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HomeMy WebLinkAbout0290 STARBOARD LANE - Health 290 Starboard Lane OsterVille P A = 166 050002 q , i y " t � n c A N G ° COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: .290 Starboard Lane Osterville, MA 02655 Owner's Name: Paul Mverson Owner's Address: S'7— Date of Inspection: November 19, 2005 Name of Inspector: (Please Print) Janes M. Ford Company Name: James M. Ford Mailing Address: P.O.Box 49 Osterville,MA 02655-0049 Telephone Number: (508) 862-9400 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section.15.340 of Title 5(310 CMR 15.000). The system: ✓ Passes Conditionally Passes Nee Further Evaluation by the Local Approving Authority Fail a Inspector's Signature: Date: November 28 1005 µme. The system inspector shall sub a copy of this inspection report to the Approving Authority(Boardfof Healtar DEP)within 30 days of completing this inspection. If the system is a shared system or has a desiow of 1+0'1100 gpd or greater,the inspector and the,system owner shall!submit the report to the appropriate regiq� office fhe DEP. The original should be sent to the system owner and copies sent to the buyer,if applicably d the al5pDovin authority. -a 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 6/15/2000 page I Page 2 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 290 Starboard Lane Osterville, MA Owner: Paul Mverson Date of Inspection: November 19, 2005 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 replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not detennined(Y,N,ND)in the 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 the tank is less than 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 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 explain: 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 obstruction is removed ND explain: 2 Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 290 Starboard Lane Osterville, MA Owner: Paul Myerson Date of Inspection: November 19, 2005 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 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 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. 3. Other: 3 Page 4 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 290 Starboard Lane Osterville, MA Owner: Paul Mverson Date of Inspection: November 19, 2005 D. System Failure Criteria applicable to all systems: You must indicate either"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 or clogged SAS or cesspool ✓ Liquid depth in cesspool is less than 6"below invert or available volume is less than ''/z day flow ✓ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number 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. ✓ 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. [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.] No (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist a.s 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 System: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) Yes No the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "Yes",in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 4 Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 290 Starboard Lane Osterville, MA Owner: Paul Myerson Date of Inspection: November 19, 2005 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: 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) [310 CMR 15.302(3)(b)]. 5 Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 290 Starboard Lane Osterville, MA Owner: Paul Myerson Date of Inspection: November 19, 2005 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 5 Number of bedrooms(actual): 5 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 550 Number of current residents: 0 Does residence have a garbage grinder(yes or no): n/a Is laundry on a separate sewage system(yes or no): n/a [if yes separate inspection required] Laundry system inspected(yes or no): No Seasonal use(yes or no): No Water meter readings, if available(last 2 years usage(gpd)): . Unavailable Sump Pump(yes or no): No Last date of occupancy: Unknown COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no) Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Unavailable Was system pumped as part of the inspection(yes or no): 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) Tight Tank Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: Installed in 1997 -per information on file Were sewage odors detected when arriving at the site(yes or no): No 6 Page 7 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 290 Starboard Lane Osterville, MA Owner: Paul Mverson Date of Inspection: November 1.9, 2005 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction: _cast iron _40 PVC _other(explain): Distance from private water supply well or suction line: Comments (on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: ✓ (locate on site plan) Depth below grade: 2.5' Material of construction: ✓ concrete _metal _fiberglass _polyethylene _other(explain) If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of certificate) Dimensions: 1500 gal. Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle: 30" Scum thickness: 6" 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: 10" How were dimensions determined: Measuring 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.): Tees were present. The liquid level was even with the outlet invert There did not appear to be anv signs of leakage A riser was installed on the inlet cover which-is now 6"below grade GREASE TRAP: None (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 (on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence.of leakage, etc.): 7 Page 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) . Property Address: 290 Starboard Lane Osterville, MA Owner: Paul Myerson Date of Inspection: November 19, 2005 TIGHT or HOLDING TANK: None (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: _concrete _metal _fiberglass _polyethylene _other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: ✓ (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 even. No solids were present. PUMP CHAMBER: None (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.): 8 Page 9 of l l OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 290 Starboard Lane Osterville, MA Owner: Paul Mverson Date of Inspection: November 19, 2005 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number: ✓ leaching chambers,number: 4-500 Qal. leach chambers leaching galleries,number: leaching trenches,number, length: leaching fields,number,dimensions: overflow cesspool,number: Innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure, level.of ponding,damp soil,condition of vegetation, etc.): The leach chambers were dry. There did not appear to be any signs offailure The bottom to Qrade was 7' A riser was installed and the cover is now 6"below Qrade. CESSPOOLS: None (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 or no): Comments (note condition of soil, signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: None (locate on site plan) Materials of construction: Dimensions: Depth of solids: Conunents(note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation,etc.): 9 Page 10 of 11 OFFICIAL INSPECTION FORM=NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 290 Starboard Lane Osterville, MA Owner: Paul Mverson Date of Inspection: November 19, 2005 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. 30 a 33 y q 3 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: 290 Starboard Lane Osterville, MA Owner: Paul Myerson Date of Inspection: November 19, 2005 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 20+/- 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: Topographic and water contours maps . Checked with local excavators, installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: Using Barnstable topographic and water contours maps, the maps were showing approximately 20'+/-to groundwater at this site. This report has been prepared and the system inspected and passed as of the date of inspection. This report is not a warranty or guarantee that the system will function properly, the future. There have been no warranties or guarantees, either expressed, written or implied, relating to the system, the inspection and/or this report. 11 a a• „ . COMMONWEALTH OF MASSACHUSETTS Z EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION SJ e..T TITLE 5 OFFICIAL INSPECTION.FORM—.NOT FOR VOLUNTARY: SUBSURFACE SEWAGE DISPOSAL SYSTE FOE PART A CERTIFICATION AUG 8 2002 � TOWN OF BARNSTABLE Property Address: 90 QS� ' & HEALTH DEPT. Owner's Name: .Z 6 4 Owner's Addres . Date of Inspection �� ©�-°� Pica. . - Name of Inspect r: (pleas pr'nt) )(-�� \`-C, an PY Name - — LOT � Mailing Address: ,0- 7 V � ,� aaC� �.,�• Telephone'Number: x' CjZ • 7/„ �'-��J CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate.and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems..I.am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: Conditionally Passes Needs Further Evaluation by the Local Approving Authority. Fail Inspector's Signature: _ Date: 5W&A. The system 'inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this.inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. Notes and Comments � yy���. Cie, v. v /'f/ ///�� /j// ****This report only describes conditions at:.the time of inspection and under the conditions�of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page I Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address:0)qb Owner: { dl� Date of . pection: / Ga 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: CAI* B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or re a�red. The system�,upon?completion of the replacement or repair; as approved by the Board of Health;Will pass. Answer yes,no or not determined (Y,N;ND)in the 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'infiltr'atioh or exfiltration or.tank failure is imminent:System will' ass 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 