HomeMy WebLinkAbout0122 WIANNO CIRCLE - Health y 122 Wianno Circle
Osterville
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TOWN OF BARNSTABLEI
LOCATION 122 Oianno C ,zcie SEWAGE # 10115103
t!ILLAGE 0.6 t e z v i e e, Ala-6,6. ASSESSOR'S MAP & LOT
;NS7WJ& Jl�NAME&PHONE NO.a' %, ('1 a c o m e 2 an.
SEPTIC TANK CAPACITY 1500 gaiionz 1—Diztztigution &ox
LEACHING FACILITY: (type) 3-500 chamge�zz (size) 2500 gaiione
NO. OF BEDROOMS
BUILDER OR OWNER Flank 4dam.o
PERMIT DATE: 10115103 COMPLIANCE DATE: 10/15/0 3
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 fee of lea chi f ili Feet
Furnished
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GENERAL REQUIREMENTS SYMBOLS c g
ADAMO RESIDENCE
I _ 122 WIANNO CIRCLE
�0M- OSTERVILLE, MA
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MISCELLANEOUS NOTES
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f WINDOW SCHEDULE i DOOR AND HARDWARE SCHEDULE
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FIRST FLOOR PLAN
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A •,SECOND FLOOR PLAN �—------- - - �
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TOWN OF BARNSTABLE �L
L&ATION ew,)A 4,,4-(5 ►2 .' SEWAGE # �
VILLAGE _� S / ASSESSOR'S MAP & LOijqQ—
INSTALLER'S NAME&PHONE NO._1(u� i.�..� '7 2,.S
SEPTIC TANK CAPACITY
LEACHING FACILITY:.(type) (size)NO.OF BEDROOMS
BUILDER OR OWNER
PERMTTDATE: COMPLIANCE DATE: -G —,'),d-<�
Separation Distance Between the:
Maximum Adjusted Groundwater Table`anottom of Leaching Facility Feet
Private Water Supply Well and Leachin acility (If any wells exist
on site or within 200 feet of leac ' g facility) _ Feet
Edge of Wetland and Leaching F ty(If any wetlands exist
within 300 feet of leaching f cility) Feet
Furnished by
e
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a
1/ r8c� S s.
t � [
No. / F I. B— 1 FeA 5 0
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
Zipprication for Mi5po5al *potent Con.5truction Permit
Application for a Permit to Construct( )Repair( X)Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. Owner's Name,Address and Tel.No.
122 Wianno Circle , Osterville Jeanne Cooley
Assessor's Map/Parcel
NO
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
m. E'. Robinson Septic Serv.
0 box 1089, Centerville , YA
Type of Building:
Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Grinder( )
Other Type of Building No. of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil S and.
Nature of Repairs or Alterations(Answer w n applicable) new Title-5 septic , tank, D-box
and. 4 leach chambers
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 issued by;his ar of Health.
Signed 1, DA 0 A Q q01 Date
Application Approved by Date
Application Disapproved for the following reasons
Permit No. Date Issued
$50
No. Fee
THE COMMONWEALTH OF MASSACHUSETTS -Entered in computer:
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS- Yes
application for ]igpogal *pgtem Congtruction Permit
Application for a Permit to Construct( )Repair( X)Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Addr ss or LmNo. Owner's Name,Address and Tel.No.
122 Wianno' Circle, Osterville Jeanne Cooley
Assessor's Map/Parcel ft
�,
..;—
/I I
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
Im. E. Robinson Septic Serv.
0 box 1089, Centerville , MA
Type of Building: �(
Dwelling No.of Bedrooms VI + Lot Size sq. ft. Garbage Grinder( )
Other , Type of Building - No. of Persons Showers( ) Cafeteria( )
Other Fixtures
t
Design Flow gallons per day. Calculated daily flow gallons.
" Plan Date Number of sheets Revision Date
` Title
Size of Septic Tank Type of S.A.S..
Description of Soil S and. r
Nature of Repairs or Alterations(Answer w n applicable) new Title-5 septic , tank, D-box
and. leach chambers
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 issued by this oar of Health. "�
,I Signed 6 Date `� 4-
-97
Application Approved by ll Date
S
Application Disapproved for the following reasons i
Permit No. o Date Issued `
THE COMMONWEALTH OF MASSACHUSETTS
Cooley BARNSTABLE, MASSACHUSETTS
(Certificate of (Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal Systejn Constructed( )Repaired( X )Upgraded( )
Abandoned( )by Wm. E. Robinson Septic Service
at 122 i as constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. dated
Installer Wm. E. Robinson S r. Designer
v
1� 1 .a� .!/'.t� r i
The issuance of this pe i/ sh!all °t bZy
ued as a guarantee that the system I function as desi-gned!�
Date ! I/1 // ✓ Inspector
/
_ _ _._/
No. (/ ) --------------------------Fee $50--
THE COMMONWEALTH OF MASSACHUSETTS
Cooley PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS
Zigogal *pgtem Congtruction Permit
Permission is hereby granted to Construct( )Repair(X )Upgrade( )Abandon( )
' System located at 122 Wianno Circle, Osterville
and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to
comply with Title 5 and the following local provisions or special conditions.
