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HomeMy WebLinkAbout0027 YORK TERRACE - Health 27 YORK TERRACE, OSTERVILLE A= 140 150 f o u a , a 71 TOWN OF BARNSTABLE, TION `f6/g SEWAGE # 2 e) Is-.LAGE_ �j-Vj �, ASSESSOR'S MAP Cz LOT7-7 INSTALLER'S NAME & PHONE NO. h1e-XC7 ('0 60, :�' e SEPTIC TANK CAPACITY J, 0700 LEACHING FACILITY:(type) ,�%T- (size) (}Zr() NO. OF BEDROOMS PRIVATE WELL PUBLIC WATER BUILDER 6R OWNER /yi/xj Gi9e�Oti✓ri2 DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: e VARIANCE GRANTED: Yes No '4 j I V � ci a f r� 1 F 11 n 41 Nof'� Fics !�'.. THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH TOWN OF BARNSTABLE Ap.pliration for Disposal arks Tonstrnr#inn rumit Application is hereby made for a Permit to Construct ( k') or Repair ( ) an Individual Sewage Disposal System at: ........12.- 14/1 w✓m. .. 05 fvlI l�....... f W q I j_t Add Vl -, / J q Uu ..................or Lot No. —__......_ •- ... .......•....----•-.............................. •...................... •.......... .. 1 I f 0(S f` ner Address Installer Address Type of Building Size Lot----------------------------Sq. feet v Dwelling—No. of Bedrooms................................ .Expansion Attic ( ) Garbage Grinder ( ) •-+ 4 Other—Type T e of Building No. of persons............................ Showers 1 — Cafeteria a YP g P ( ) ( ) Q' Other fixtures ............................................. d --------------------•-----------------------•----•-------------------------------------------. W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. ` WSeptic Tank—Liquid capacity............gallons Length---_----------- Width................ Diameter---------------- Depth................ x Disposal Trench—No-------------------•• Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area.................sq. ft. Z Other Distribution box ( ) ' Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date--------------------•----------------- aTest Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Test Pit No. 2.............:..minutes per inch Depth of Test Pit.................... Depth to ground water......................... �+ ------------------------------------------ -------------- ••---------------------------------- -------------- •-------- --.................,-------- ...... ODescription of Soil...............................................................................=----------------------------------------------------------------•--•................---- x UNature of Repairs or Alterations—Answer when applicable.............................................................._.........._..._...._.........._.. .............................................-.............................................................................--------------------•-----------...--------------•-.........-•--••......---- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental 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 p `1� - �,] Dare Application Approved By ------------- -- --------— .... ------- ---- ----,...------------------.------................... ... 2`-Daze� -jP4 Application Disapproved for the following reasons: -..............................................................................................---------------------------------------- . Dare Permit No. Gn '.......-�---- --------------- Issued ..-------`............ -------- .09 --------- THE COMMONWEALTH OF MASSACHUSETTS _ BOARD OF HEALTH ` TOWN OF BARNSTABLE k t Appliration for Disposal ,Iforks Tonstrnrtion Frrmit Application is hereby- made for a Permit to Construct or Repair ( ) an Individual Sewage Disposal System at: � y a 20 ........11 'f0/k r�ac� 05-- /vll �( ......... .p t W q 1� / U U) kcat o n-Address P' I V'Wf,,A, 0 or Lot No. ---•-•...........................--......._.._._._....--•-------(-.....1---•-------•-------------•-•- ..........-•--'-t--V__V_i._.......--•---•---•-••------................................................. Owner Address a HICVY ( nU��, -------------------------•T....................•.................................................. -•----................_...._..........._....................--•-•----•••-•----........-----.------ Installer Address Type of Building g Size Lot............................Sq. feet V Dwelling—No. of Bedrooms.- ----------- .:.:.::..:.... .______._..__Expansion Attic ( ) Garbage Grinder ( ) Other—Ty PL4 pe of Building No. of pers6ns____________________________ Showers 1 — Cafeteria Other fixtures ...........-•----•-------------- W, Design Flow...................._.......................gallons per person per day. Total daily flow............................................gallons. WSeptic-Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................ x 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 ( ) a` Percolation Test Results Performed by-•-••--------------•-----••------•--------•-----•-----•------......_..... Date......................................... Test Pit No. 1_=:_ .........minutes per inch Depth of Test Pit.................... Depth to ground water--____-__________-__-__. 44 Test Pit No. 2._.........._...minutes per inch Depth of Test Pit.................... Depth to ground water........................ Fj ! ODescription of Soil............................--• ...----........._....--•--•--••••-••••--••--•=........................................................................................ x :....... W == ------------------- VNature of Repairs or Alterations—Answer when applicable............................................................................................... .........................................=.............................................:=.--------•--------•-----------••------••••----•-•--------•-------••-•---•------•-----•••-••.._...........•-- Agreement: a. The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental 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 ............... ...........nil-------- .....�. 1`. ..... �------------------. ---...----...... to................ Application Approved BY .: -... '2 ` Application Disapproved for the following*reasons: ............................... ----------------------------------------------------------------------------------- --------------------------------------- • Date Permit No. G�!.'J�.�d -............................ Issued ---------- ' -'r�...------ -..------ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ._�. TOWN OF BARNSTABLE r Q.1Ekttfirate Df Q-11IIrityliance THIS IS TQ CERTIFY, That the Ind ual Sewage Disposal System constructed ( �` ) or Repaired ( ) j� i � - ....---- -_------------ at �r ...... ..:/...... .. ................. ;2 ..i�------------------------------------ --- ---------------- .......----.... has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in the application for Disposal Works Construction Permit No. dated ...... THEISS'UANCE OF THIS CERTIFICATE SHALL NOT BE CONSTR AS A GUARANTEE THAT THE ' SYSTEM WILL FUNCTION SATISFACTORY. �r 5, i DATE........... ......................�-.............----------.........-..--.........------............. � .Inspector ....----------�...........-----....----;�---.......-----------�,....---............... THE COMMONWEALTH OF MASSACHUSETTS „r w BOARDe OF HEALTH TOWN OF BARNSTABLE No..,7.�....` ....... .3 FEE... Disposal ' /park Torn tr ion 'f amit .. �. Permission is hereby granted------------1 .!%.......f.?�......_.__ 1. __... :......................... to Construct ( (,)/or Repair ( ) n Individual Sew a e Dis. osal System at No..---... "� %I��� C. 1�?. :..... Street .� as shown on the application for Disposal Works Construction Permit No._ � ated..... ........ ..........� ...............................0 ----.7r. ..--:�_.... DATE-•- 3 . �--•--•...... Board of Health-;- FORM FORM 36508 HOBBS&WARREN.INC..PUBLISHERS ` I I' a�7�fr ?,;�W OF BARNSTABLE LOCA. 10N L® � � ��r�c� SEWAGE # L (�✓ VILLAGE ( ` LlkL ASSESSOR'S MAP & LOT INSTALLER'S NAME & PHONE NO. Anc)r" ! SEPTIC TANK CAPACITY I� LEACHING FACILITY:(type) 'P 'ZS (size) NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER BtM-EWR OR OWNER' DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No f �___ _ � Q. r ��d ('� 1 I � r ;V'? �, .• l .. � ,f�� �{,__ (� r, ,t � ��:o •-a=ys:9 ..... ........... No._ y 3 ..jC/���, �+'EE .. THE COMMONWEALTH CIF MASSACHUSETTS BOAR® OF HEALTH TOWN OF..... d Appliration for Uiivoiial Works Tonitrurtion . Fermi# Application is hereby made for a Permit to Construct ( ) or Repair ( X) an Individual Sewage Disposal System at: York Terrace — Osterville Lot 15 .............................................y------....-----.............------•-•-••......... ...--••---•---------•..-----•----•-..--------.....---•--•..-------------•-------................. Location-Address or Lot No. David recjor 760 Plain St Marshfield, ---------------------- .............. -----•-- ...... ....----........... .... r ................................Address ............ � ........� ....................... Installer Address 25098 d Type of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms.........._..............................:.Expansion Attic ( ) Garbage Grinder �o ) aOther—Type of Building ............................ No. of persons.....................:...... Showers ( ) — Cafeteria ( ) G4Other fixtures -----------------------•---------------------•------.•-----------•----------------------------••••..........----------------------------...--------- allons per person per day. Total daily flow........... gallons. W Design Flow.....---•-----55----•---.....---•-------g P P P Y• Y 44•©-------------------------� , WSeptic Tank—Liquid capacity1.2_1.0.gallons Lengthl.0.!__.G!!. Width-_- Diameter................ Depth!_...4!!... xDisposal Trench—2 o. .................... Width j............._.... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No..................... Diameter----1o............ Depth below inlet.5...67.-........ Total leaching area..5.1 ft. z Other Distribution box (x ) Dosing tank ( ) ot'VA,A Percolation Test Results Performed by.......................................................................... Date....... ....7...... sg�. aTest Pit No. I................minutes per inch Depth of Test Pit--------------------- Depth to ground __.S.TEPREN... fi Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to groun r....ALLYN•----__ Ri --•--- c9 WILY ON xDescription of Soil-------------•-•------.........-•---•----..........................------------•----•------------------------------......-----------• �4s,�� g� U •--------•-•-------------•-------------•-------•-----------•---•----------------------------------------------------------------------------------------•------------.... . ........ gy W ----••------------------------•--------------------------------••----------------------•------------------•--------------------------••------------•------••-----•......------. f U Nature of Repairs or Alterations—Answer when applicable.__ReGOxlstX'UQt _ dipsal-sstem for an__ext . addlton...............y - •- n -- � ._a _ p � Agreement: j The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of iiTli� 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance h been issued by the board of health. �---•""ter—ned f a e APPlication Approved ---------- v ---- ------------------ *Da Application Disapproved the of wing reasons--------------------------------------------------------------•----------------•-----••••-------•-•..........--- ....................•-----------.....-------•----------------.....-------••------•--...........---------------------••.......---------•---------------------------------------------------••------------ ` Date PermitNo......................................................... Issued....................................................... Date No...................... ,, Fps.......... ...._ THE COMMONWEALTH Or MASSACHUSETTS BOARD OF HEALTH . . ......... OWN......................OF......PARNSTABLE. , ppliration for Bhop t ial Worka C onfitr tr#ion ramit Application is hereby made for a Permit to Construct ( ) or Repair ( X) an Individual Sewage Disposal System at: York Tetraee - Osterville Lot 15 .... ........_ ..... ............. -•--•-•-•-•--••••••••••--• •...._•--_.. -- ------------------•-•-- Location-Address or Lot o Davy e ry 760 Plain St. _Marshfield, MA___02©50 Address._.......... .........._. Installer Address 2 5099 C� Type of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms___...._.__:_____________________________Expansion Attic ( ) Garbage Grinder (no p4 Other—Type T e of Building •I yp g ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( ) Q, Other fixtures --•----•----•-•----••-•••-••-••-••••••-•••••-•••--••--•-••-••-•---••-••---••-•---••-•---••....-•--•---•--------------•-•---•••......._...._.......... gallons per person per day. Total daily flow......_._._ gallons. W Design Flow---------------5-`�-•-••---------......-•--g P P P Y• Y ��44--•--------------------- 9 Septic Tank—Liquid capacity.12_5 gallons LengthZ4!_4©_!!'Width._.3_!_,...0!1 Diameter..........•..... Depth5_!.•.V_- W Disposal Trench—'o_ ____________________ Wi 7_____:___________ Total Length...........:.___•___Total leaching area....................sq. ft. No. .........Seepage Pi. ..... Diameter.................... Depth below inlet_5x17.__..___ Total leaching area.. Z Other Distribution box (X) Dosing tank-( ) �Q,b'��OF A f 04 Percolation Test Results Performed b .......................................................................... Date._..____. -' � 4 _ � -STEFHEIV' SG 4 Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground ------Attu______. Gi, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground -----W&SON...... y Q+' �l No,30216 O Description of Soil 9 `�lSCT_>� w x -•-•------•-•-••••••---•----•••-••-•••••-•••••..._.................................................................................................................... ---- ------------------------•-------------...-------------------- ------------------ ----------------------------------------------------- - g Nature of Re airs or Alterations—Answer when a liable_. __subsuraCe•sew e U P P - - --�---- --G��J�--• r disposal Est for existInq dwelling.and prmosed addition . . �'/ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of IL LE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance been issued by the board of health. tied.-----• - ___ ________________• ................................ --- D to Application Approved r--•--• •-•• •••-••---------------------•---------•---....--•----•---•-••-------•------ _y -_ ' .._...._..._ �. e Application Disapproved, or the - owing reasons: -----------------------------------------------------------------------------------------------------------.....----------------------------------------------------------------------------------•-_-- Date PermitNo......................................................... Issued........................................................ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................OF.................................................................................... Tatifiratr of Toutpliattrr RTIF'.That the Individual Sewage Disposal System constructed ( r Repaired ( ) byJ,, .....g............................. ........................•- ry -.....----------...-instaii�-----------------......----------....._.....------------------------._...--------•-------...._ at ......................... ---_••--....• -•••• .-------------•----•----•-.....-•-•---•••-------------•------.......__...__...••-••••••------ has been installed i acco dance with the provisions of �Lam, j of The State Sanitary C de a escribed in the application for Dis os ��Vorks Construction Permit N ___. .77:.?LV_ .__._____._. datc ^" r __________________________ THE ISSUAN E 9F THIS CERTIFICATE SHALL NOT BE CONSTRP6 AS A G ARANTEE THAT THE SYSTEM WI N I N SATISFACTORY. :. ��ii �f DATE..!✓... 1. ... .......... .............. Inspector ..._ .....•-- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Q No......................... F$ ..................... prr isin ------------------------------------•-•-•--...._--••-•••-•-••-•Pm Y grant .. to Constr. or -- , r Rep _( „�) n ivl Sewage Disposal System at et as shown on they pli Mori for isposal Works Constructiol? streNo..................... Dated.......................................... ••. •-• - --•---•-------••--•--•••••-•-- --•-------••-•-•--••-•--•-.....-•-••._.._.._.._•••----_•-._ DATEf Board of Health ••-- -;.................................................. •••- FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS _ WARD TITLES I/ O-152O�Oo P.O,BOB 1934,MA?10MET,MA 02345 509-224.5149 CO'v1M0\ I�'L�I�ALTH OF ASS.ACHUSETTS -3 ' EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAM R'S Tim, J 1',.I�EPART�IENT OF ENVIRO\MENTAL PAR TEC�bO \'E�FW'INT�'R)STREET. BOSTON. NIA 0_109 61 •'9?//�.I ���,C- {�C W'1LLIA�+.F.WELD / '" NORM' sM tO% TRUDY CORE Govemo $ Secretwn ARGEO PAUL CELLUCCI DAVID B.STRUHS Lt.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION 6 Commissioner �G v� �-+ f rL PART A CERTIFICATION y � 1 Property Address: J v, /Q Address of Owner: Date of Inspection: �`' ,` 7 ��9 (If different) ,r•- AV A—e-lk- Name of Inspector: �dd;� L�O. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 1S.000) Company Name: WARD TITLE 5 Mailing Address: P.O.BOB 1934, MANOMET. MA 02345 Telephone Number: 50E-224-5749 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 wage disposal systems. The system: on-site _ Condincinally Passes _ 'Feeds Further Evaluation By the Local Approving Authority _ Fails Inspector's Signature: .� � Date: 7 The Svs,em Inspector shall 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. IN'�SPECTIO\ SUMMARY: Check A, B, C, or D. , I A) SYSTEM PASSES: I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure_ criteria not evaluated are indicated below. COMMENTS: S� EM 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. (r*vis*d 04/25/97) 1a9• 1.09 10 . CEP on the Wono Woe Web http./rwww magnet 912Ie.m&.VV*ep Printed on RecycJe4 Paper WARD TITLE S P.O.BOB 1934,MANOWIT.MA 02345 MI.224-»19 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A. CERTIFICATION (continued) Property Ads- 7 Owner: Date of Inspection: MAY 7 '1998 lnhm BJ SYSTEM CONDITIONALLY PASSES (continued) 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). 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 ,411kCj FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health, safety and the environment. F. 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 IS FUNCTIONINGAN 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 coin the well is free from pollution from that facility and the g pounds indicates that e tY 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 - I (revised 04/25/97) lap. 2 of 10 I WARD TITU S I P.O. BOB 1934,MANOMET.NAOZ345 509-224-5749 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Ad�/dffess: / Owner: Date of Inspection: VAY D) SYSTEM FAILS: r1 Nr/Yau 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 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 112 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'pri%y 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 coliiorm bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen: - E] LARGE SYSTEM FAILS: You must indicate either 'Yes" or as to each of the following: �1 The following criteria appiv 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 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 11 of a public water supply well) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program. requirements of,314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. f:.vixod ,04/25/97t rag. 3 of 10 p WA7tD TITU 3 P.O.BOB 1934.MANOMBT.WA 02345 309-224-5749 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Adsiress: 027 �J Owner. Date of Inspection: �,,. � 7 1998 Check if the following have been done: You must indicate either "Yes' or"No" as to each of the following: 5 No ..Pumping,information was provided by the owner, occupant, or Board of Health. _ None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates, during that period. Large volumes of water have not been introduced into the system recently or as pan of this'inspection. r , _ As built plans have been obtained and examined. Note if they are not available with N/A. _ The facilify or dwelling was inspected for signs of sewage back-up. _ The system does not'recerve 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: ` The facilin• o\vner(and occupants, if different from owner) were provided with information on the proper maintenance of Sub-Surface Disposal System. 