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HomeMy WebLinkAbout0130 STURBRIDGE DRIVE - Health 130 STURBRIDGEDIOTERVILLE } A= 166 082 rt� { i i a E 3 -44 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments t 130 Sturbridge Dr. Property Address Kennedy Owner Owners Name information is required for every Cisterville Ma 02655 12/6/2010 page. Cityrrown 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, use only the tab 1. Inspector: I key to move your cursor-do not Sean M Jones use the return Name of Inspector key. S M Jones Title V Septic Inspection Company Name . 74 Beldan Ln. Company Address Centerville Ma 02632 Cityfrown State Zip Code 774-248-4850 smjonestitle5@gmaii.com SI4522 Telephone Number License Number rtb B. Certification I ce that I have personally inspected the sewage disposal system at this address and that the r information reported below is true, accurate and complete as of the time of the inspection. The inspection I 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: t - C' ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 12/6/2010 Inspectors Signature Date 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. ****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-09/08 Title 5 Official Inspection Form:Subsurface Sewage D' I System- a A 1 of 17 sperxi 9a Y 9 Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �< 130 Sturbridge Dr. Property Address Kennedy Owner Owner's Name information is required for every Osterville Ma 02655 12/6/2010 page. Citylrown 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 replacement 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 the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND(Explain below): t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 Commonwealth of Massachusetts lugTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 130 Sturbridge Dr. Property Address Kennedy Owner Owner's Name information is required for every Osterville Ma 02655 12/6/2010 page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) 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-09108 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 130 Sturbridge Dr. Property Address Kennedy Owner Owner's Name information is required for every Osterville Ma 02655, 12/6/2010 page. City/Town 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 Wfunctioning 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 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 or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than %day flow !Sins•09/08 Title 6 Official inspection Forth:Subsurface Sewage Disposal System-Page 4 of 17 Commonwealth of Massachusetts Title 5 official Inspection Fora Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 130 Sturbridge Dr. Property Address Kennedy Owner Owner's Name information is required for every Osterville Ma 02655 12/6/2010 page. Cityrrown State Zip Code Date of Inspection B. Certification (coat.) 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. ❑ ® 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 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. ❑ Z 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 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. t5ins•09108 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 130 Sturbridge Dr. Property Address Kennedy Owner Owner's Name information is required for every Osterville Ma 02655 12/6/2010 page. Cityrrown State. Zip Code 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: Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 god x#of bedrooms): 330 god t5ins-09106 Title 5 Official Inspection Forth;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 yA� 130 Sturbridge Dr. Property Address Kennedy Owner Owner's Name information is required for every Osterville Ma 02655 12/6/2010 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No , Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? ® Yes ❑ No Water meter readings, if available(last 2 years usage(gpd)): Detail: 2008= 15,000 total=41 gpd 2009=12,000 total= 33 gpd 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.ft., 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: t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 130 Sturbridge Dr. Property Address Kennedy Owner Owner's Name information is required for every Osterville Ma 02655 12/6/2010 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gauons 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•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 