the tank is less than 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 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 explain: 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 obstruction is removed ND explain: 2 Page 3.of 11 OFFICIAL INSPECTION FORM-.NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE.DISPOSAL SYSTEM'INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 0 Owner. Date of pection: 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. Systein-will`pass unless Board of Health determines in accordance with310 CMR 1.5.303(l)(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 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 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. 3. .Other: 3 Page 4 of 11 OFFICIAL.INSPECTION FORM-,NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION.(continued) Property Address: Owner: Date of pection: D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No/ X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool fl/ 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 clogged SAS or lcesspool 1/ Liquid depth in cesspool is less than 6"below invert or available volume is less than '/z day now Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number / of times pumped V Any portion of the SAS, cesspool or privy is below high ground water elevation. ✓✓✓ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface / water supply. _ t1 Any portion of a cesspool or privy is within a Zone 1 ofaTublic 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 coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facilityand the presence:of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria U are triggered. A copy of the analysis must be attached to this form.] (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the systernhils.The system owner should co*ntact.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.gpd10 15,000 gPd You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no — _ the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply _ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any questibn in Section E the system is considered a significant threat,or answered . "yes"in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15:304.The system owner should contact the appropriate regional office of the Department. 4 Page 5 of I] OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: a A Owne o-4i-)A0UbAY,(.z, Date nspection: 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) LL — 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) [310 CMR 15.302(3)(b)] r 5 Page 6 of 11 OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: dQ Owner: Date of I pection: (/ 0 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.2example: 1 10 gpd x#of bedrooms):9 Number of current residents: Does residence have a garbage grinder_(yes or no - -- Is laundry on a separate sewage system (yes or no) p,4if yes separate inspection required] Laundry system inspected(yes or no)L,4,& Seasonal use:(yes or no -_/ Water meter.readings, if available(last 2 years usage(gpd)): d� /fq®®�®S� Zj�D Sump pump(yes or n Last date of occupancy: CO,MMERCIAL%INDUSTRIAL,� Type of establishment:. Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): . Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no):— Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: PU AIM kpw ��"� Was system pumped as part of the i spection(yes no):4 J�-�/ CIO— If yes,volume pumped: ,*. gallons--_How.was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM _IZ�eptic tank,distribution box,soil absorption system Single cesspool _Overflow cesspool Privy _Shared system(yes or no)(if yes,attach previous inspection records,if any) Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) _Tight tank —Attach a copy of the DEP approval _.Other(describe): proximate a e of alp c;Q�on nts,date installed(if known)and source of information: Were sewage odors detected when arriving at the site(yes or no 6 Page 7.of l 1 y OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM:INFORMATION(continued) Property Address: Owner: Date of spection: BUILDING SEWER(locate on site plan)L—,460- Depth below grade: Materials of construction:_cast iron _40 PVC. other(explain): Distance from private water supply well or suction line: _ 1 Comments(on condition of joints,venting,evidence of leakage,`etc.): SEPTIC TANK: (locate on site plan) . Depth below grade!()&bV Material of construction:j,,t<oncrete metal_fiberglass polyethylene —other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach.a copy of certificate) Dimensions: Sludge depth: Distance from top of sludge to bottom of outlet tee.or baffle: Z Z Scum thickness: / Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bo om of outlet tee or baffle: How were dimensions determined: Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels related to outlet invert, evidence of lea age,et . : r / O G p r[ it GREASE TRA,DAL(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(on pumping recommendations, inlet and outlet tee or baffle condition, structural.integrity,liquid levels as related to outlet invert, evidence of leakage,etc.): 7 Page 8 of 11 OFFICIAL INSPECTION FORM=NOT FOR.VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C . SYSTEM INFORMATION(continued) Property Address: ✓ll6� Owner: Date of I ectionj (jQ TIGHT or HOLDING TAN! c; -tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete— metal fiberglass_polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches, etc.): DISTRIBUTION BOX: (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert(�>`:P/�l.�a� Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover.;any evidence of kale into or out of box,ete. : .. 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.): 8 Page 9'of 1 I ' OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM.INFORMATION(continued) Property Address:. Owner. Date o spection: CJoL SOIL ABSORPTION SYSTEM (SAS): ocate on site plan,excavation not required) If SAS not located explain why: Type _. . leaching pits,number:_ aching chambers,number:�. leaching galleries,number: leaching trenches, number, length: leaching fields,.number,dimensions: overflow cesspool,number: _innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure,level of ponding,damp soil, condition of vegetation, etc. : Oe SW V;� 6� CY 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 or no): 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.): 9 Page 10 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY'ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM.INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 49 "A Owner• Date of spection: /I �Ua 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. ' I f 91 10 Page 11 of I I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 02 0 Owner: Date.of I ection: % a SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water Z3 feet Please indicate(check).all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date.of design plan reviewed:. Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with.local-excavators, installers-(attach documentation) -Accessed USG database-explain: You must describe how you established the high ground water elevation 1 l 11 Perrin Number: n/ Date: Completed by. ell- !'GH GRO•UND WATER LEVEL COMPUTATION Site Location: z/7 Af s i "'I le Lot Nb Owner: /►�[GC^Gl k Address: Contractor: 9,pC&/a�� e!2a I.!5 _c Address: STE.R• 1 . Measure depth to.water table to nearest.1.`10 it.. ...................... .Date month/day/...ear• S T.E,P 2 Using.Water-Level.Range Zone and In.de.x Well`1I,Vl:a.p:locate site and,determine: OAppro.priate.index well_..................................................... C Water-level range zona._.........:_....._........-.._...._ :... G STcP;:3:: Using-month ly.raport<:"Curren-t - - Water R.esourcestonditions" determine current•de:pth=to ®7hz 7i3 7 water level for-indez well ............................ month/year STEP. 4 Using:Tabie.o .Water-.level Adjustments for index-well (STEP 2PN;),.currant depth' to water•level for.index well ('STEP 3-), and water-level zo.ne (STEP•2B) I determine water-level adjustment ...................................:....................................... :.'.... .._-.... r STEP: 5 stimate•depth to:high water by subtracting th.e water level adjustment.(STEP 4) from measu.red:.depth to-water . ler•el•at site.(STEP 1)'............................................................................................_................ Figure 13.-,9e?r.adufible-compu atioi;form. 100 " ', i _ 0_ OOP— a . No. Fee--M 4 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS rication for M!5 oml !tem Cow6truction Permit � p Application for a Permit to Construct epair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. 2——1 5-Ag12 Oj', Owner's Name,Address and Tel.No. Assessor's Map/Parcel / 0 5D _ Installer's Name,Address,and Tel.No. 3 Designer's Name,Address and Tel.No. Type of Building: �+ Dwelling No.of Bedrooms Lot Size Z' `7 sq.ft. Garbage Grinder( ) No. of Persons Showers(SC'S Cafeteria Other Type of Building ( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date - I 7) o Number of sheets Revision Date Title Size of Septic Tank UU Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ens a coi2ruction and maintenance of the afore described on-site sewage disposal system in accordance with the provisio of Title 5 the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been i sued by t ' d of ` Signed Date 1 D Application Approved by DateJ. �� 7 Application Disapproved for the following reasons Permit No. f-7--KS I Date Issued s No. G 9 �+ lJ l./ k ww._Fee THE COMM ON1LIlFaALTM OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH ,DIVISION --OWIV OF BARNSTABLE., MASSACHUSETTS 0[ppYication for Mie;potar *pe;tem Construction Permit a Application for`a Permit to Construct( air(. )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. Z q 0 57tq/1 1,3W _D Owner's Name,Address and Tel No. �AeV Assessor's Map/Parcel ' ( 0 Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size 7'17 sq. ft. _ ,r Garbage Grinder( ) Other Type of Building No. of Persons e t ''Showers Cafeteria( ) Other Fixtures Design Flow gallons per,day; C;al"culated daily flow gallons. Plan Date o Number of sheets 'r "T Revision Date Titles t ` ,. rtt_ , Size of Septic Tank Type of S.A.S. y Description of,Soil �^ Nature of Repairs or Alterations(Answer when applicable) ..l Date last inspected: $� Agreement: The undersigned agrees to ens a con uction and maintenance of the afore described on-site sewage disposal system in accordance with the provisio of Title 5 the Environmental Code and not,to'place the system in:operation until a Certifi- cate of Compliance has been i sued by t ' dW ro% ` Signed Da `te,_ Application Approved by _ -` Date- Application Disapproved for the following reasons Permit No. 1 "-7 �3 - Date Issued --------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of (Compliance THIS IS TO CER that the On-site S wage Dis al System Constructed( )Repaired( ) Upgraded( ) Abandoned( )by �Lo / nee at Z�10 �� rl - has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. C''/7-2'e`3 dated ld Installer Designer The issuance of this permit shall not be construed as a guarantee that the system will function as designed. Date Inspector No. -------------------------Fee / o�� I THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS Mi!6pooafl em �Con�truction Permit Permission is hereby granted to Construct( )Repair )Upgrade( )Abandon( ) f System located at vf�ODc;,r and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this' t. cr Date: Approved b" �— a 1 3— 22 TOWN OF B/AMSTABLE vv LOCATION ZED ✓Y�'/ Oar '!< , SEWAGE # I7`Z" VILi AGE S I^!//�le ASSESSOR'S MAP do LOTZ/d.—._0 K INSTALLER'S NAME&PHONE NO. AO/ �17/ CO/LSr- SEPTIC TANK CAPACPTY (94 LEACHING FACILITY: (type) C -4 (size) /? A'9�/,Q NO.OF BEDROOMS__ BMDER O OWNE QC ., k` PEwrrDATE: COMPLIANCE DATE: I .a.. 1 , Soaradon Distance Between the: MWffium 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 Ed $0:6f.Wetland and Leaching Facility(If any wetlands exist 300 feet of leaching facility) Feet F&Wshed by { ri I P4 - 33, qq i • 4 TOWN O B STABLE V LOCATION Z7� 5� aoar `�, SEWAGE # VILI�4,.GE ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. 0/' �1� ' Cp/1 ���`�✓��� SEPTIC TANK CAPACITY f/�90 Gar 1 LEACHING FACILITY: (type) l`�l�� LG��MS (size) NO.OF BEDROOMS BUILDER O �OM�E PERMITDATE: COMPLIANCE.DATE: I 7 Separation Distance Between the: Maximum 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 Furnished by r LA <° / 3 g, as — q9 ' �7 TOWN OF BARNSTABLE LOCATION a010 SNA(60,4r� 1AAk SEWAGE # VU,LAGE osan iLL ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY / SU'D C�� LEACHING FACILITY: (type) DW 0/11, (size) NO.OF BEDROOMS s BUILDER OR OWNER MV BcSon PERMITDATE: COMPLIANCE DATE: 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 leachin facility) Feet Furnished by on A T A. y a 33 `+9 TEST HOLE LOG DATE: Gam'-o6ee 31,1g9c.- P 85o7 SOIL EVALUATOR:'[), WITNESS: ED Iawp'y PERC RATE: c 2 4G o 5 .S �oYR 4l i 44 Z I DY%Z*s ¢� LOAINJ 43, s '°Ye�g �" �2 3 "'Y1z`'/s " Z8 0 3c., 120" 34.r� N o �JcaJ � s DESIGN DATA { DAILY FLOW: (5)BDRMS.a 110 GPD=550 GPD SEPTIC TANK:55o GPD a 200%= 11 o GPD USE: k Gt>c> GALLON PRECAST SEPTIC TANK LEACHING FACILITY: USE: 414�o� OF MAsf CAPACITY: ,&IN OF M—�4 Nun nN y G�^ SIDEWALL: u S EVEN W. � U No.11111c W BOTTOM: 13 X 42 K o,"74. _ �•O RUMBAti ^�, 4�`� TOTAL: pl— ✓ 0 SURVEIO � - 9 sun NOTES: / 1. ALL PIPE TO BE 4"DIA.SCII 40 PVC. r. 2. PIPE TO BE LAID LF..VFf,FOR 2 _ .,n79ISTfZ'i 1•..... - �•.• _ ----� ..t�aS •.� BOX. 3. RAISE ALL APPLICABLE MANHOLE COVERS TO WITHIN q 6"OF FINISH GRADE. 4. SEPTIC SYSTEM IS NOT DESIGNED FOR THE USE OF A GARBAGE DISPOSAL. SEPTIC TANK AND DISTRIBUTION BOX TO BE INSTALLED A ON A 6"LAYER OF STONE I 6. INSTALL GAS BAFFLE IN OUTLET TEE. 2•LAYER OF 3/8•PEASTONE OVER UP-1 1/2•WASHED STONE ALL AROUND TOP OF FOUND. EL. � Ub \ 10• u• -ar- `F3,o0 �g2,23 4Z,�S 42,E dz 4i,55f'C°''l .,. SEPTIC SYSTEM PROFILE SITE SEWAGE PLAN GENERAL NOTES° FOR 1. CONTRACTOR TO BE RESPONSIBLE FOR THE LOCATION q OF ALL UTILITIES,ABOVE AND UNDERGROUND,PRIOR 2/o �e✓] �L�i` ��tiZ✓1 LLC-7 r HA, TO ANY EXCAVATION OR CONSTRUCTION. _ � Za $o -7 I 2. SEPTIC SYSTEM TO BE INSTALLED IN COMPLIANCE WITH PREPARED FOR 310 CMR 1&00:TITLE V. 1, THIS PLAN IS NOT TO BE USED FOR PROPERTY LINE TA� � 4 `y DETERMINATION. 6�- •{/ 4. ALL DISTURBED AREAS TO LOAMED AND SEEDED. DATE: Z 9,1917 SCALE: ^5 CONTRACTOR TO PROVIDE 24 HOUR NOTICE FOR ANY REQUIRED INSPECTIONS. WELLER & ASSOCIATES F[1645 FALMOUTH ROAD CENTERVILLE, MA. 02632 TEL: (508) 77M735 FAX: (508)77M754 APPROVED BY: — — — — — — +fit 01% OF ,N / .t' ,p�S� OF v 0 y f ij DANIEL E. y •,Gomm W l U`/IL SUR16", Sr} _ td-Y G,cc> K)AIL-SK 10T1,K 06A ,i It , I 6 f C4p (0• � � � /j � / j I l . 1 � 2.117 A6. o ^I o'er (• �' ' � A J I / � � , i 3o Z.r o 40 --,JI r ;..y. , 'fir ►.� -,: .