absorption System, cesspool or.privy is btrlow the high groundwater eievatior, Anti por,.on of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. _! And pomon of a cesspoo! or prnv is within a Zone I of a public well. An,. porno- o;a cesspool or pr,,.1• is within 50 feet of a private water supply well Any por,ior. o;a cesspool or pmy is less than 100 feet but greater than 50 feet from a private water suppl- well with no acceptable water qualm analysis. If the well has been analyzed to be acceptable, attach cope of well water analysis for cohiorm baaena, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E) LARGE SYSTEM FAILS: You must indicate either "Yes" or"No" as to each of the following: The following criteria appi, to large systems in addition to the criteria above: The system serves a facilit\ with a design flow of 10,000 gpd or greater (Large System; and the system is a significant threat to public hea!th and safety,and the environment because one or more of the following conditions exist: Yes No . the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area- IWPA) or a mapped Zone Il of a public water supply well) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treat ment;program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. revised 0� 75 97 t � � ). I+eg• 3 of 10 c ► SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: � -7 ! Co Owner: Date of Inspectio ✓✓ Check if the following havebeen done: You must indicate either "Yes" or "No" as to each of the following: Yes No Pumping information was provided by the owner, occupant, or Board of Health. None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as pan of this inspection. As built plans have been ob:a:ned and examined. Note if they are not available with N/A. The facility or dwelling was inspected for signs of sewage back-up. 4 _ The system does not receive non-sanitary or industrial waste flow. The site .%as inspected for signs of breakout. _ All s\stem components, excluding the Soil .Absorption System, have been located on the site. _ The septic tank manholes "ere uncovered, opened. and the interior of the septic tank was inspected for condition of baffies or tees, material o`construction, dimensions, depth of liquid,.depth of sludge, depth of scum. The size and location of the Soil Absorption System on the site has been determined based on: The iacdiv, o"ne, tano occupants. if d:fteren: from o",nert were provided with information on the proper maintenance of Sub•Suriace Disposal System. Existing information. Ex. Plan at B.O.H. _ Determined :n the field :tf am of the failure criteria related to Part C is at issue, approximation of distance is unacceptable 115.302.3t;b'l (revised 04/25/97) ?ago 4 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM ®INFORMATION Property Address: �'�� Sc-7 L (.Ce Owner_T Date of Inspection: / FLOW CONDITIONS RESIDENTIAL: Design flow y y_Q_g.p.d.,bedroom for S.A.S Number of bedrooms. O� Number o'current residents: d Garbage g•; der (yes or no�:4A Laundry con-ected to system (yes or no!. l S Seasonal use Ives or no:: f—jo Water meter readings, if available (last two i2; year usage (gpd): NO Sump Pump (ves or no):�(� Last date of occupancy COMMERCI,kUINDLISTRIAL: Type of establishment. Design fio%% ¢alionsida% Grease trap present. ryes or no-_ Industria! lhaste Holding Tani; present. Ives or no Non-sanitar,, v,aste discharged to the Ta,e 5 system. ;ves or no= \later meter readings if availabie Last pate of o c.-Pane-, OTHER: Describe Last sate of occuoanc. GENERAL INFORMATION PUMPING RECORDS and source of information. System pumped as par, of inspection: (yes or no: 90 If yes, volume pumped ¢allons Reason for pumping TYPE OF SYSTEM T Septic tank/distribution box/soil absorption system _ Single cesspool Overflow cesspool Pri%y Shared system (yes or no) (if yes, attach previous inspection records, if any) I/A Technology etc. Copy of up to date contract? Other APPROXIMATE AGE of all components, date installed (if known) and source of information: '► 2Uu,�� Sewage odors detected when arriving at the site: (yes or no) d (revised 04/25/97) page 5 of 10 SUBSURFACE SEIWAGE DISPOSAL SYSTEM INSPECTION FORM PART C Dq SYSTEM INFORMATION (continued) Property Address: S lv ✓�y ,-V_ Owner: c� Date of nspection- ,--9z BUILDING SEWER: �t) (Locate on site plan) Depth below grade: Material of construction. _cast iron _40 PVC _other (explain, Distance from private water u I • well or suction Ire supply y Diameter Comments: (condition of joints, venting, evidence of leakage, etc.( SEPTIC TANK:-�LS (locate on site plan Depth belov. grade�t material of construct on: �concre;e _meta' _F�berglass _Polyethylene _othenexplaim If tank is metal, list age _ Is age confirmed b� Cen;ficate or Compliance _(YesNo Dimensions J 000 1WI. Sludge depth 1*1 Distance from top o. sludge to bottom of outlet tee or baf';e 33" Scum thickness:_ Distance from top of scum to top of outlet tee or bar Distance from bottom of scum to bot:om oi outlet tee or bare ,A,� � ���� � p —1-L - How dimensions were determined YNR.01��1�7L9�. Comments. trecommendation 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.i 1zt 'toWr ` e� ou T GREASE TRAP: �J (locate on site plan) Depth below grade: Material of construction: _concrete _metal Fiberglass _Polyethylene _other(explain) Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments: (recommendation for pumping, condition of i!,let and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.; (revised 04/25.17) Page 6 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C q �Q SYSTEM INFORMATION (continued) Properh Address: S©cJ( �y 'AaW- Owne Date ot—In-s�pection: TIGHT OR HOLDING TANK: Tank must be pumped prior to, or at time, of inspection) (locate on site plan; Depth below grade: Material of construction. _concrete _metal _Fiberglass _Polyethylene —other(explain) Dimensions: Capacit-% gallons Design floes. gahons,da, Alarm level Alarm in „orking order Yes; _ No Date of previous pumping Comments (condition of inlet tee, condition, a alarm and float switches, etc.) DISTRIBUTION BOX: (locate on site pan Depth of houid level aoove outie: in%e^ 9AVa� Comments: mote if level and distribution is eaua'. evidence of%olids carryover, evidence of leakage into or out of box, etc:)-' , -.o Q�►v PUMP CHAMBER: rid (locate on site plan. Pumps in working order: (Yes or No, Alarms in working order (Yes or No, Comments: (note condition of pump chamber, condition of pumps and appurtenances; etc.) (revised 04/25/9",) Psg• 7 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) yy Property Address: ��� S v ��Y Owner: ©2�c/ Date of Inspection: 77 q SOIL ABSORPTION SYSTEM (SAS): (locate on site plan, if possible; exca tion not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: Type: leaching pits. number. (,Y� leaching chambers, number: leaching galleries, number: leaching trenches, number,length: leaching fields, number, dimensions. ovei4low cesspool, number Alternative system Name of Tecnnolog\. Comments: incite condition of soil, signs of hydraulic failure, level of ponding,.con �tio f vegetation, etc.) . L 1 INO �Sisoas. o� CESSPOOLS: (locate on site plan (� Number and configura:,on t Depth-top of liquid to inleIi yer, G ` Depth of solids layer 4D ` Depth of scum layer. n`r Dimensions of cesspool L x `] Materials of construction CPAteAA_t-t_ 1611 f5cAt Indication of groundwater 00 inflow (cesspool must oe pumpeC as par, of inspection:. Qcz fig:,l Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condin vegetation, etc.) cVQ;� tJn 2ri1at 4.. PRIVY: go (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.) (revived 04/25/97) page 8 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C // SYSTEM INFORMATION (continued) Property Address:.4�z/ Sp tea 1 Qz1 /Zw. os �/`,< x& O%ne� Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) h * ILI W. . f �S � y I'EZ-3S; �y•S3 , ray- 40 A, Lf bS• �5� (revised 04!25!5-,) Page 9 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C /a / } SYSTEM INFORMATION (continued) �Property Address: /loG�I v LG ILY "'e , Owne� Date of Inspection: 1 Depth to Groundwater r Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design.Plans on record Observation of Site (Abutting property, obsenat�on hoe basement sump etc.} Determine it from local conditions Cnec'K with loca! Board o• nea!tn Chec*h FE.MA maps Check pumping records Check local excavators, installers L se L SCS Data • ` Describe in �ojrown %%oras n.o,.. \o:; established the High Groundwater Elevation. (Must be completed: Z, lz•v:s•d Page 10 of 10 e&IdTOWN OF BARNSTABLE ( LOCATION412,�ZSEWAGE # V kl.LAGE ASSESS R'S MAP & LOTDg�. s ZNSy�� NAME&PHONE NO. 2(, SEPTIC TANK CAPACITY /000 LEACHING FACILITY: (type) ,4. 9 (size) 660 ate, NO.O EDROOM BUILDER O OWNER PERMITDATE: COMPLIANCE DATE:" J Separation Distance Between the: Maximum Adjusted Groundwater Table to the 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 Furnished by i� as 3& yS y y TOWN OF BARNSTABLE LOCATION Zf S 14 )3! SEWAGE # 7 " ( 26 VILLAGE C) aSter ASSESSOR'S MAP LOT INSTALLER'S NAME PHONE NO.`J. SEPTIC TANK CAPACITY �,�(f o LEACHING FACILITY:(type) i (2-) (size) ocl> - L-. NO. OF BEDROOMS PRIVATE WELL OR UBLIC WATER BUILDER OR OWNER DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No ��6tt 7 \�24 � i &7k y� THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH Town...................OF............Barn.atab.l:a------------------------------- ........... Apli ira#iun for Uiipuua1 Works Tunitrurtiun amit Application is hereby made for a Permit to Construct ( ) or Repair (Y&) an Individual Sewage Disposal System at: _RQ.ad_...Jat.e_rullla............ ............•--------------.........•--------•-•-••-•---••----•---•••-•-----•--•-...............-- Location-Address or Lot No. M.T;,Go rdI---rA..........................._. ... Owner Address ' ............................... Installer Address Type of Building Size Lot............................Sq. feet U Dwelling XQo. of Bedrooms......... ................... ...........Expansion Attic ( ) Garbage Grinder ( ) U Other—Type of Building No. of persons............................ Showers — Cafeteria Q' Other fixtures ------------------------- ------ . W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. R; Septic Tank—Liquid capacity............gallons Length................ Width................ Diameter_............. Depth................ Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area.....................sq. ft. Seepage Pit No..................... Diameter.................--. Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by........................................................................... Date......................................... Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water------------------------ rZ4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water..---.-----.........--.. 1:4 ---•--------------------------------- ....................................................................................................................... ODescription of Soil--------•.......................Elan LA---L ray.e1-.......-•---•----------------------------------••-----------------------------------------------. x V W VNature of Repairs or Alterations—Answer when applicable--------1"15Q1 .'