't 130 Sturbridge Dr. Property Address Kennedy Owner Owners Name information is required for every Osterville Ma 02655 12/6/2010 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 repaired 2/7/2000 per town records Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 2 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.): joints ok, no leakage, vented through roof Septic Tank(locate on site plan): Depth below grade: 2 feet Material of construction: ® concrete ❑ metal ❑ fiberglass El polyethylene El 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: 1000 Gallons Sludge depth: 3" t5ins•09MB Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary.Assessments 130 Sturbridge Dr. Property Address Kennedy Owner Owner's Name information is required for every Osterville Ma 02655 12/6/2010 page. Cityrrown 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 3 Scum thickness 2„ 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? opened covers and took measurements Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank does not need to be cleaned now but should done soon and again every 2 years as maintenance. Outlet tee intact and in good condition, water level was at bottom of outlet invert, tank not leaking and was structurally sound. Outlet to grade with steel cover. Grease Trap(locate on site plan): Depth below grade: 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-091W 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 130 Sturbridge Dr. Property Address Kennedy Owner Owner's Name information is required for every Osterville Ma 02655 12/6/2010 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): 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 t5ins•09/08 Title 5 Official Inspection Fond:Subsurface Sewage Disposal System•Page 11 of 17. Commonwealth of Massachusetts 13lugTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 0 Sturbridge Dr. Property Address Kennedy Owner Owner's Name information is required for every Osterville Ma 02655 12/6/2010 page. Cityfrown State Zip Code Date of Inspection D. System Information (cunt.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0" 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.): D-box was level and in good condition. Water level was even to both outlets, No soilds carryover, no rot holes, box was water tight and not leaking. Cover was 18+/-"below grade. 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.): Soil:Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 130 Sturbridge Dr. Property Address Kennedy Owner Owner's Name information is required for every Osterville Ma 02655 12/6/2010 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 4 infiltrators 30'x10' ❑ leaching galleries number: ❑ Teaching 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.): Soil and stone was probed in various locations with no sign of past or present saturation. 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 b t5ins-09/08 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 130 Sturbridge Dr. Property Address Kennedy Owner Owner's Name information is required for every Osterville Ma 02655 12/6/2010 page. Cityrrown 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.): t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 130 Sturbridge Dr. Property Address Kennedy Owner Owners Name information is required for every Osterville Ma 02655 12/6/2010 page. Cityfrown State Zip Code Date of Inspection D. System Information (cost.) 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 Or NL�J4- iA4K, , , /3•7= 7' t5tns-09/08 Title 5 Official inspection form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 official n Insp ecti0 Form r rn Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 130 Sturbridge Dr. Property Address Kennedy Owner Owner's Name information is required for every Osterville Ma 02655 12/6/2010 page. Cityrrown 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: 20+/- 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: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USES database explain: You must describe how you established the high ground water elevation: Groundwater elevation was determined by accessing Town of Barnstable groundwater contour map. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-09/08 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 °t 130 Sturbridge Dr. Property Address Kennedy Owner Owner's Name information is Osterville Ma 02655 12/6/2010 required for every _ page. Cityrrown 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 l t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 TOWN OF BARNSTABLE j LOCATION %�) SEWAGE # vII.LAGE= �' /ZV/L.�� ASSESSOR'S MAP &LOToaO�: INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY __F,ri,STilt� e ldy n LEACHING FACILITY: (type) ! /,,I (size) AJ X3J ,AID NO.OF BEDROOMS eD0OROW`NER.&s,,t PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: 1 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 a i p � o i of .s� �9 TOWN OF BARNSIA.BLE ; llz:I SEWAGE Vu",(i ASSESSOR'S MAP cat LO'f INSTALLER'S NAME&P14ONE NO. �04►,+� �� � - -' SEPTIC TANK CA.PACTI'I' j!S T/� r. loe 0 I_, ACHING FACILM: ( Y �i!N-z• I�r 3 Cv , 3, a' type) � <Nlsize)Ly X'3 NO.OF BEDROOMS_ eDF>OR OWNER 6: . ,4 °T ZI Ide4 s s .. PERMITDATE: LV CO.MPLIANI CE DATE: gff — Separation Distance Between the: Maximum Adjusted Groundwater Table and°Bottom of Leaching Facility wFeet Private Water Supplyy Well and Leaching Facility ► g ty (If any wells exist ` on site or within-200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist a}: within 300 feet of leaching facility) -'Feet Furnished by-- fir✓TI -3 I' �n 3 3 B TOWN OF BARNSTABLE LOCATION 1 5 SEWAGE # '— VILLAGE 0,S%Z1fLIGG E ASSESSOR'S MAP & LOT 6 v L� INSTALLER'S NAME&PHONE NO. ViV ' SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) o?6 L NO.OF BEDROOMS FOR OWNER _ �1S. 1�G�����T!/ �5%��£4C PERMITDATE: COMPLIANCE DATE: 7 Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility y� 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 lea hing.facility) Feet Furnished by %�� r .� � L r� w ,� �i �F �R�h' i �� - i ��� � I� �� I 1 ,. •-- N6, Fee �D, THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS Application for Mi5poaf 6pelem Con!arurtion Permit Application for a Permit to Construct( )Repair(Upgrade( )Abandon( ) O Complete System El Individual Components Location Address or Lot No. Inv S�Zuta ,,t" Owner's Name,Address and Tel.No. Assessor's Map/Parcel C7 SZ—r,_ILV►lJX_ Installer's N Addre s,and Tel.No. Designer's Name,Address and Tel.No. A430 STEPHEN J. DOYLE & ASSOC. 42 Canterbury Lane East Falmouth, MA 02536 Type of Building: Telephone: 5 0 8 - 2534 Dwelling No.of Bedrooms Lot Size Z I- sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow -3.AD gallons. Plan Date _"DM C.,_ I< k! qRq Number of sheets Revision Date Title 5M.�fw 22 1C O)_ �A�-J� �o�l_ � � "wT3,VU-0ta rm- �_ Size of Septic Tank WDO Type of S.A.S. Description of Soil o 4�1-►•t--g,_R al 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 proMdt he Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has bend of alt .Signe Date Application Approved by Date Application Disapproved for the following reaso VVV Permit No. ''a Date Issued 4. r s Xx Fe THE COMMO W�AL`TH-OF-MASSAC�I .USSETTS_-- Entered in computer:` Yes '-PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS _ 0(pprication for &!5pogaf *pgtem Congtruction permit Application for a Permit to Construct( )Repair(Pl Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. Owner's Name,Address and Tel.No. Assessor's Map/Parcel Installer's•N e,Add re s,and Tel.No./ Designer's Name,Address and Tel.14 STEPHEN J. ' DOYLE & ASSOC. f{ 42. Canterbury Lane c e.rFalmnlltb Type of Building: T = 1 ern e: 5 0 8/5 4 0-2 5 3 4 Dwelling No.of Bedrooms�f Lot Size I1.0itS sq.ft. Garbage Grinder( ) Other Type of Building No`.,of Persons Showers( ) Cafeteria( ) Other Fixtures `•. + Design Flow gallons per day. Calculated daily flow ~SAD gallons. ? Plan Date 1 S 1�,Atq��Number of sheets Revision Date ' Title 5 to_AM& j-: �,_ #44_r ;Am VIP :0 2QaVIA-D jA r-- --L>- _ Size of Septic T Tank %QD0 Gr %,Ua Type of S.A.S. kL_r4l1MK_ 1 Description of Soil i 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 Code and not to place the system in operation until a Certifi- cate of Compliance has been " ed y t is and o eal 4 Signed Date e Application Approved by r Date Application Disapproved for the following reaso Permit No. Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of (Compliance THIS IS TO CER ,that.the On-site Sewage Disposal System Constructed( )Repaired( )Upgraded( ) Aband ( )b Al A Ie at J _ a e constructed in accordance with the provisions of Title 5 and the for Disposal System Constructiot Permit No. dated Installer Designer =N A(� IV A _-� The issuance of this permit shall of bey ns � ed as a guarantee that theoystewill funedo a�esir. j��Date I Inspector # �� 9 ! t , - 6l \, I V - _ _ - � No. - �?b7y-------------------------Fee---- THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS lwigpogal bpgtem Congtructton erTnit Permission is hereby granted to Construct( )Repair( )Upgrade )Abandon( ) System located at and asiaescribed 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 permit. Date: Approved by 0 SMOKE DETECTORS O.K. BARNSTABLE BUILDING DEPT. OVA U rfI N''5 hD 3ASE m � (� `b b \ ' 9 -\ COMMONWEALTH OF MASSACHUSETTS , EXECUTIVE OFFICE OF,ENVIRONMENTAL A S .� DEPARTMENT OF ENVIRONMENTAL PR CTI(I & O ?' ONE WINTER STREET. BOSTON. NIA 02108 617•293.5 (W 0 2 3 1998 N s' CoXE WILLIAM F.WELD Secrctary Governor 13 ti ARGEO PAUL CELLUCCI ID B.STRUHS Lt.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Commissioner PART A • CERTIFICATION Property Address: A30 STk v.b,0,/ ✓ �r, ✓vr Ila Address of Owner:' y� .13, Date of Inspection: /O 3/— 9, (If different) AYA"OK /1�1u Name of Inspector: 30/,-, )4 9a// I am a DEP approved system/ inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000) Company Name: 30 L,n H G �7Fr &,k4o r SPrvici Mailing Address: SO Vs 44, Telephone Number CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete-as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: !/Passes Conditionally Passes _ Needs Further Evaluation By the Local Approving Authority _ Fails Inspector's Signature: Date: 147 The System Inspectors all 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 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: Check A, B, C, or >D: AI SYSTEM PASSES: r y 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 the World Wide Web: http:/NAYW.magnet.state.ma.us/dep Printed on Recycled Paper ti SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ♦t ,,. PART A CERTIFICATION (continued) Propeity Address: / ✓(> S Z'f'.i- r�o/ .��'��� �S Owner: Hli�p/ol N/a r'#�h ��G��ar d^JV Date�of Inspection: ta BJ SYSTEM CON161TIONALLY PASSES(continued) Sewak'u�p or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(Wor 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 15 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, safety 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 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 SYSTEM 15 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 I of a public water supply 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 r (revised 04/25/97) Page 2 of 20 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Propertv Address: / 3Q S 7`aiLa/�i�.� Qi'�e.! s Pwi�/e // Owner: Date of Inspection: /v ->% 9e . DJ SYSTEM FAILS: You must 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 in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No Backup of sewage into facility 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 cbMed 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 1/2 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 Soil Absorption System, cesspool or privy is below'the high groundwater elevation. Any portion of a 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 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 SO feet from a private water supp4+ well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliiorm bacteria, 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 apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater (Large System) and the system is a significaea threat to public health 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 II of a s public water supply.well) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatrwent program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 04/25/97) Page 3 of 10 r - SUBSURFACE SEWAGE.DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: Owner: 1114✓0101 *- N/ari"/�" Date of Inspection: Check if the following have been 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 part of this inspection. (/ _ 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. i _ All system components, exexe td+g7e Soil Absorption System, have been located on the site. _ The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. The size and location of the Soil Absorption System on the site has been determined based on: t/ _ The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of Sub-Surface Disposal System. 4/ _ Existing information. Ex. Plan at B.O.H. _✓ _ Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) (15.302(3)(b)) (revised 04/25197) Page 4 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: /3o S THrh��a�� Owner: Date of y Inspection: ection: . FLOW CONDITIONS RESIDENTIAL: Design flow: .310 g.p•d./bedroom for S.A.S. . Number of bedrooms: 2 ,Number of current residents: 2 Garbage gnr.der (yes or no):-J—/d Laundry cor•nected to system (yes or no): 4­0 Seasonal use tyes or no):_4[p Water meter readings, if available (last two (2) year usage (gpd) °�° 79o�y Sump Pump (yes or no):•A(Q Last date of occupancy: . ocC yylr4d COMMERCIAUINDUSTRIAL: Type of establishment: Design flow: >;allons/day Grease trap present: tees or no)_ Industrial Waste Holding Tank present: (yes or no)_ Non-sanitary waste discharged to the Title 5 system: (yes or no)_ '. \Vater meter readings, if available Last ddate of o::cupancy: OTHER: (Describe) Last date of occupanq•: GENERAL INFORMATION PUMPING RECORDS and source of information: System pumped as part of inspe n: tyes or no)_L/ If yes, volume pumped: XMVW allons Reason for pumping TYPE OF SYSTEM Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy r Shared system (yes or no) (if yes, attach previous inspection records, if any) VA Technology etc. Copy of up to date contracts' Other %DOO ou� S( /ItC Tu`iA -1- 6Xar ,��oc/rC �BtcLi ,cif APPROXIMATE AGE of all components, date installed (if known) and source of information: 2e -t yPa�-f t Sewage odors detected when arriving at the site: (yes or no) (revised 04/25/97) ?ago 5 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: /30 1 Tw,. ;9, p" ,,,AV Owner: hk--O/�'/ �- '/yam Date of Inspection: /O 3i- 90 BUILDING SEWER: (Locate on site plan) Depth below grade:2 yv Material of construction: _cast iron C4O PVC other (explain) Distance from private water supply well or suction lief Diameter Comments: (condition of joints, venting, evidence of leakage, etc.) SEPTIC TANK: (locate on site plan) Depth below grade: /o Material of construction concrete metal _Fiberglass _Polyethylene_other(explain) If tank is metal, list age _ Is age confirmed by Certificate of Compliance _(Yes/No) Dimensions: Sludge depth: 2 Distance from top of sludge to bottom of outlet tee obaffle: Scum thickness: E of eT nrT � r- Distance from top of scum to top of outlet tee or baffle: . Distance from bottom of scum to bottom of outlet tee or baffler_ How dimensions were determined: %r 9E M PoSNri^"9 J� clr Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) 3 c cr' �r 1s A ' GREASE TRAP: (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: e• Distance from bottom of scum to bottom of outlet tee or baffl . Date of last pumping: Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) (revised 04/25/97) page 6 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: /3v STu�hrip�r o �ri�o OS/Prvi��R,.�G�. Owner: Date of Inspection: r H ti�lor 99 TIGHT OR HOLDING TANK: (Tank must be pumped prior to, or at time,of inspection) (locate on site plan) Depth below grade: - a Material of construction: _concrete _metal _Fiberglass _Polyethylene 'other(explain) ' Dimensions: Capacity: gallons - Design flow: gallons/da% Alarm level: Alarm in working order'---,- Yes; No ' Date of previous pumping: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX: (locate on site plan) Depth of liquid level above outlet invert: i Comments: n, (note ii level and di tribution is equal, evidence of solids •rryover, evidence of leakage into for out of box, etc.) PUMP CHAMBER: (locate on site plant Pumps in working order: (Yes or No) Alarms in working order (Yes or No) Comments: ' (note condition of pump chamber, condition of pumps and.appunenances, etc.) (revised 04/25/97) Pays 7 of 10 - 0" SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) (continued) ,1 Property Address: /3 ;iu r,b 0 S0-19 /Y/row Owner: �GJrpl� �- /lilgri ��/ Ta�,lvr Date of Inspection: SOIL ABSORPTION SYSTEM (SAS):_ (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: Type: leaching pits, number. leaching chambers, number:__ leaching galleries, number: leaching trenches, number,length: leaching fields, n,m er, dimensions: overflow cesspool, nu ber: Alternative system: Name of Technology: Comments: (note condition oaf soil signs of hy d raulic f ilure, level of pgnding, condition QQf vegetation, etc.) B torJt Q e4 uK c ./ / O e cvf-1 i 7qs> K, 9' c u S e m or CESSPOOLS: _ (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 (cesspool must be pumped as part of inspection) 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 pgnding, condition of vegetation, etc.) revised 01/3s/97) page 8 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 150 S TH v1jri pl� �j-i v/ �S/e{-rii JAC /W',. Owner. y 4 /Y r •a T s- 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) k/7 f /o'r Tacvvwl T.