Provided:Construction 4st be c4pleted within three years of the date of t
Date: Approved by
/ , 1
1 -
1/6/99
NOTICE: This Form Is To Be Used For the Repair Of Failed
Septic Systems Only. -
CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL
WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANS)
hereby certify that the application for disposal works
construction permit signed by me dated ��-�� � �/ � concerning the
property located at 122 Wianni Circle, Osterville . ` MA meets all of the
following criteria:
• The failed system is co ected to a residential dwelling only. There are no commercial or business
uses associated with the dwelling.
• The soil is classified'E CLASS I and the percolation rate is less than or equal to 5 minutes per inch.
• There are no well ds within 100 feet of the proposed septic system
• There are no pn ate wells within 150 feet of the proposed septic system
• There is no in ease in flow and/or change in use proposed
•. There are o variances requested or needed.
• The bo om of the proposed leaching facility will not be located less than five feet above the
ma..d um adjusted groundwater table elevation. (Adjust the groundwater table,using the Frimptor
me od when applicable]
• If the S.A.S. will be located with 250 feet.of any vegetated wetlands, the bottom of the proposed
leaching facility will not be located less than fourteen(14) feet above the maximum adjusted
groundwater table elevation,
Please complete the following:
AJ P
To of Ground Surface Elevation(using GIS information)' `
_
B) G.W. Elevation +the MAX
High G.W. Adjustment .
y DIFFERENCE BETWEEN A and B
.. I ATE:
-� SIGNED .
1
sG �i G D
(Sketch proposed plan of system on back].
q:health folder.cert '.
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AsBuilt Page 1 of 1
-TOWN OF BARNSTABLE
LOCATION122 Q-ianno Ciac:2e SEWAGE# 10/15/03
V G MLAE�`0'6;t zv i22e, Na 6,3. ASSESSOR'S MAP&LOT
r,z��c6NAME&PHONE NO.a. l• l7acomlea ;,Z.
SEPTIC TANK CAPACITY 1500 ga.2$on4 1-Dizta.igut.ion 'lox
LEAcmNe-FAcury: (type) 3-500 cham&ea.6 (S1zC) 2500 ya21?ona
NO.OF BEDROOMS 4
BUILDER OR OWNER 74 nk Adamo .�
PERMIT DATE: 10/15/0 3 COMPLIANCE DATE: 10115103
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 faeili.V) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
flwihn30 oahif il Feet
Furnished AU1'
x
�3
•
http://issgl2/intranet/propdata/prebuilt.aspx?mappar=140111&seq=1 2/10/2014
DATE lU/15/03----
PROPERTY ADORESS122 Uianno Ci2cie
----------------
On the above date, I inspected the septic system-"at the above a dr RECEIVED
Tnis system consists of the following:
7. 1- 1500 ga eion aeg-t is tank. NOV 13 2003
2. 1-l7"izi zi.gu. -ion Sox.
3. 3-500 gaiion keach.ing chamgeAz .in ze2.iea. TO''A;NOFBARNSTABLE
HEALTH DEPT.
8aseo on my inspection, I certify the lollowing condlllons:
4. 7.hiz is a title tive ae/2tic ayatem. ( 95 Code)
5. The ae/2tic ayatem is in pao/aea wo2king oade2 at MAP
the /?Zeaent time.
6. The 3- 500 ga -Pon Beaching chamgeltz ate /22eaentiy clay. PARCEL ;
LOIN �.
SIGNATUR ,
Fame P . Macomber Jr .
� orTipany ,jQjpQn Son, Inc .
� Oor25S : _ _@QX_�- ------------
' _ _ -C�1�SP:YI,<_1.�,_ Jd _ _QZ6J2=0066
P^.one - -508 • ) ) 5.. ) ) )8 - - - - - ---
THIS CERTIFtCATiON DOES NOT CONSTITUTE A GUARANTY OR WARRANTY
I
JOSEPH P. MACOMBER & SON, INC.
Tanxs•Cesspools•Leachllelds
Pumped 6 Installed
Town Sewer Connections
P 0 Box 66 Centerville. MA 02632�0066
))5.3338 775.6412
a _
COMMONWEALTH OF MASSACHUSETTS
= EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
Y
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR,VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 122 Q-ianno C.i2cie
0,6tezV-ieie, mazz.
Owner's Name:F2ank Adamo
Owner's Address: 18 (1-id-land /toad
L nn .ie.2d Road 01940
Date of Inspection:7U/7 5/03
f -
Name of Inspector: (please print);oeel?h P. Macom9ea a2.
CompanyName:j. P. Nacomge2 X Son Inc.
Mailing Address:Box 66
4 '�aa3 -026 32
Telephone Number: -
CERTIFICATION STATEMENT
I certify that 1 have personally inspected the sewage disposal system at this address and that the information reported
below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my
training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system:
/✓/Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fail
Inspector's 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.
Notes and Comments
****This report only describes conditions at the time of inspection and under the conditions of use at that
time.This inspection does not address how the system will perform in the future under the same or different
' conditions of use. 4\ `
'Title 5 Inspection Form 6/15/2000 page 1
Page 2 of I I
OFFICIAL INSPECTION FORM— NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 122 Q.ianno C.iacie
Ubte,zyiiie, Nazz.
Owner: Fnank Rdamo
Date of Inspection: I Q/15/U 3
Inspection Summary: Cbeck A,B,C,D or E/ LA WAYS,complete all of Sectlon 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:
717p .se121lc .surtem .iz .in RZo/2e2 woak.ing oadea at
Lho nao"nf ilmo.