.-tank....................................................... ---------------------------------------------------------------•--•-----------------•-•--..........-----•-•-•....2,-leach-fit•g----------=----------------••......-•-------•---•---- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of iiTL� p 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compdhas ethe board of lth. �•.�={� --- -----9115/37-------Date Application Approved By---------------•-- � ........................ ------------ ---- 1-7-r-...S ) Date Application Disapproved for the following reasons----------------------------••----•-----••--------------•-----•-------------------------------------------------- ------••----------•-----------------------•---------------------•------------------••-•--•-•-•----- ----- ------------ Date PermitNo--------- _?._-_t?. -- .................. Issued....................................................... Date THE FOLLOWING IS/ARE THE BEST IMAGES FROM POOR QUALITY ORIGINALS) M A�C(, I DATA Fps ., THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Apptiration for Uiopooal Workii Tonotrnrtion rumit Application is hereby made for a Permit to Construct ( ) or Repair Q1'� ) an Individual Sewage Disposal System at: _1: .. '`= 4=.............. =`•-...a--- -------------- ---------•------------------------------- --------•------- -------------- Locat:on-Address or Lot No. .............:2.....4 .........f......... ............................................... ............................................... .............................................. Owner Address f t" - 1 r a i _ Installer Address Q Type of Building Size Lot............................Sq. feet Dwelling,;-:No. of Bedrooms--_- A..................................Expansion Attic ( ) Garbage Grinder ( ) pal Other—Type of Building ........:................... No. of persons............................ Showers ( ) — Cafeteria ( ) a' Other fixtures .................................. W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. 1:4 Septic .Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................ Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area_-_____-._-___--..sq. ft. Seepage Pit No.--__--_--_-.-_---- Diameter.................... Depth below inlet.................... Total leaching area------------------sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by..............................................:.....••-•-----•--•-•---•••• Date........................................ Test Pit No. I................minutes per inch Depth of Test Pit.................._. Depth to ground water........................ fX4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 19 •-•----••----•--------------•--•-•••-•----•----------------•----........••..............•-•--------•.............:.......................................-.-- xDescription of Soil.................................. ---------------------- ---------------------------------------------------------------------=-------- W ----------------------------------•-------•---••---------•--------•---------------••-••••-•-•-•••••---••-------••---•-------------•------•-----•-------•••---•--------•-•••---•--•-•----•----------•... UNature of Repairs or Alterations—Answer when applicable_.._..: 1q;.�;J0 ... .... ..... ....................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE -5'of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been ii�ued,by,the board of health. J, f Signed .... a , ,�.. = *°� ............. 01`t i,C'l , Application Approved By................. ... ... _- /.7 Date Application Disapproved for the following reasons---------------••-----...----------------------•-------....--•-•-------------•--•------------------•-••..0......_ ......................................................................................................................................................................................................... ^� Date Permit No.......--7--=--&-E ,D................... Issued...................- ....................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH `I` ' OF.........: = c? '............................................... Trrfifiratr of Tamplianrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaire&( ) b3' -f'.:.... ----------------------------------- !.!s i C)r- {"t' }. i Installer .. has been installed in accordance with the provisions of TITIE. j of The State Sanitary Code as described in the application for Disposal Works Construction Permit No----- ...... dated------------------------------------•_-_--_----. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT YHE SYSTEM WILL FUNCTION SATISFACTORY. DATE.................. `= cis. ` �•--------•---- Inspector................. .............................................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH � OF.. rt, t �l. � L No. o io�roo 1 orko Tonotrudivit pamit Permission is hereby granted--- •t--".....'-...::l F •------•--.•------•••••••••••----•-•••-•-•-•--••-••---••-•--•.......................••••......--•.•.... to Construct ( ) or Repair (% ) an Individual Sewage Disposal System , !�! ,-)UZL .--1� -,� 3 �t ' rL ii.LC at 1�0............. ••........_............................---------•------•-•-•---•--••-----._...---•-------•------..............................: -••----•--•-----••--------------------•--- Street G� as shown on the application for Disposal Works Construction Permit Ne�-� ��<?_. Dated.......................................... ----•----....---•---_C:)� . .....--. -. Board of Health DATE................ •. • Z. FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS