HomeMy WebLinkAbout0061 SUNSET LANE - Health 61 SUNSET LANE, OSTERVILLE
o e
DATE: 8/12199__—_
PROPERTY ADDRESS:_61_Sunse� a_n�________
—_ 0sterville ,Mass__
02655
On the above date, I Inspected the septic system at the above address.
This system consists of the following:
1 . 1-1500 gallon septic -tank.
2 . 1—Distribution box.
3 . 1-1000 gallon precast leaching pit packed in stone .
Based on my Inspection, I certify the following conditions:
4 . This is a title five septic system. ( 78 Code )
5 . The septic system is in proper working order ll `
at the present time .
6 . The septic system meets a three bedroom;Not a five
bedroom design. This property has five bedrooms .'
SIGNATURE:
Name:_ _ Macomber ,Tr-______
Company: Jo_seTh_P. Macomber_& Son , Inc . � A?
helvEe
Address: Box 66 ________ q�C
Centerville , Ma . 02632-0066 3 19
10 9 y
------------ ------- c
0� N
481
Phone:___508_775_3338_______
THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY
JOSEPH P. MACOMBER & SON, INC.
Tan ks-Cesspools-Leachflelds
Pumped & Installed
Town Sewer Connections
P.O. Box 66 Centerville, MA 02632-0066
775.3338 775-6412
COMMONWEALTH OF MASSACHTJSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
ONE WINTER STREET, BOSTON MA 02108 (617) 292.5500
TRLrDY CO)
Secreu
ARGEO PAUL CELLUCCI DAVM B. STRUI
Governor Corr wss:oc
SUBSURFACE SEWAGE DISPOSAL SYSTEM WSPECTION FORM
PART A
CERTIFICATION
PnopeMAd&es.s:61 Sunset Lane NarrwofOwrw John Hurley
Osterville ,Mass . 02655 Address of Owner:
Date of Inspection: 8/12/9 9
Nam. o f Inspector:(Ptaasa Prirn) Joseph P.Macomber J r .
I am a DEP oved system Inspector pursuarnt to Section 15.340 of Trde 5 (310 CMR 15.000)
Conx).61yName: J.rMacomber & Son Inc .
ttamngAdaass: _B_ox fib CPnt-Prvi11P - Mace 02632
TdepI,—Number: s n 7;c ;3
38
CERTIFICATION STATEMENT
I certify that I have personally Inspected the sewage disposal system at this address and that the Information reported below is true. accurst•
and complete as of the time of Inspection. The Inspection was performed based on my training and experience in the proper tunction and
maintenance of on-site sewage disposal systems. The system:
2Pesses
Conditionally Passes
Needs Further Evalu Lion By the Local Appr ving Authority
_ Fails
lnspecto's Sigrnature• Data: ��
The System Inspec o all submit a copy of this Inspection report to the Approving Authority (Board of Health or OEP)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 otEnvkonmetttal Protection. The original should be sent to MR
system owner•and copies sent to the buyer,If applicable, and the approving authority.
NOTES AND COMMENTS
e
revised 9/2/98 Page I of it
h
t� inMeO on Recyeled 7rprr
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (corrtirwed)
PropertyAddro= 61 Sunset Lane Osterville ,Ma.ss .
Owner: John HUrley
Data of kmi"'cs": 8/1 2/9 9
INSPECTION SUMMARY: Check A, 8, C, or A
A. SYSTEM PASSES:
1 have not found any information which Indicates that any of the failure conditions described in 310 CMR 1-6.303 exist. Any failure
criteria not evaluated are Indicated below.
COMMENTS: The present septic system is designed t o hand( P a
-0 r c O h o rl room a-s—Not—a—g-i-y-e—b e d rr A 9 m , h e• ! Cottage
\
3—bedrooms=330 gallons per Five Bedroom 550 gallons per day .
B. SYSTEM CONDITIONALLY PASSES:
One or more system components as described In the "Conditional Pass" section need to be replaced or repaired. The system, upon
completion of the replacement or repair,as approved by the Board of Health, will pass.
Indicate yes,_no, or not determined(Y, N, or ND). Describe basis of determination in all Instances. If "not determined", explain why not.
The septic tank Is metal, unless the owner or operator has provided the system Inspector with a copy of a Certificate of
Compliance (attached)Indicating that the tank was Installed within twenty(20)years prior to the date of the Inspection; or
the septic tank, whether or not metal,is cracked,structurally unsound, shows substantial infiltration or exfiltration, or tank
failure Is Imminent. The system will pass Inspection if the existing septic tank is replaced with a complying septic tank as
approved by the Board of Health.
Sewage backup or breakout or high static water level observed In the distribution box Is due to broken or obstructed pipe(s)
or due to a broken, settled or uneven distribution box. The system will pass Inspection if(with approval of the Board of
Health).
broken pipe(s) are replaced
obstruction Is removed
distribution box is levelled or replaced
�- The system required pumpMg-mom than-fou -dunes•a yeardus to broken or obstructed pipe(:). The vy7tam wilfjesv--
Inspection If(with approval of the Board of Health):
broken pipe(s) are'replaced
obstruction Is removed
revised 9/2/98 Page 2of11
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 61 Sunset Lane Osterville ,Mass.
Owner: John Hurley
Date of Irupeotion:8/12/9 9
C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
A- 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 IN ACCORDANCE WITH 310 CMR 15.303(1)(b)THAT THE SYSTEM
IS NOT FUNCTIONING IN A MANNER WIi1CH.WILL.PRQTECT THE PUBLIC W-ALTHAND SAFETY AND THE FNNO@ONMENT:
Cesspool or privy is within 50 feet-of surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
21 SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUB
LIC WATER SUPPLIER,IF ANY)DETERMINES THAT THE SYSTEM IS
FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of 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 o—(approximation not valid).
3) O//T��HER
revised 9/2/98 P2ge3orii
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 61 Sunset Lane Osterville ,Mass .
Owner: John Hurley
Dane of 4upection:8 12 9 9
D. SYSTEM FAILS:
You must Indicate either"Yes" or"No" to each of the following:
I have determined that one or more of the following failure conditions exist as described In 310 CMR 15.303. The basis for this
determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure.
Yes No
Backup of-eewage imto4ecili"r-e/aten+componentduelto an overloaded or-clogged-SiAS-or-cesspod.
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 he istrib u�n fox p ve outlet invert due to an overloaded or clogged SAS or cesspool.
Liquid depth in eeeapeol IIi 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 j,.
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 50 feet from a private water supply well with no
acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for
»coliform bacteria,volatile organic compounds, ammonia nitrogen-and nitrate nitrogen. -
E. LARGE SYSTEM FAILS:
You must indicate either "Yes" or "No" to each of the following:
The following criteria apply to large systems In addition to the criteria above.-
The system serves a facility with a design flow of 10,000 gpd or greater(Large System) and the system is a significant threat to public
health and safety and the environment because one or more of the following conditions exist:
Yes No
�/ the system is within 400 feet of a surface drinking water supply
L/ the system•is-within 200 4etof-&4f;butar"o-asucfsoa4finking w ter-supPIV- --•• - _ ._
the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area=IWPA) or a mapped Zone li of a public
water supply well)
The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional
office of the Department for further inforjnatioh.
revised 9/2/95 Page 4or11
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I'I j SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
PropertyAddre:s: 61 Sunset Lane Oster'ville ,Mass .
Owner: John Hurley
Date of Inspection:8/1 2/9 9
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�compoaants hars23aan pup4md4aira4•Jeast twoweeks aadthe'system hasbaaoQscaiaiwg+aar"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.
_ All system components,8k1
//luding the 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 orrthe site has been determined based on:
_ Existing information. For example, 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)]
The facility owner.(and.onsupants..lf different lnfauna2ioafln thA prnpar mAintersr:,f
SubSurface Disposal Systems.
I ,
revised 9/2/98 Page 5of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
ProperyAddlross: 61 Sunset Lane Osterville ,Mass.
Owner: John Hurley
Date of Inspection: 8/12/9 9
FLOW CONDITIONS
RESIDENTIAL:
Design flow: Ah _g.p.d./bedr m.
Number of bedrooms d s'g Number of bedrooms(actual):
Total DESIGN flow ,
Number of current residents:
Garbage grinder(yes or no):
Laundry(separate system) 1 as or Ono If yes, sepau"Inspection.required
Laundry system inspects ye or no) _�y (q P.D
Seasonal use(yes or no): ``) G
Water meter readings,If available(last two year's usage(gpd): v • J
Sump Pump(yes or no):
�
Last date of occupancy:
COMM ERCIAUINDUSTRIAL:
Type of establishment:
Design flow: d ( Based on 15.203)
Basis of design flow Am
Grease trap present: (yes or no)
Industrial Waste Holding Tank present: (yes or no)&d
Non-sanitary waste discharged to the Title 6 system: (yes or no)A/ '
Water meter readings,if available: AZA
Last date of occupancy:_
OTHER:(Describe) VA
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information: p/IA 0 e(;„1 G�l S
System pumped as part of ins a tion:(yes or no) 1C
If yes, volume pumped: r al ns
Reason for pumping: K�✓ , � FQ1d�I J6Ll�j �����s ^� +.r,
TYPE 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)
-- I/A Technology etc.Attach copy of up to date operation and maintenance contract
VF Tight Tank �M Copy of DEP Approval
Other .vA
APPROXIMATE AGE of all components, date installediif known)-and source of.iwformation:
Sewage odors detected when arriving at the site: (yes or no)"
revised 9/2/98 Page 6of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 61 Sunset Lane Osterville ,Mass.
Owner: John Hurley
Date of 4upecdon:8/12/9 9
BUILDING SEWER:
(Locate on site plan)
Depth below grade:, �
Material of construction:_cast iron0 PVC_other(explain)
Distance from private water supply well or suction line /D —
Diameter 4W _
Comments: (condition of joints, venting, evidence of leakage,-etc.)
Joints appear tight No evidence of leakage
SEPTIC TANK: Q CA S
(locate on site plan) 7
Depth below grade:
Material of construction: concrete_metal_Fiberglass _Polyethylene_other(explain)
If tank is(petal,list age ls.age•confirmed by Certificate of Complianc (Yes/No)
Dimensions:
Sludge depth:_
Distance from top of sludge to bottom of outlet tee orbaffle:
Scum thickness:_,_
Distance from top of scum to top of outlet tee or baffler
Distance from bottom of scum to bolt of o t t e or baffle:' _
How dimensions were determined:
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.)
Pump tank every' 2-3 vear—T.—T-nlet & outlet tees are in place ,
TrFe tank is structurally sound Tank shows no PvirlPnrP of 1PakaoP
GREASETRAP:LM
(locate on site plan)
Depth below grade:
Material of constructs :tAconcrete,dFnetaPWFiberglass��Polyethylenegother(explain)
Dimensions:
Scum thickness: Of
Distance from top of scum to top of outlet tee or baffler
Distance from bottom of gcum to bottom of outlet tee or baffler
Date of last pumping:QA
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.)
Grease trap is notpresent
revised 9/2/98 Page 7of11
I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 61 Sunset Lane Osterville ,Mass .
Owner: John Hurley
Data Of Inspection:8/12/9 9
TIGHT OR HOLDING TANK(Tank must be pumped prior to, or at time of, inspection)
(locate on site plan)
Depth below grade:
Material of constructions dconcreta44metalaFiberglasal�Polyethylen"Sother(explain)
AM
Dimensions:
Capacity: gallons
Design flow: gallons/day
Alarm present
Alarm level: Alarm in working order:Yes: Nq&g
Date of previous pumping: 104
Comments:
(condition of inlet tee, condition of alarm and float switches,etc.)
Tight or holding tanks are not present .
DISTRIBUTION BOX:_keoof
(locate on site plan)
Depth of liquid level above outlet invert: Ab
Comments:
(note-if level and distribution Is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) — -Distribution box has one lateral . No evidence of solids carry over .
No evidencp of 1pnknRP infn nr niit of tha hnv
PUMP CHAMBER:
(locate on site plan)
Pumps in working order:(Yes or No)el1✓1}
Alarms in working order(Yes or No)—
Comments:
(note condition of pump chamber,condition of pumps and appurtenances,etc.)
umD chamber is not present .
revised 9/2/98 Page 8of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (corrtinued)
Property Address: 61 Sunset Lane Osterville ,Mass .
Owner: John Hurley
oats of Irtspectkm: 8/12/9 9
SOIL ABSORPTION SYSTEM(SAS)
(locate on site plan,if possible:excavation not required,location may be approximated by non-intrusive methods)
If not located, explain:
Type:
leaching pits,number: AA
leaching chambers,number: t,r_
leaching galleries,number:�j
IeacWn trenches,number, length
9 g
leaching fields, number, dim slops:
overflow cesspool,number:
Alternative system: � �
Name of Technology:
Comments:
(note condition of soil, signs of hydraulic failure,level of ponding, damp soil, condition of vegetation, etc.)
Loamy -,and to marli iim fin@ e8F}d - Die ai-s1380i y d r a tt, _ _ r _ • ,
l . 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: i
Materials of construction:
Indication of groundwater:
inflow(cesspool must be pumped as part of Inspection)
0
esspools are not =rPgPnr
Comments:
(note condition of soil, signs of hydraulic failure,.level of ponding,condition of,vegetation, etc.)
esspools are not p'Pgpnt
PRIVY:, &
(locate on site plan) ,/
Materjals of construction: �/� Dimensions: &1W
Depth of solids:,
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation;etc.)
Privy is not present ,
w
revised 9/2/98 Page 9of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PXRT C
SYSTEM WFORMATION(Conttrxiad)
Pr Address:
opwty 61 Sunset Lane Osterv 'i11e ,Mass .
Owr.*(r John Hurley
8/12/99
SKETCii OF SEWAGE DISPOSAL SYSTEM:
Include des to at Fast two permanent re(srence landmarks or benchmarks
locals all wells within 100' (Locate where public water supply comas Into house)
R d
33 W6 Q
I5 3�
S-3 � e
Col Toy
rou
O o 0
3
119l si,,A�ser 4N osrervdle
revised 9/2/98 Ne10ocu
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Pr.p"Ackireu: 61 Sunset Lane Osterville ,Mass .
owner: John Hurley
Date of Inspection:g/12/9 9
NRCS Report name
Soil Type_
Typical depth to groundwater
USGS Date website visited
Observation Wells checked
Groundwater depth: Shallow Moderate Deep _
SITE EXAM Slope
Surface water
Check Cellar
Shallow wells
Estimated Depth to Groundwater/ Feet
Please Indicate all the methods used to determine High Groundwater Elevation:
_Obtained from Design Plans on record
Observed.Site (Abutting property, bservation hole, basement sump etc.)
Determined from local conditions
Checked with local Board of health
Checked FEMA Maps
hocked pumping records
�hecked local excavators, Installers
Used USGS Data
Describe how you established the High Groundwater Elevation. (Must be completed)
Used water contours Map.
Gahrety & Miller Model
12/16/94
i
revised 9/2/98 Page II of1I
{ d
1a•�nT�rnlT�a_.Ta— rnrmr•nt.werlart a7afa7aanlrllRlflla�TRa1T nTA7J 1ti'v/iT1�T
I TOWN OF Barnstable BOARD OF IIEALTII
SUBS�. A-•Tn-..•.-::._..,,,,_.,�„, UItFACF 9F.HACR DISPOSAL SYSTEM IN�9I'�FCTION FORM - PART D^- CEII'1'IFICATION I
-TYPE OR PRINT CLEARLY-
PIlOPERTY INSPECTED
STREET ADDRESS 61 Sunset Lanp 0sterville .Mass _
ASSESSORS MAP, BLOCK AND PARCEL #
OWNER' s NAME John Hdrley
0
PART D - CERTIFICATION
NAME OF INSPECTOR Joseph P.Macomber Jr/ . ,
COMPANY NAME J. P.Macomber & Son Inc .
COMPANY ADDRESS Box 66 Centerville ,Mass . 02632
Street Town or City Stat• tIp
COMPANY TELEPHONE (508 ) 775 - 3338 FAX ( 508 ) 790 - 1578
R
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at
this nddress 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:
_zSysteoi PASSED
The inspection which I have conducted has not found any information
which indicates that the system fails to adequately protect public
healLh 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 con21acted has found that the system fails to
Protect the jiublic 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 LDate
One copy of this certification must be provided to the OWNER, the BUYER
( where applicable ) and the 130ARD OF 11EAL711
* If the inspection FAILED, the owner or""operator shall upgrade ayetem
within one year of the date of the inspection, unless allowed or required
otherwise as provided in 3.10 CMR 16 . 305 .
partd .doc
P
Commonwealth of Massachusetts
Executive Office of Environmental Affairs
Department of
Environmental Protection
Nam F.Weld
oAMmor Trudy Cox*
Argo*Paul Colluecl a-ftuy
tt Goasma David B.Struhs
Cennrariorrr
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
- PART A _
CERTIFICATION RECEI I9 7
Property Address: ( S C Address of Owner. 1�
Date of Inspection: 7 r C J'7 (If different) AUG 8 1997 1
Name of Inspector. /10-ul
Compan Name,Address and Tele hone Number. HEA�.Tf•��=y ,
/YI6-u..• S TOWN OF E?AE o*-
0�3�
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:
asses
_ Conditionally passes— Needs Needs Further Evaluation By the Local Approving Authority
Fail
Inspector's Signature: Date: 7-1,F-
The System Inspector shall mit 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:
A] SYSTEM PASSES:
C/
I have not found say information which indicates that the system violates any of the failure criteria as dewed is 310 CMR 16.303.
A49 failure criteria not evaluated are indicated below.
Bl SYSTEM CONDITIONALLY PASSES:
One or more system components need to be replaced or repaired. The system,upon completion of the• replacement or repair,pesses
Indicate yes,no,or not determined(Y,N,or ND). Dese nl*basis of determination in all instances. If'n t determined",explain why not)
_ T>se septic tank is metal,craekd,structurally wwound,shows subtaatial inSksation ar uAltratwn,.or teak Wure is
imminent. The system will pass inspection if the existing septic tank is replaced with a poai°rmla8 kPuc tank
by the Board of Health. at approved
(revised 11/03/95) I
One Winter Street • Boston,Massachusetts 02108 • FAX(617)SM1049 • T•hphon•(617)292-UN
Pnmed an Ra W Paper
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address:
Owner.
Date of Inspection:
B)SYSTEM CONDITIONALLY PASSES(continued)
Sewage backup breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s)
or due to a broke settled or uneven distribution box. The system will pass inspsetion if(with approval of the Board of
:Health):_ .
-� broken pipe(s)are replaced
obstruction is removed
distribution bey is levelled or replaced
The system required pumping ore than four times a year to broken or abstracted pipe(e). The system will pass
iaspeetion if N.' approval of Board of Health):
it broke pipe(s)are reply
obstru 'on is rem
C) FURTHER EVALUATION IS REQUIRED BY TH ARD OF HEALTH:
Conditions exist which require further ev tion by the oard of Health in order to determine if the system is failing to protect the
public health,safety and the environme .
1) SYSTEM WILL PASS UNLESS OARD OF HEALTH D INES THAT THE SYSTEM IS NOT FUNCTIONING IN A
MANNER WHICH WILL PR T THE PUBLIC.HEAL. AND SAFETY AND THE ENVIRONMENT:
Cesspool or privy within 50 feet of a surface water
Cesspool or p ' is within 50 feet of a bordering vegeta wetland or a ash marsh.
2) SYSTEM WILL F L UNLESS THE BOARD OF HEALTH (AND UBLIC WATER SUPPLIER,IF APPROPRIATE)
DETERMINES T THE SYSTEM 1S FUNCTIONING IN A THAT PROTECT THE PUBLIC HEALTH AND
SAFETY E ENVIRONMENT:
e system has a septic tank sad soil absorption system and is wi ' 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 is within Zone I of a public water supply well.
_ The system has a septic tank and soil absorption system and is within feet of a private water supply well.
The system has a septic tank and soil absorption system and is less than 1 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 pol cation from that facthty and the presence of ammonia nrbwn and nitrate nitrogen.ice equal to or less than 5 ppm.
S) OTHER
(revised 11/03/95) 2
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(Continued)
Property Address: (q l 's
Owner.
Date of Inspection: 7 off-F-7
D) SYSTEM FAILS:
I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 16.303. The basis for
this determination a identified below. The Board of Health should be Contacted to determine what will be necessary to oorrect the
failure.
Baclru 'of sewage into facility or system component due to an overloaded or clogged SAS or Cesspool.
or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or
ass 1.
Static li 'd level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
Liquid depth ' cesspool is less than 6"below invert or available volume is Iess than 1/2.di y flow.
Required pumping mo than 4 times in the last year&OT due to clogged or obi rusted pipe(s).
Number of times pumped
Any portion of the Soil Absorption m,cesspool or privy is ow the high groundwater elevation.
Any portion of a cesspool or privy is Kit 100 feet surface water supply or tributary to a surface water supply.
Any portion of a cesspool or privy is within I of a public well.
_ Any portion of a cesspool or privy ' thin 50 feet of a rivate water supply well:'
Any portion of a cesspool or rivy is lees than 100 feet but ter than 50 feet from a private water supply well with no
acceptable water quality ysit. If the well has been be acceptable,attach copy of well water analysis for
Coliform bacteria,vo a organic compounds,ammonia nitrogen nitrate nitrogen.
El LARGE SYSTEM FAILS-
The foll teria apply to large systems in addition to the criteria above:
The serves a fieility with a deign flow of 10,000 gpd or greater(Large System)and�the m is a
� significant threat to public .
and safety and the environment because one or more of the following conditions exist: \
the system is within 400 feet of a surface drinking water supply \
the system is within 200 feet of a tributary to a surface drinking.eater 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)
The owner or operator of any such system sh&U bring the system and facility into!lull Compliance with the groundwater treatment prograa►
Requirements of 314 CMR 5.00 and 6.00. Please eonsuh the local regional office of the Department for flusher information.
(revised 11/03/95) 3
° C
•
t
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Proper Addrew / S °
Owner.
Bate of IrsPee c` :'7_f�- 7
Check if the following have been done:
�.�'Pumping information was requested of the owner,occupant,and Board of Health.
_N e 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.
_fAs built plats have been obtained and examined. Note if they are not available with N/A.
t�Theme facility or dwelling was inspected for signs of sewage back-up.
The system does not receive non-sanitary or industrial waste flow
_lie site was inspected for signs of breakout.
system components,excluding the Soil Absorption System, have been located on the site.
e -*The septic tank manholes were uncovered, opened,and the interior of the septic tank was inspected for condition of baffles or
tea,material of construction,dimensions, depth of liquid,depth of sludge,depth of arum.
The size and location of the Soil Absorption System on the site has been determined based on existing information or
ronmatsd by non-intrusive metbods.
_The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of Sub-
Surface Disposal System.
(revised li/03/95) 4
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address.' L
Owner-
Date of Inspection: -7` e� °7
IIMSIDENTIAI: FLOW CONDITIONS
Design flow: sallons
Number of bedrooms:� �..
Number of current residents: 2
Garbage vinder(yes or no):�,j
Laundry connected to system(yes or no):__?2-
Seasonal use(yes or no):_
Water meter resd np,if available:_ L&J c3
Lest date of occupancy: Q
COMMERCIALANDUSTRIAL-
'type of establishment:.
Design flow: sal1ons/day
Grate trap present: (yes or no)_ ---
Industrial Waste Holding Tank present: (yes o)T
Non-sanitary waste discharged to the Title 5
Water meter read i:►gr, if available:
Lest date of occupancy:
OTHER;(Dwor )
Lest date occupancy:
GENERAL INFORMATION
PUMPING RECORDS and of information:
System Pumped as part of inspection: (.es or no) f�
If yes,volume pumped: aa__lions
Rsason for pumping:
TYPE OF SYSTEM
Septic tanL%ft t'bution boshoil absorption system
Sin&cesspool
OMerflow oesspool
Privy
Sbared system(yes or no) (if yes,attach previous inspection records,if any)
Other wplain)
APPROXIMATE AGE of all oomponenU,date installed(if known)and source of information: 'O
Sewar odors detaeted when arriving at the site:(yes or no)1.i/�/
(revised 11/03/95) S
y
O
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (oontinued)
Property Address:
Owner.
Date of Inspection:
SEPTIC TANK C---'
(locate on site plan)
Depth below grade:#
Material of construction:Lt6onc ete_metal_FRP—other(explain)
Dimensions:
Sludge depth: 2-2,
Distance from top of sludge to bottom of outlet tee or baffle: �b
Scum thiclmess: // " !!
in
Distance from top of scum to top of outlet tee or bae:l
Distance from bottom of scum to bottom of outlet tee or baffle:
Comments:
(recommendation for pumping, condition of inlet and outlet toyor bafIIes, depth of liquid level in relation to outlet invert; ral integrity, t
evideneg of leakaa,etc.)
s
GREASE TRAP_
(locate on site plan)
Depth below grade:
Material of construction: _concrete_metal_F otheNespllaa n)
Dimensions:
Scum thiclmess:
Distance from top of scum to top of outlet tee o e:
Distance from bottom of scum to bottom of tlet tee or baffle:
Comments:
(recommendation for pumping ndition of inlet and outlet tees or bates,depth of liquid Level in relation to outlet invert,structural integrity,
evidence of leakage,etc.
(revised 11/03/95) 6
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFF�ORMATION(continued)
Property Address:
Owner. 4,�,
Date of I upection:
TIGHT OR HOLDING TANK_
Aooate\plan)
Depth below ptade:�_ �-
material of construction:=amcrete_metal_FRP—Other(explain)
Dimensions:
Capacity: Qoons
Design flow: sallons/day �1
Alarm level:
Comments:
(condition of inlet tee,conditio of alarm and float switches,eta.)
DISTRIBUTION BOX:
(locate on site plan)
Depth of liquid level above outlet invert:
Comments:
(note if level and distri�do '• equal,evidence of solids carryover,evidence of leakage into or out of box,etc.)
Ca ,.
PUMP CHAMBER
(bone on site plan)
Pumps in order:(yes or no)
Cammentr
(note aomditiom of pump chamber, of pumps and
(revised 11/03/95) 7
•■f
I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM t
PART C
SYSTEM INFORMATION(continued)
P,vperty Address: 4S C X"ta'
Owner.
Date of Inspection: '7 _ S ` 7
SOIL ABSORPTION SYSTEM (SA5):—L-�-'
OsosRa on site plan,if pomile,excavation not required,but may be approximated by aca-intrusive methods)
If sot determined to be present,explain:
Type.
lsaehi:►g pits,number:
leaching chambers,number:_
Lsching galleries,number:
leaching trenches,number,length:
Iseehiag fields,number, dimensions:
overflow cesspool, number:
Comments: (note conditi n of soil,sigw of hyC1LSu1icf&Uurejrvel of ding, condition of vegetation etc.)47
-
Y
CESSPOOLS:_
(locate on site plan)
Number and ooaflguratio
Depth-top of liquid to Inlet vert:
Depth of solids layer:
Depth of scum layer:
Dimensions of oesspool:
Hateriak of construction:
Indication of groundwater: EZ
inflow(cesspool must be pumped as part of ins io
Comments: (acre condition of'soil,signs of alit failure,k 'eel of pin ooaditaon of vegetation,etc.)
PRIVY:_
Qx ate on site
ISaterials eouNbu bon: Dimensions:
LOPLh � +
ts:(note condition of soft,signs of hydraulic faam,.lr.el of ponding,condition of etc.)
(revised 11/03/95). g
• • T
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: S �—
Owner:
Date of Inspection:
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100'
Cam.'�•��.
33
J
•
�} G
DEPTH TO GROUNDWATER
Depth to groundwater.-4k_�_feet
meth of determination or roximation:
l
(revised 8/15/95) 9
4.7 TOWN OF BARNSTABLE
LOCATION SEWAGE #
9
VILLAGE - ✓: r ASSESSOR'S MAP & LOT
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY 7t +
LEACHING FACILITY: (type) (size)
NO.OF BEDROOMS
BUILDER OR OWNER
a
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 well s exist
within 300 feet of a ng ac. 'ty) Feet
Furnished by
1
z`
15
-7 'S 3 per
+ torT0s
PA _fe o wZ'
o 0
ASSESSOR'S MAP NO. //f PARCEL / y
L A DS» sIWAOE PERMIT NO.
AL ey
VULAOE
INSTALLER'S NAME I ADDRESS
A a/3
9-:A-.4 L D E R OR 0 W H E
E PER Vs-1T ISSUED
C:7/�
D A T E 0M P L I A N C E ISSUCD��ms� �
- �
J�V�
1
a J 3 ,, �►
'` � lG
�3 5 3 �
-.. . • .,
PARCEL NO.:
No.. ..........- •• Fxs.....7...._............_.
THE COMMONWEALTH OF MASSACHUSETTS
f' BOAR® OF HEALTH
1--vw-n.....................0F 'V.pi �g�a�a►...-----------------------------•...............-----
Applira#iou for Uiipniia1 Works Tomitrurtiuu Prrutit
Application is hereby made for a Permit to Construct ( ) or Repair (*) an Individual Sewage Disposal
System at: /I '
Cbr�j��e.•...................... ......•---....•-----..........---......-••-------•••-------••-•--•-----•--•---•--•-••-------......
........
Location Location-Address "� oz t ha I
..._.._.. fravi/o�c� S' '.
----------------------r-......... sn m A.._..........._..
Owner Addr9ss
� .. . 3Sa /17amn r
Installer Addre
Type of Building . Size Lot............................Sq. feet
Dwelling—No. of Bedrooms._'.....4 __...._...Expansion Attic ( ) Garbage Grinder ( )
a Other—T e of Building ............... No. o persons.__..._.._.............._... Showers — Cafeteria
Q' Other fixtures ........................................................................................................................
W
Design Flow............................................gallons per person per day. Total daily flow-----_......................................gallons.
1:4 Septic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................
Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area___---.._-____------sq. ft.
Seepage Pit No--------------------- Diameter-------------------- Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed bY..........................................-•••---•---------•--------••--• Date........................................
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water.........................
fZ4 Test Pit No. 2................minutes per inch Depth of Test Pit-_______-.•-___-._•. Depth to ground water.-_________-___--...___-
P4 -•••--•---••-----------•----••----•---------•------------------•.....-----------•----•-••-•--•-••-••-•--••--------•----•-----•---•............•-•-•----•----
0 Description of Soil.......................................................................................................................--------......................................
V - I
----------- ----------------------------•-•-•-•-----------------------------•--•••----•------•--------------------•----------•
U N ture f Repairs or Alteratior�—Answer when applicable___/S '02/ t. J
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of i T T LEZ 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of h lth.
----- -------
1 i Date
Application Approved B ----�_ 6
PP PP Y••--••---•-
Date
Application Disapproved for the follnwingons:--------------------------------------------------------------•------------------------------------------....._
-•------•-•----------------------------------------------------------------------------------------------•-•---------••------•------•-••••----••-••-------•-••--•---•••--•-----•--•----••------••------
_� Date
PermitNo.---- 4. ...................... Issued........................................... at.....•.
Date
'4
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Applira#ion for Dispaoul Works Lonstrnrtinn rami#
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
Sf/yst(em at: le-
.............................................t................................................... .................................................................................................
Location-Address 1 / sf. ort Lot.iQo.,//
11f elf.....................................------. -•--•._..._......................... .............................................................-•••-•-•-.........._..................
Owner �, Add
s ess
W l Pra .�Sd Armgin t f�roarac,
,.a ....................... ........................................................... --------------•-••--•.....••-•-.......---..._•...................................................
Installer ? Address
Q Type of Building 3�,�f( S E��, Size Lot............................Sq. feet
Dwelling—No. of Bedrooms. �SIrVJ. ._.7'____.___.___Expanston Attic ( ) Garbage Grinder ( )
aOther—Type of Building ____________________________ No. o persons............................ Showers ( ) — Cafeteria ( )
dOther fixtures ----------------------------•----•--------------------••-•--------•-••--•-••••••-••-•----•-••--•--•••••••.....-••-•------•-••--•-••••................
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity._..........gallons Length___-•_--•---_- Width................ Diameter................ Depth................
Disposal Trench—No_.................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by.•--------•--•-----•-•••-•--•-......--•-••-••--•......--••-----•----••••. Date........................................
Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water-.__--_.___-_-____-__._.
ri Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
P4 ---•------••-----------------••••••••••••-•-••••-•--•-------------........------------------•-----••.........................................................
0 Description of Soil......................................................................................................................................................................
x
W ----••-----•-------------------------------•---••••---•-••-•-------•••--•-••••---------••--•-••-•••----••------•-•......••••--._...•-- -------------------- .
„----------
V Nature,of Repairs or Alterations—Answer when applicable_�:��5?.��+���?." ��r• «' - t
t . ------------ -'�c
s 1) • ic�t�. �,Jl .�. E�1Fw, rI r+ '!-rr,rrt� / t/ /
Agreement
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITI—iE ;of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued[!by the board of health.
Signed.. �� = I'l ..... -----•-----•---•••-•-•----- ----------
J
Application Approved By...... - ....... ........ . -------- _ ,ce �b
Date
Application Disapproved for the following asons--------------------------------------------------------•------------ ----------•-------------Date
-•---------------------------•-----------------------------------•--.........-----------------------...--•••--••••.......•-•••••••----- --•-•-------•••••••-•••••-•-----••---••------------•••---•----
h Date
PermitNo..... " C�- - •---------------------. Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
1 BOARD OF 'HEALTH
i,: aC,4J Y Of�rYN-sF ......... ........ r.........................................................
Trrtifirtttr of Tamplianrr
y TH{S IS TOCE�iT�IFY, That the Individual Sewage Disposal System constructed ) or Repaired, }
b l l`.(,. .----. --------------------------------------------•---•--•--•-----•----•---•-•-•---•--...�.........--•-•-----•-....----------
11 Installer
has been installed in accordance with the provisions of Tci�T E " of yThe State Sanitary Codes scr n the
application for Disposal Works Construction Permit No..A_/..�1.01................ dated_-..-_.___-_-___,` ��_____._....__..._..
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT YHE
SYSTEM WILL FUNC�TIO SATISFACTORY. �j
DATE..............................�. F Inspector......
v
THE COMMONWEALTH OF MASSACHUSETTS
BOAR,,��D OF�-. HEALTH
........................... ......................----------------..................................... ..
................. FEE.... S......
Rapmall orko T nstrnrti.an r ntit
Permissio 's hereby granted---------�.1. .. -? Gl�''�.� .----•-•-----•------•----------.-------------------------•--........-----.............---------•-
to Construct () or Repair ( ) an Individual Sewn�e (D�ispo System
at No......6.1..........54 t lU�� ��_.:�-----L)-J-�_�� �—
Street pp
as shown on the application for Disposal Works Construction Pe t No:"..6-yU . Dated.... -Y.................
oard of Health
DATE--
FORM 1255 /088S & WARREN, INC., PUBLISHERS