� lu '� Covlr 'f(�c�r4dP C,ncr.el e O.14#4e f (revised 04/25/97) Page 9 of 20 i. SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: l 30 571,rbri� y ,(��i-i v� �SfPrvi��� "l, Owner: �4/v�d 9F /LJ 4r/�yy ����or Date of Inspection: Depth to Groundwater Feet Please indicate all the methods used t.o determine High Groundwater Elevation: Obtained from Design Plans on record Observation of Site (Abutting property, observation hole, basement sump etc.) ✓ Determine it from local conditions Check with local Board of health Check FEMA Maps Check pumping records Check local excavators, installers f/ use USGS Data Describe in your own words how you established the High Groundwater Elevation. Must be completed) jq w"a-lelY � 9 (revised 04/25/97) Page 10 of 10 CERTIFIED SEPTIC SYSTEM REPORT LOCATION 130 STURBRIDGE DRIVE OSTERVILLE, MA MAP 166 PARCEL 082 LOT 46 PREPARED FOR SELLER MS . ELIZABETH STEELE 414 CAMINO LAGUNA VISTA GOLETA, CA 93117 BUYER , MR. & MRS. HAROLD F . TAYLOR 47 BAY SHORE RD PLYMOUTH, MA 02360 �a PREPARED BY HILLIARD HILLER, JR. P.O. BOX 250 CENTERVILLE, MA 02632 508-778-1472 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Address of property 13o owner's name 17,5. BL/�A4�T� 6T G�f Date of Inspection 7/a2119sl PART A CHECKLIST Check if the following have been done: V Pumping information was requested of the owner, occupant, and 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 part of this inspection. IVII 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 site was inspected for signs of breakout. /.v J� All system components, voEcluding the SAS, have been located on the site. tZ The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. The size and location of the SAS on the site has been determined based on existing information or approximated by non-intrusive methods. The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of SSDS. s ' 8 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION FLOW CONDITIONS If residential number of bedrooms o number of current residents �6Z_ garbage grinder, yes or no. Yris laundry connected to system, yes or no 115 seasonal use, yes or no If nonresidential, calculated flows Water meter readings, if available: 15y"11.1/ L 9 y Last date of occupancy GENERAL INFORMATION Pumping records and source of information: Ala System pumped as part of inspection, yes or no if yes, volume pumped Reason for pumping: Type of system Septic tank /soil absorption system .Single cesspool Overflow cesspool Privy Shared system (yes or no) (if yes, attach previous inspection records, if any) Other (explain) Approximate age of all components. Date installed, if known. Source of information: A?72 N�Xi5� 6vi�i Sewage odors detected when arriving at the site, yes or no 9 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION continued SEPTIC TANK: (locate on site plan) depth below grade: material of construction: '-,"concrete metal FRP other(explain) dimensions: a X 5�a� ��✓� ��d � � /D/1 sludge depth �" distance from top of sludge to bottom of outlet tee or baffle �! 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 Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, recommendations for repairs, etc. ) AF Ti`LvK [d/gS T' Low , /,"4 �xc h'f�GTo Th'f G?ol/� Sr�.PG/'a'! 71� /l Ile • DISTRIBUTION BOX: /-">" Fovvo (locate on site plan) depth of liquid level above outlet invert Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, recommendation for repairs, etc. ) PUMP CHAMBER: (locate on site plan) pumps in working order, yes or no i Comments: (note condition of pump chamber, condition of pumps and appurtenances, recommendations for maintenance or repairs,etc. ) 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION continued SOIL ABSORPTION SYSTEM (SAS) :L (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: Type leaching pits and number leaching. chambers and. number leaching galleries and number leaching trenches, number, length leaching fields, number, dimensions overflow cesspool, number Comments: (note .condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, recommendations for maintenance or repairs,etc. ) Tft,E IiQY /T L��CIO /%y I/e L_Ci Ud L Hffa GXJC% Q,"N C//a CESSPOOLS (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 (cesspool must be pumped as part of inspection) Comments: (note condition of soil, signs of hydraulic failure, level' of ponding, condition of vegetation, recommendations for maintenance or repairs,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, recommendations for maintenance or repairs,etc. ) " 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION continued SKETCH OF SEWAGE DISPOSAL SYSTEM: l3o STv/lB�iOG�' I�T�'ila�� include ties to at least two permanent references landmarks or benchmarks locate all wells within 100 ' \ DEPTH TO GROUNDWATER 3yl depth to groundwater i method of determination or approximation: �3fIRA/51A/s/�E (,/S Tti'r- 6/1cri1,1,0 /f T wi7T�/I 1-4111-A / LASS T/Hfl4,-' /, 12 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C FAILURE CRITERIA Indicate yes, no, or not determined (Y, N, or ND) . Describe basis of determination in all instances. If "not determined", explain why not) W Backup of sewage into facility? _11.b Discharge or ponding of effluent to the surface of the ground or surface waters? NMD' Static liquid level in the distribution box above outlet invert? _A,V Liquid depth in cesspool <611 below invert or available volume< 1/2 day flow? 44 Required pumping 4 times or more in the last year? number of times pumped /Ip Septic tank is metal? cracked? structurally unsound? substantial infiltration? substantial exfiltration? tank failure imminent? Is .any portion of the SAS, cesspool or privy: 02 below the high groundwater elevation? _&X2 within 50 feet of a surface water? &0 Within. 100 feet of a surface water supply or tributary to a surface water supply? X0 within a Zone I of a public well? t,O within 50 feet of a bordering vegetated wetland or salt marsh (cesspools and privies only, not the SAS) ? &V within 50 feet of a private water supply well? 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 analysi for col.iform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. TOWN OF 13i9/Iti57?9RGfL BOARD OF HEALTH SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART D - CERTIFICATION -.------- -------- ------------------ -TYPE OR PRINT CLEARLY- PROPERTY INSPECTED STREET ADDRESS 130 /2RP34/,0G.E Os%.Eil[i/1-6lr' ASSESSORS MAP, BLOCK AND PARCEL # /Ge S,;?- L oT ya OWNER' s NAME /Z1__1z 9Xr_1f� 15rZX41E PART D - CERTIFICATION NAME OF INSPECTOR /Y`LLI_115W0 If/LL,e/l. j4, COMPANY NAME COMPANY ADDRESS &PX el AI ZfVe? 't Street Town or City State ZIP COMPANY TELEPHONE ( ,rep -27F - /V7�2 FAX CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposa-1 system at this address and that the information reported is true , accurate , and complete as of the time of inspection . The inspection was performed and any recommendations regarding upgrade , maintenance , and repair are consistent with my training and experience in the proper function and maintenance of on- site sewage disposal systems . Check one : &I System PASSED The inspection which I have conducted has" not found any information which indicates that the system fails to adequately protect public health or the environment as defined in 310 CMR 15 . 303 . Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form. System FAILED* The inspection which I have conducted has found that the system fails to protect the public health and the environment in accordance with Title 5 , 310 CMR 15 .303 , and as specifically noted on PART C - FAILURE CRITERIA of this inspection form. Inspector Signature Date 7131 .S- One copy of this certification must be provided to the OWNER, the BUYER (where applicable) and the BOARD OF HEALTH. * If the inspection FAILED, the owner or operator shall upgrade the system within one year of the date of the inspection, unless allowed or required otherwise as provided in 310 CMR 15 . 305 . partd.doc KEY NUMBER <4392 > NAME <STEELE, EDWARD > B-C 1 B-C 2 B-C 3 B-C 4 STREET 414 CAMINO LAGUNA VISTA CITY GOLETA ST CA ZIP 93117-1532 REF 1 REF 2 PHONE ( ) - REF 3 REF 4 METER NO. < 4577> DATE READING CONS STREET <STURBRIDGE DR NO. 130> 06/30/95 0 0 CITY OST 0 L46 ST LOC 12/31/94 0 8� PHONE ( ) - 12/19/94 0 0 12/19/94 335 8 'h ROUTE NUMBER 14 06/30/94 327 3 SERVICE DATE 09/18/72 12/31/93 324 4I- METER . DATE 12/19/94 06/30/93 283 1 CAPACITY 7 12/31/92 282 10 STYLE T10F SIZE 1 RATE SCHEDULE KEY PIT PLASTIC NOTE RR ON FRONT ADDITIONAL CONS 0 ALTERNATE MIN 0 3. ALL COMPONENTS OF THE SANITARY SYpTEM SHALL BE CAPABLE OF WITHSTANDING H-10 LOADING UNLESS THEY ARE UNDER OR WITHIN 10' OF DRIVES OR PARKING. H-20 LOADING SHALL BE USED UNDER OR WITHIN /B' TO 1/2' WASHED STONE 10' OF DRIVES OR PARKING UNLESS NOTED. 4. THE EXCAVATOR/CONTRACTOR SHALL RIFY THE LOCATION OF ALL SITE UTILITIES PRIOR TO ANY EXCAVATION. 2, 5. SEWER PIPES SHALL BE 4" SCHEDULE 40 PVC LAID AT 0.02 SLOPE. S EFT. DEPTH �. �E �:`� �4 zr 6. ANY MASONRY UNITS USED TO BRING CQVERS TO GRADE SHALL BE MORTARED IN PLACE. , �EFF. DEPTH 7. FINISH GRADE SHALL HAVE A MINIMUM SLOPE OF .0.02 FEET PER FOOT. 0R CHAMBERS t x 48. r Exist. 48 J Pave Existing lOQQ GalYon Precast Tank Resting Cesspool Shall Be Pumped Removed a` o i 53 40* and Filled With Clean Coarse Sand. co ` 48.2 C / r r 1 13g•IB7° Proposed S.A.S. Infiltrator Trench x 49.24 x 49.11 - r i rr ,rr - r r ^I 6' i i '~' -J x 9 7° '•' 1 r r CV / " fl 48.3$ x 49.07 p5 r 1° - •ry r "yt t r � 10. 49.07 • �` ���/// 'i, `� Res.ing _••• •` ' .. .8 Driveway, LOT 46 12,926 sq.ft •��1rh '� > ! ` / x 49.24 r I 100 00, * 49.07 Y. 49�• • r ,,., ,urn -�.,,.,�. s s ,. IT I , - - GENERAL CONSTRUCTION NOTES • TOP FOUND. EL # 1. ALL WORKMANSHIP AND MATERIALS SHALL CONFORM TO D.E.P. TITLE 5 AND THE TOWN OF M fir'&3�9 RULES AND REGULATIONS FOR THE SUBSURFACE DISPOSAL OF SEWAGE. 2. AT LEAST ONE ACCESS PORT OVER TANK TEES SHALL BE—ACCESSIBLE ,... . �� ,`.�.��y���,,`0"•�-- '�, ,�� �., ,. ,. ,.y _ . �. `.. �`�;..r-�• '`�,,`��, �- ., �, �� �.. ..a.°�• , _ -- k �. .• ,. . , ,,... w , ._.....v-..-._..�,�__._._. WHITHIN SIX INCHES OF FINISH GRADE WITH ANY REMAINING ACCESS PORTS BROUGHT TO WITHIN TWELVE INCHES OF FINISH GRADE. WAIM MIGHT COVER 3. ALL COMPONENTS OF THE SANITARY SYaTEM SHALL BE CAPABLE OF INV. EL. "to V: c,hl 7 - " WITHSTANDING H-10 LOADING UNLESS THEY ARE UNDER OR WITHIN 10' .`, OF DRIVES OR PARKING. H-20 LOADING SHALL BE USED UNDER OR WITHIN FLOW LINE _ ----�—�-- �" MIN. — 1/6' TO 1/2" WASHED STONE 10' . OF DRIVES 0R PARKING UNLESS NOTED. INV. EL. �r t�1Y`x A(*,, :•:• �f. 'L 4. THE EXCAVATOR/CONTRACTOR SHALL VERIFY THE LOCATION OF ALL MIN. 8, SITE UTILITIES PRIOR TO ANY EXCAVATION. -0 UOUID DEPTH ` lir INFILTRATOR �— „ " � • DEPTH 0 PVC LAID AT 0.02 SLOPE. -•4b S SEWER PIP BE SCHEDULE^_ INV. EL ,1, t 3 4" 1 1 2 WASHED STONE r 'r � r 2 ES SHALL 4 S DUL � �� INV. EL. s�.t�.� , INV. EL 6. ANY MASONRY UNITS USED TO BRING COVERS TO GRADE SHALL BE •...r,.._,rw•,....w..:w�:.i'TAE¢tidtri:tCCY '+a. Y.: ,y.. .. MORTARED IN PLACE. _. _.. S.A.S. .LONG x�4_WIDE x I EFF. DEPTH PRECAST REINFORCED CONCRETE WITH NIGH CAPACITY INFILTRATOR CHAMBERS 7. FINISH GRADE SHALL HAVE A MINIMUM SLOPE OF 0.02 FEET PER FOOT. DISTRIBUTION BOX INSTALL ON A LEVEL BASE , MINIMUM WALL THICKNESS ,. 2" / r A1,9. EXISTING PRECAST 1000 GALLON TANK , MINIMUM INSIDE DIMENSION - 12" OUTLET INVERTS SHALL BE EQUAL TO EACH ; Exist. , —"' Pave 4$.2 OTHER AND AT 2 MINIMUM BELOW INLET INVERT. � , THE DISTRIBUTION LINES FROMr THE DISTRIBUTION Box / _ — Existing 1000 Gallon Precast Tank , M1 ' SHALL ALL HAVE EQUAL INVERTS AS DETERMINED BY FLOODING ; f tl• THE DISTRIBUTION BOX TO THE HEIGHT OF THE DISTRIBUTION ,' Q© 5 5 Existing Cesspool Shall Be Pumped Removed LINE INVERT AFTER ALL LINES HAVE SEEN SEALER 1N PLACE. '40„ ' ANINVERT NON—DEFORMABLE MATERIAL MADE ERMANENTLY FASIENDIl1?ABLE r' �r /! CV // \ 3� ADJUSTMENTS SHALL BE R' and Filled With Clean Coarse Sand. TO THE UNE OR RECONSTRUCTING THE LINES UNTIL ALL INVERTS ARE Of # 48.2 EQUAL ELEVATION. ; r 1 5 _ — Proposed S.A.S. Infiltrator Trench L r F `. zo x 49.24 x 49.11 p ;' ^ co 60 MV , • r r r ~ / r - �"• '\— Mere i 1& •; k WI At l r � '., ') S .. • , , � . / � � 1 , �it "o` •.. � '!' ~'••"� •, Y «a f r r �48.38 • 7x 49.07 r , - �//r/) 1,/ .••.i ' «_� v „_.•,: r � .1,.. �� . •:F� -�, I'- .- � r :. • 'fC�' N //7` /�/r p� TP'1p . . t .,,� 1 ,••. a� , , r Ex<S+in / x 49.07Drive7ay 7 . z:"� a;.• •., 3° it 48LOT 46 $Z , r ' 1 12n Q ,928 3Q.ft. ��n- •�; .:p, M ".`" 1 rr�'� ••.f.NS� lbw7k'„�+t"'�j� ,. x 49.24 $°' ' , 100• , `. A 49.07 40 , 49.25 - r BM: FIN. FLOOR EL. 51.75' DATUM: NGVDf SOIL OBSERVATION DATA: GRA 'HIC SCALE EXISTING AND PROPOSED GRADES SHALL REMAIN 20 ESSENTIALLY' THE SAME UNLESS OTHERWISE NOTED o �0 20 ' �Io so TEST DATE DESIGN DATA: SOIL EVALUATOR s.�a�=,, STRUCTURES LOCUS DOES NOT LIE Il�T A FLOOD HAZARD ZONE IN 1 inch 20 fL, TYPE NO. BEDROOMS GARBAGE DISPOSAL ZONING DISTRICT: RC DESIGN FLOW ���� 3"�s2 +?-� ,ham BUILDING SETBACK: H FRONT 20' p PERC/RATE -� 1��0�,•�e�ta4 SIDE 10' x REAR 10' SEPTIC TANK -3.30 � -e-�•' ' = �G 0 — �S"` 1p00 �p.�u.ol� GROUNDWATER OVERLAY DISTRICT: AP 51.. Soy �• 's/Z ASSESSORS MAP: 166-82 LEACHING 'FACIUTY s.A: S �:�1 lL-c1ti 2�,uau_ #130 STURBRIDGE DRIVE -g `S oor t,/q �A _ ✓ Y Ul 10 x -So �OV V I C) •4 •;.ov 1L o•'14 t .4 1�P 1aa �i •fir 1`Z 8 SEWAGE SYSTEM REPAIR PLAN r OF LAND IN d WILLIAtvi LIERERMAIV I ,, FOR A} z� / FAST SAY ZTI E `-- Date: December 15, 1p99 Scale: 1" = 20' - 4', - Prepared By. Stephen J. Doyle and 'AssoCiatos, 42 CanterburyLane East' Falmouth, MA 02536 ,' . • h, �' • Telephone: 50$/5 40-2534 , , ,