B. System Conditionally Passes:
,1!96 One or more system components as described in the "Conditional Pass"section need to be replaced or
repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass.
Answer yes,no or not determined(Y,N,ND) in the for the following statements. If"not determined"please
explain.
The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the
existing tank is replaced with a complying septic tank as approved by the Board of Health.
$A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
Observation of sewage backup or break out or high static water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will'pass inspection if(with
approval of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will
pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain:
2
page 3 of
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBS URFAC-E SEWAGE DISPOSAL SYSTEM INSPECTION FORM
I PART A
CERTIFICA'FION,(continued)
Propert), Address: 122 0t*czizn.o C_ilict2e
ow o e r C c2 ii k .4 min
Date of Fri spe—Cti-007TT�-n—
C. Further Evaluation is Required by the Board of Health:
Conditions exist which require further evaluation b* y the Board of Health in order to determine if the system
is failLng to protect public hca4h, safety or the criviii-orurient.
1. S'vitern wilt pass unless Board or Health determines in accordance with 310 CMR 15.303(1)(b) that the
system is not functioning in a ininne I r which will protect public health, Safety and the environment:
Cesspool or Cesspool or privy privy is within 50 feet of a surface water
-, 50 feet of a borde1ing vegetated wetland or salt rnarsh
' with�r
System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the
SYStelrrl is fOnctioning in a manner that protects (We public health, safety and environ*rrient:
Jl.
T h e system
Ystem has a septic Laril, and soil absorption system (SAS)and the SAS is within 100 feet ot'a
surface water supply or rributary to asurface water supply.
-]-he sY5tdl_n'has 2 septic larik, and SAS iind tile SAS is within a Zone I oi'a public water suppj\'
if The system has a septic tan}; and SAS and the SAS is within 50 feet ofa private water supply well.
Z)d The system has a septic. 1, lank and SAS and the SAS is less than 1t 0 fei:t b 0 fee', or more from a
private water SuPPIV Well" Method used to determine distance
4"_his s'Yslcm passes if the well water arialYsis, performed at a'DEP certified laboratory, I, for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution front that facility a
ny
the presence ofati-irrionia nitrogen and nitrate nitrogel, is equal to or less than 5 Ppm, provided that no other
'ailwc criteria are triggered. A copy of the analysis must be artached to this form.
3. Other;
4 '
. ~
Page S of I I
OFFICIAL INSPECTION FORM — NOT 1 C);ft �ii)Lv?�'T','�I�Y a.SSI�SS"viE" 'S
SUBSURFACE SEWAGE DI SYSTEh'S I;'\'SP C'TI<,)N I C_)IZ.N!
PART P '
Property Address:122 Oian_no Cbz c.(c
67Te 57 F7(�7;lac
Owner: Tvcank Adaino
Date of luspection:7 Ui 773
Chtck if the followin have been done Yct) indicate "ves ' or"tlo'' es to erch of('1P follo`h'in
.. _ ..__ Pi_ a s,t n
Ye<. o
-- 1 Pumping infonnation was provided by (he own<;, occupant, or Boa;d of Hcalth
Were any of the system components purn,cd oul in Gle 1.—yIouS
i
_ -k4as the system received nonna! tlo,`rs in the previous tv,o week period
l
Lz Have large volumes Of water bCtn i_n�ioCtu`,.,j 10 01G S)'S(erl rtctri(1)'Ur as pelt Of hiS inS7)CCliUn
Were as built plans of the systen) o'Oto,fined and tx;;rnined? (!f they yrere not available r;o(c as> -
- � WcS the facllfiy or d—1 ir,b ;n.'pectcj i0r 'I�'1S Oj St1Ya�e back up ?
Was the site inspected for signs of brc k oul °
v' Wcre all system componrnt.s,e;4ilUd; L (hr SAS loaned on si[c
L/ _____ Were the Septic tw',k n,anholcs ur;CU'`'e;tlft O of the b;tflcs or tees nii :inC:u, Ifl!trlor 01 L'1C (u;i�; inspected f0i l lr dll
. COn10n
(eri41; cf cot, „w',-S ICil, Gif7lCiiiiGn$, uCp(!'i 01 lY quid, depth of Sludg, Pnd depth O1 SCu'rn �
Was the faclllry Owner(and o(ccupant'i If dlifcrcn( ti 0rn U'A-ner) prOYlded with infom-tiflion On tl;C p.,ope
rna,nttnanr.t Of subsLrfac:' sevragc dl:j OSlI SyS(Cln'.> ?
The sire and locution of tht Soil Absort (ion Sysitrn (SAS") orl tl;r site Lea, been dcicnnincd based on:
Yes ,no
Existing, infor-ma,60n. For exarnp!c, a pl;n at (h c 13oa d of;ita!lh.
kuc. criteria eel:tcd p q C i
issue
i<. unaccc tahici (-10 C�.?R 't.30.201 1 s ;l pp„Jxirnauon of d dance
o
' 7
Page 6 of I 1
OFFICIAL INSPECTION FORM — NOT FOR VIOUMTA.R Y ASS.0 SS;NIEN-FS
SUBSURFACE SEWAGE LETS'POSAL SYSTEM, f-,N ECTION FOP-M,
?A1 T C
SYSTEM Ci' Y0i1R2. 1:i l-jo'N
Property Address:122 6)ianno Ci2c.P.e
0-6te'zvi e,
Owner: Taank 4damo
Date of Inspect1on:1-U-1.�Z23 __�
FLOW C0tMD] 1'[0NS
RESIDENTLAL
Number of bedrooms(design): Number of brra!onrr.s (,ctua'): !_
r
DESIGN now based on 310 CMR 15.201 (tor t>:ar„p!c: 110 ;pd x A
Number of current residents:
Does residence have a garbar,c U-i idcr(yes or no):
Is laundry on a separate sewage system (yes or no):-_ (I? yes Separate i)sPertion re^'„ir.Oj
Laundry system inspected(yes or no):
Seasonal use: (yes or no): X)S
Water meter readings, if available(last 2 years usage (gpd)):�0 !?- 3 c%/ 000 c'c==./ c'ort! 3 72 6 ; Dil i?
Sump Pump(yes orno):No �'�r T(1, i;,, r ...__J r °t 6. 99 t=jPi�
Last date o(oeeupaney:�i1�A,y (
COMM ERCIALANDUSTRIh1.
Type of establishment: ��t
Design flow(based on 310 C1v 15.203):
Basis of design now(seats/persons/sgft,c(c,):
Grcmc trap present (yes or no):
Indusmial waste holding tank present (yes or no): _L:
Non-sa.nitnry waste discharved to t1,c Title 5 system (ye: or no):
Water meter readings, if tvailablc:
Last date of occupLncy/usc: 777
OTHER (describe);
CENEFLAL. IN}'0:r%'MAT10N
Pumping Records
Source of information:Non.e AL)cz,LiQ(.Qe
Wes system pumped Ls pan of thz inspzctioo (yes or :;o);'
If yes, volume, Pum ed: J gallons • ,'on Qins glkntt�, i;��r;npcd Rctson forpumping: r,
TY!?I OF SYSTEM
Septic tan1, distribution box, soil absorption 5ystcrn
Single cesspool
,overflow cesspool
Privy
Sh:,rcd system(yes or no)(i(yes; bttr.ch p!'rY;Ous tnsp::ci.on rccwd5, iI any)
,,nnovative/,tltern,tive lcOV10k.)?y. Attach a copy r,f!ne ct:r;tnl operation end contract (it) be
obtained from Micro own�;r)
�r✓cJTifht trn_k -{%/' Attach a copy of the D17P approyaI
Approximate aer oral) components, dat-
, �,i. 70`.Y. rinC: ;ti'JrCi: Or,niC'^113i:Gfi:
I i e"C<sc%v3v Odors d�tCCIGd %vhtn 4I"'ii1'tl1g 31 dh(1 5i1: (Y $ or
6
J
f
Page 7 of I I
OFFICIAL INSPECTION FORM — NOT FOR 'VOY,-INTARY AS:SESSNTE:NTS
SUBSURFACE SEWAGE DISPOSAL SYSTI NI aidSl' ,CTlON FUF�I
PART C
SYSTEM 1`? F011�ryt;VTIC)N (co:;titn)ed)
Property Address: 122 Oianno CC2C_Pe
0,6 erzvi e, rlae�.
Owner:f2ank 4damo
Date of Inspection: 10/15/03
BUILDING SEWER(locate on site plan)
Depth below grade: x1V �
Materials of construction: cast 'von F/4t7 PVC Zkbther(exniain): —• _— od
Distance from private water supply well or suction line:
Comments (on condition ofjoints, venting, cvidcncc of
aointa appeal tight. No ev_:denc: of (ec�k261C; lr' r�; L,fen- ::1,
vented th.zough .the zoos verif,I
SEPTIC TANK: locate on site plan)
Depth below grade:
Material of construction: 2cloncrete&q meta I fVfiberglass s/',?pciyethylene
/✓l)other(explain) A( 4
If tank is metal list age:eVp Is age confirmed by a c enitiicmc of Compliance_(;rs of
crnificate)
Dimensions: `jA 6ry
Sludge depth. 1 �
Distance from top of sludge to bottom of outlet ice or ba.fflc:.:
Scwn rhickncss:Z,_.
Distance from top of scum to top of outlet tee or baffle: i
Distance from bottom of scum to bottom of outlet 'ee: cr 1 lr,:< V,
How were dimensions determined: �
Comments (on pumping recommendations, l ,let and Outlet tee,' of bail; ;'vflCilUon, siYUCi'. i.i ifl! �ity, ilCiu! I"Ye is
as related to outlet invert, evidence of leakage, eic.):
/�LL m/7 t h e e(?t.!.C trt 2 k— l/"2./'t t t 61, 1 C'_ C/_. 6 4 O.h
boitnd on,d. 6ho!,).6 nUrC.;LkCI.C/ C?iE .�
G�REAS 1 A13 (locatc on site. plan)
Deprh below grade: .+.0
Material of cons tnjction: concrete j�met_aI-/ fi.beriili;.> ., /i poly-:;ti,ylrnr r othcr
--
Dimensions:
Scum thickness: ✓li'
Distance from top of scum to top of outlet tee or bj iffk:
Distance Font bottom of scum to bottor`1 0:' Outlet tee or
Dvc of last murripi
Corn..,mcnts (on pumping recorlvncndalions, tfli t and ol.ltict Ice or baffle, coi",dll!ior!; StfliC!ll'1i intej rit)', lig,,:id icvcl5
_S related to oijOci hover,,, evidence. OT ,.akage,
Page 8 of 1 1
OFFICIAL INSPECTION FORM - NOT FOR
SUBSURFACE SEWAGE DISPOS/J_- ,SYS'1111,1 INS i_:.C;TiO`; ;"'OI:M
PART
SYSTEM fNFO11WATION (continued)
Property Address: 722 �Vianrzo CiRC�)e
e2v-e e, a 56.
Owner: 7aank A amo
Date of Inspection:7 0/1 5/0 3
TIGHT or HOLDING TAN14, r Ai(tank must be pumped at timt, of inspection){la.air- on sit+ plan)
Depth below grade:
Material ofconsn-uction: 434 concrete metal Fiberglass.,VA _1s_otl:er(exo; :ir
Dimensions:
Capacity: AIA _ gallons
Design Flow: fir$ gallons/day
Alarm present(yes or no): 4�4
Alarm level: fz,g Alarm ui working order(yes or no): �•a a
Date of last pumpurg: A7-4
Comments(condition of alarm and float switches, etc.):
7 i_ylz t o e h o cl n p t n k h a rc e —
DISTRIBUTION BOX: 1/ (if present must beoprned)(locate on sii 1)1t1;1)
Depth of liquid level above outlet invert: lVe.1
Comments(note if box is level and distribution to outlets .r,ua!, ar:; :vider;ce cf'saiids c.;rr,e)v r, an,, r: i '�e,c of
leakage into or out of box; etc.):
Via-f,U `�on 9ox Vlgc one .Pal_t/t.c7C�No ov-Lc! <rac:c, o ,,oP.�c1,a
C 2/7.? UQ/7. . . !: 'i .. 2 ( . .h e o v) �
PUMP CHAMBERVe (locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no):
Comments(note Condition of purnp chamber, condition of putnp- And it})1)UC(Cn7i?Cet, i:tC.;:
---_--------- -..__...—-------
s
g . ..
Page 9 of I I
OFFICIAL INSPECTION FORM —NOT FOR VOLUNTA—RY ASSESSM—EN 'S
SUBSURFACE SEWAGE DISPOSA.I_, SYSTEM. TNSPE:C'rlON FOR.N!
SYSTEM INFOI':F✓IAl"IOrti (continued)
Property Address: 122 0.eaano C.i/tcie \
03 it eay.e e,7772A ,
Owner:F2ank Adamo
Date of Inspection: IO/15/O3
SOIL ABSORPTION SYSTEM (SAS): (locate on site plan, excavation not requires';)
3-500 ga,teon eeach.inq sham&ea,6 .in he/?- e,,�
If SAS not located explain why:
L o c a t P_d P S P_P_ /?a Cg e 10
Type
Teaching pits, number:
leaching chambers, number: ;�=r� A�j (✓/'�'
Sleaching galleries, number: re-�
leaching trenches,number, length:
46 leaching fields, number, dimensions:
Fdoverflow cesspool, number: CJ
D innovative/alternative systemType/name of technology;
Comments (note condition of soil, signs of hydraulic failure, I v ! of[i0ndii?f;, :i;li:p `Cif; ^C 'llt;0li of ti'e_. [align,
etc.): -
Loamy hand to medium Line. 6czncl, 41 / (:z. cr-(' �o cz 'r.e
02 pondinpo ASP O� ,the 500._.iQ (/. t>! :{t. ' _�� Y '_ n _ Rn i'nC! CRrL�
d2y. So-1.Q6 ate dn,-y, Ve. -/e-1-, .Z i o;,T- .t.:i Rp't
CESSPOOLS (cesspool must be pumped as part of inspection)(loceate on site,
Number and configuration:
Depth-top of liquid to inlet invert: ._ i
__._..._
Depth of solids layer:
Depth of scum laver:
Dimensions of cesspool
Materials of consrruction:
Indication of groundwater inflow(yes or no):
Comments (note condition or soil; sivnti Cf fl./Cll'311i1C fa lure, If VCI of l)-on ling, condition of 4c-i,,et£11iCn,,eIC,)'
C e a o o 4 C 2 e is o.z 2/e _e:.!?_4
PRIVY'pt .r(locate on site plan) ,
Materials of construction:
Dimensions:
Depth of solids: lj-rig
Comments (note condition of soil.; signs Cf hydraulic faikire; level el Bonding, condition o' �' �;C:i<itiC:'i, ctc.):
•
•
9
Page 10 of I I
OFFICIAL INSPECTION FORM -r NOT FOR VOLUNTARY ASS'-SS)i ?.N"'i'S
SUBSURFACE SEWAGE DTSPO'SAr: SYSTEl'-4 )T'NiSy' Qiti FORM
APT(;
SYSTEM I1\"a'0RMk.ATl0 coniirueu)
Property Address z2 ianno C�2 c Pe
eay.c T T—e—, rt7T,7,--
Owner:Faank R amo
Date of Inspection: _ 3 -
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at bast rwo prr 7mn-nt r << en::e iandmar';:s or
benchmarks. Locate all wells within 100 feet: i oWe w ,:re public waicr sup:)Iy inters ti-IF building.
10
Page I 1 of 1 I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSINI NTS
SUBSURFACE SEWAGE DISP0SAl, S Y S T EM, INS EC"'I'l0? f", ?vi
PART L
SYSTEM INFORMATION (continu! d)
Property Address: 122 Oianno C.i.2c ee Uzte2vtt,ee,, ah.6,
Owner:72ank ammo r�
Date of Inspection: 9 0/15/0 3
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water';;rfeet
Please indicate (check)all methods used to determine the high ground water elevation:
yCS Obtained tiom system design plans on record • lfchc krd, ,e ct'dcsigri ia.tl rrvi :ved; S/03
c!
Observed site(abuning property/observation hole within 150 fee! of SAS) —
1 er, Checked with local Board of Heaph explain:CoLz�_t;_ :ec_ a 6.rr.i.t� el!;ia.(<:
1� Checked with local excavators, installers. (artacl; dcc nicnt a t;)
Accessed USGS dwabase-explainazitt12 /%t°'",r., G L-?.rzh ' ( e, nr L.: a• :
You must describe how you established the igh�proutld sum: r elzv::t n:
sect. Cah2ety S /'ii2e2 Node . 1Z/P6/ �' C . L ! z ..% t fi e
y G[, i;i C' l +_j0a •LCR.r� 1L! C .L vC 6
s e d: ll S S: 0 9,6 e 2 v a :con
seed: % S�:S _ lechn 'cci auQi?ef '- _ 07I, 77,. -- ,_____.__--- . 7 , —
..,n �_C� ! 7 .,.� ��. ��;_,_.T n r.L cL 2.�_.�� �ii�it.rl i'Z Y 47L72 J e
uncl wate2 e-ee. )c > r--.c.,i
-- 500 yaiion
each.iaq chain&e2�� -� - '
L74
I 1 ~
Groundwater:( anal Arcct Below Bottom orPil
$oaf y#r tr tit )da !i g<(l 'ft r f rlti�vltt !+ E�ri�d'
li.{. 4 :hsll��":l}at•�.i,'S th; d+,��� YILCt �,)r -lIC1\Y I6.I 16p I _ li.
4 r E`
In
iliN
6X
"• a•Ani9 lei. rr-trn Inr•nTRrl.nrm m.l T'.*.f.r*R+'tnrm m+wii M'�n�.i r+ t
• 'I'UNN Up.: BaAnsta&$e [lUAIiU OF HEnr.TH
,SUI)SURFACF ,SUAU 1)18POSA6 .9YSTF, "INShECTI0H FQ11H PART:,D .�, I_;r.1 1711 ;
•••T'1 T '.:t 111 .�TT4.TIf•1'RTfI T•iR.71Tb/TrTT:T'�t'I_vr"IM.,�`"►bR1'Tt(itY'bPT�1►T� IWHII Pib •'\Y'E•,S` i.:r.:
TYPC:OA,P-AINT.CI,CAAL1'= J
P110PERT Y.`..INSPECTED
STREET ADDRESS 122 Wanno •C.iac.2e 0iteaviiie, ala6,3,
`ASSESSORS MAP , :BLOCK ANU `PARCEL
OWNER' s -NAME; 7,zank .Adamo
!'A RT U CEIiTIFLCATION,,. u
r
NAME' OF INSPECTOR,7oseph :`P.Macomb'er 'Jr.
COMPANY....NAME :J,P.Macomber & SoR 'Ind.
COMPANY �ACDRESSBox 66 Centeryiile.,Mass , 02632
' ;Cruet --^
Tuwn or N t/ ~�
COMPANY TELEPHONE ( 508 1 775 ,3338 FAX (` 508°). 790"
CERTIFICATION :STATEMENT. ti _
I certify that I hive personally: inspected the sewage 'dar
®r,
his nddress. and .that the information .:rep'o.vted•-- i.s true , accur tomplete as of 'the' time rof .inspection. The inspection. wasecommendations regarding upgrade , In airitenanceanCi ? n is-,;
with my` .trn•ining .and experience in the proper function an{#
site sewage. disposal systems ;
Check om*e , ' .
�Systeci PASSED
The inspection n which I have conduoteti has not found Ur,f
which indicates: that the system fiail,s to i�degi!cte1 �' t:}i°oar
heRith% of the ..eriviro( ment as defines! in31U , Ctft ii „ ✓
� .
cri teria not `evalunte' d. are rts` st`Atad i r try; " , ?"T
this form -
Sys teal FAILED
The inspection wh )cll, I : have conducted . has . found_.
protect the hubl lc .heal th Find the environment i,t ,7
5 ,., 116 CH 15 303 ; and as .specificul1.
l,t;:
r.
CItITER.IA of this inspection form , -.r �
Inspector .Siddntature � 'r� V `t'�
O.
'— •{�• ..scaaaaa*rrsxuaxoi.ttccarn,c::s:uci..:�,x::z:z..n,.�eta.;
a
ne copy of this 6 rti f ication must bey ' prow' ld d
uhvro : applicable ) . and the BOARD Olt,_:)(JIAJ,,TH, -
If the• inspe-ctio'n FAILED ,, thb ai4nc,1 or op iv.a
F' t iin one - ,ear of ° the ~date `of" the''ino"
o the r°uise as P1•0vided,:in 3.10 Ch(R -15
\ ,
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Parcel Location Owner Village Index Map
140-111 122 WIANNO CIRCLE RYAN, GARY W& ERIN A OST 1833 140111
http://issgl2/intranet/propdata/lookup.aspx 4/24/2014
TOWN OF BARNSTABLE
1 t
LOCATION SEWAGE # — t`
A VILLAGE n S
7—ASSESSOR'S MAP& LOT
INSTALLER'S NAME&PHONE NO. :2
/
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) C.
(size)
NO.OF BEDROOMS
,> f
BUILDER OR OWNER '��-,ems
PERMITDATE: /C — COMPLIANCE DATE:
I
Separation Distance Between the:
Maximum Adjusted Groundwater Table an Ottom of Leaching Facility Feet
i Private Water Supply Well and Leaching�Faci-lity (If any wells exist
on site or within 200 feet of lea c ' g facility)
Edge of Wetland and LeachingF Feet
.ty(If any wetlands exist
within 300 feet of leaching f cility)
Feet
Furnished by
a
7
o �
' I
w ,v •���.
` S
- CONENIONVE ALTH OF MASSACHU SETTS '
1e; EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
_ DEPARTMENT OF ENVIRONMENTAL PROTECTION
ONE WINTER STREET, BO5TON MA 02108 (617) 292-55(10`
s TRUDY CORE
Secretary
ARGEO PAUL CELLUCCI DAVID B. STRUHS
Governor Comaussioner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ;
PART A
CERTIFICATION
Property Address: 122 Wianno Circle., Name of owner Cynthia Shield.S
0 S t e V* 11 e , MA Address of Owner:
Date of Inspection:
Name of Inspector:(Please Print) Wm. E . Robinson Sr .
am a DEWw ov sy ir%spector pur ant tQ Section 15.440 of.Title 5(310 CIIAR 15.000)
Company Name: 0 ins on Septic Service
MaiingAddress: 9,
ox Centervllle'100` MA
Telephone Number: 775-8776
CERTIFICATION STATEMENT
i certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate
and complete as of the time of 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:
yz r
asses •
Conditionally Passes
a
Needs Further Evaluation By the Local Approving Authority . :
Fails.
Inspector's Signature: Date:
The System Inspector shall submit a copy of this inspection report to the•Approving Authority(Board of Health or DEP)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.
NOTES AND COMMENTS
e
,
a
-a
4
revised 9/2/98. Page Iof11
ow
i
• P
. ed o Recydrda
Pc
- ..
..
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
"roperty Address: 122 Wianno Circle , Osterville
Jwoer: Cynthia Shields
Date of Inspection: — _ 0
P� f
INSPECTION SUMMARY: Check >, C, o/ D:
A. SYSTEM PASSES:
I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist. Any failure
criteria not evaluated are indicated below.
COMMENTS:
B. SY TEM 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 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
revised 9/2/98 Page 2of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
' CERTIFICATION (continued)
Property Address: `122 Wianno Circle ,; Osterville
Owne►:
Cynthia Shields `
Date of Inspection: A�4$r8
C. RTHER EVALUATION IS REQUIRED BY.THE BOARD OF HEALTH:
Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the
public health, safety and the environment.
1) - YSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 15.303(1)(b)THAT THE SYSTEM
NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
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.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER,IF ANY)DETERMINES THAT THE SYSTEM IS
FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH 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 1 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 r •
revised 9/2/98 Page 3of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Prop" acre 122 Wianno Circle , Osterville r
Owner: �yntiia Shields
Date of Inspection:
D. SYSTEM FAILS:
You t indicate either "Yes" or "No" to each of the following:
have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this
termination 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 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 1/2 day flow.
_ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
—f 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.
n f a cesspool or privy is within a Zone I of a public well.
_ Any porno o p p y
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 YSTEM FAILS:
You must in icate either "Yes" or "No" to each of the following:
T e following criteria apply to large systems in addition to the criteria above:
T e 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
ealth 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 public
water supply well)
The owne 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 a Department for further information.
revised 9/2/98 Page 4ofII
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address_ 122 Wianno Circle , Osterville
Owner: Cynthia Shields w
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 rwrmal 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, excluding 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 on the site has been determined based on:
v _ 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)
115.302(3)(b)1
_ The facility owner(and occupants,if differeni from owner) were provided with information on the proper maintenancsof
Subsurface Disposal Systems.
revised 9/2/98 Page 5ofII
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
$ropertyAddress: 122 Wianno Circle, Osterville
owner: Cynthia Shields
Date of Inspection:
FLOW CONDITIONS
RESIDENTIAL:
Design flow:,KT6g.p.d./bedroom.
Number of bedroomsAesign): Number of bedrooms (actual
Total DESIGN flow 6 $a
Number of current residents:
Garbage grinder(yes or no):/j,0
Laundry(separate system) (yes or no);4,6 If yes, separate inspection required
Laundry system inspected (yes or no)
Seasonal use (yes or no):-&,p
Water meter readings,if available (last two year's usage(gpd): 1998 69, 0°00 -gal.
Sump Pump(yes or no):A/0 - 1997 60, 000 gal.
Last date of occupancy: ) -G—, 6 G Ca,
COM ERCIALIINDUSTRIAL:
Type'o establishment:
Design flow: gpd ( Based on 15.203)
Basis of Jesign flow
Grease ti ap present: (yes or no)_
Industria Waste Holding Tank present: (yes or no)_
Non•sani ary waste discharged to the Title 5 system: (yes or no)_
Water ter readings,if available:
Last da of occupancy:
OTHE IL
Last d occupancy:
GENERAL INFORMATION
PUMPING RECORDS an ource of information:
System umped as part of inspection: (yes or no)A,0.
If yes, volume pumped: gallons
Reason for pumping:
TYPE O 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
Tight Tank Copy of//DEP Approval
Other 4-is so ,
APPROXIMATE AGE of all components, date installed(if known)and source of information:
136
Sewage odors detected when arriving at the site: (yes or no), d
revised 9/2/98 Page 6of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
'rop"Address: 122 Wianno Circle , Osterville
Owner: Cynthia Shields
Date of Inspection:
BURING SEWER:
(Lot a on site plan)
Depth below grade:_
Materi I of construction:_cast iron 40 PVC_other(explain)
Distan a from private water supply well or suction line
Diame er
Com nts: (condition of joints, venting, evidence of leakage,-etc.)
SEPTIC TANK:_
(locate on site plan)
Depth below grade:
Material of construction:�ncrete_metal_Fiberglass _Polyethylene_other(explain)
If tank is metal, list age_ Is.age confirmed by Certificate of Compliance_(Yes/No)
Dimensions: i1C
Sludge depth: 0
` r
Distance from top of sludge to bottom of outlet tee or baffle: 'I'll -
Scum thickness:
Distance from top of scum to top of outlet tee or baffler r
Distance from bottom of scum to bottom of outlet tee or baffler
How dimensions were determined: -�ba 110��i /!i
'omments:
(recommendation for pumping, c edition of inle�nd outl t tees�affles, depth of liquid level in relation tg iNtlet invert, structural integrity,
evidence of leakage, etc.) ���� t�- 1� �. �/ s /1 .<. �.�3• �Q /(/�'�tr !�/ ��3 e-
G SE TRAP:
(Ioc a on site plan)
Depth elow grade:_
Materia of construction:_concrete metal Fiberglass _Polyethylene_other(explain) '
Dimensi ns:
Scum t ickness:
Distanc from top of scum to top of outlet tee or,baffie:
Distant from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Com nts:
(reco mendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity,
evi ce of leakage,etc.)
revised 9/2/98 Page 7of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
,Iroperty Address: 122 Wianno Circle , Osterville t
owe: Cynthia Shields
Date of Inspection:
TIG,
T OR HOLDING TANK: (Tank must be pumped prior to, or at time of, inspection)
(local on site plan)
Depth elow grade:_
Materia of construction:_concrete_metal_Fiberglass_Polyethylene_other(explain)
Dimensi r
Capacity gallons
Deslgn fl w: gallons/day
Alarm pr sent
Alarm le el: Alarm in working order: Yes_ No_
Date of revious pumping:
Comme ts:
(condi 'on of inlet tee, condition of alarm and float switches, etc.)
DISTRIBUTION BOX:_v
(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, etc.) -
� �IitJ 1 — f✓. —i C-t�
PUMP CHAMBER:_
(locat on site plan)
Pump in working order: (Yes or No)
Alar s in working order(Yes or No)
Co ments:
(n condition of pump chamber, condition of pumps and appurtenances, etc.)
revised 9/2/98 Pagesofll
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
'rop"Address: 122 Wianno Circle , Osterville
Owner: Cynthia Shields
Date of Inspection:
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._
leaching chambers,number:
leaching galleries, number._ `
leaching trenches,number, length:
leaching fields, number, dimensions:
overflow cesspool, number:_
Alternative system: `
Name of Technology:
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, clamp soil, condition of vegetation, etc.)
'V 2 L n "-L'G�/ 4 z
O
CESSPOOLS:
(locate on site plan)
Number and configuration:
Depth-top of liquid to inlet invert:
Depth of solids layer. fil
)epth of scum layer.
Dimensions of cesspool:
Materials of construction: s'
Indication of groundwater: µ
'inflow (cesspool must be pumped as part of inspection)
Co m ents:
x
(note) of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
PRIVY _
(locatel on site plan)
J•
Mate ials of construction:
Dimensions:
Dep of solids:
Co ments:
(n condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
revised 9/2/98 Page 9ofII
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
--ropertyAdd►ess:122 Wianno Circle , Osterville
owner: Cynthia Shields
Jate of Inspection:
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent reference landmarks or benchmarks
locate all wells within 100' (Locate where public water supply comes into house)
r
`V
r`
•
.c�
P
Q l
revised 9/2/98 Pagc.10of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(corrbnued):
row-ty Address:12 2 Wianno Circle , Osterville
Owner: Cynthia Shields
Date of Inspections:
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-20 Feet
Please indicate all the methods used to determine High!Groundwater.Elevation:
Obtained from Design Plans on record
Observed Site(Abutting property, observation hole, basement sump etc.)
V Determined from local conditions `
Checked with local Board of health
Checked FEMA Maps
Checked pumping records f
Checked local excavators, installers
Used USGS Data
Describe how you established the High Groundwater Elevation. (Must be completed)
199
revised 9/2/98 Page 11ofII