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; 115.302(3)(b)J (revised 04/25/57) Prago 4-of 10 WARD TITLE 5 t P.O.BOB 1934,MANOMET.MA 02343 501-224-5749 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C ' SYSTEM I FORMATION Property Address: Owner: / G Date of Inspection: FAY FLOW CONDITIONS RESIDENTIAL: Design flow: Z�'P R,p"d"/bedroom for S.A.S. 41 Number of bedrooms: Number of current residents: 01, Garbage gnr der (yes or no): G, S h vim.��/. ,6 t "�'o I-,47 tJ" Laundry corrected to system`(yes or no):�/� Seasonal use ryes or no):� ✓ Water meter readings, if available (last two (2) year usage (gpd)J` Sump Pump (yes or no)A e °sY — 7 Last date`of occupancy: , COMMERCI.AUINDUSTRIAL:�e Type of establjshment. Design flow: eallons%day Grease trap present: (yes or no)_ Industrial Waste Holding Tank present: Ives or no)_ Non-sanitary waste discharged to the Title 5 system: (yes or no)_ Water meter readings,.if available _ Last Pate of o:cupanc)•: OTHER: (Describe) Last date of occupancy. GENERAL'INFORMATION PUMPING RECORDS and source of i formation: System pumped as part of inspection: (yes or noi-4-0 If yes, volume pumped gallons Reason for pumping TYP SYSTEM . Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system (yes or no) (if yes, attach previousinspection records, if any) I/A Technology etc:Copy of up_to date contract? Other APPROXIMATE AGE of all components, date instilled (if known)and source of information: _ �y /ae�.-- IV Sewage odors detected when arriving at the site: (yes or no) (rwimeId 04/25/97) Page 5 of 10 WARD TITLE 3 P.O.BOB 1934,MAROMLT.MA 02343• 308-224-3749 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C L _ SYSTEM INFORMATION (continued) Property Address. Owner: / � ` g Date of Inspection: ` BUILDING SEWER: (Locate on site plan) Depth below grade: Material of construction: _cast iron_40 PVC other (explain) Distance from private water supply well or suction Im., Diameter Comments: (condition of joints, venting, evidence of leakage, etc.) SEPTIC TANK: (locate on site plan) � /� t Depth below grade: lam. Material of construction: concrete _metal _Fiberglass Polyethylene _other(explain) If tank is metal, list age_ Is age confirmed by Cenuficate of Compliance _(Yes/No) Dimensions:_ r Sludge depth /r r Distance from top 9.f sludge to bottom of outlet tee or baffler Scum thickness: Distance from top of scum to top of outlet tee or baffler Distance from bottom of scum to bosom of outlet tee or ar,Ie: �[ Mow dimensions were determined. ZA/42 r— Comments: (recommendation for pumping, condition of inle and outlet tees or, a es, epth of liquid level in relation to outle invert, structural integrity, videncS of leakage etc.) -C .� .L I x? - z� SE TRAP: (ocate on site plan! Depth below grade: Material of construction: _concrete _metal _Fiberglass _Polyethylene —other(explain) Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bonom of outlet tee or baffle: 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.) (revived 04/25/si) Page 6 of-10_ WARD TITLE S P.0-BOB.1934,MANOMET.MA 02343 3W224.3749 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address- Owner: Date of Inspection: 9 s FY — 7 1 � TIGHT OR HOLD I#xNK: (Tank must be pumped prior to, or at time, of inspection) (locale on site plan; Depth below grade: Material of construction: _concrete metal _Fiberglass _Polyethylene _other(explain) Dimensions: Capacm: gallons Design floe: gallons'da Alarm level Alarm in w rking 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 imert V Comments: (note if level and distribute n is equa', evidence of solids carryover, evide ce of leakage,into or out of box, etc.) PUMP CHAMBN/A (locate on site plan; Pumps in working order: (Yes or Not Alarms in working order (Yes or No Comments: (note condition of pump,chamber, condition of pumps and appurtenances, etc.) (revised 04/25/97) Page 7 of 10 I WAItD TITLE 3 P.O.BOB 1934,MANOMET.MA 02343 30E-224-3749 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) n� Property Addr ss: 0P-7 Owner— Date of Inspection: t`°sy — 7 19 SOIL ABSORPTION SYSTEM (SASatlo (locate on site plan, if possible; ex n not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: . i i Type f leaching pits, number. c 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, ondition of vegetation, etc.) CESSPOOLS: (locate on site plan) Number and configuration: Depth-top of liquid to inlet rover,, Depth of solids layer: Depth of scum layer: Dimensions of cesspool Materials of construction: Indication of groundwater: inflow (cesspool must be pumper as pan of inspection) a Comments: (note condition of soil, signs-of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY:l`a1 (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.) (revised 04/25/0) Page t of 10 WARD TITLE 5 P.O.BOB 1934,MANOMIT.MA 02343 ` 301-224-3749 SUBSURFACE. SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property A dress:/ J G f"' k /e'!,-- � '/� ' Ile Owner. At: � Date of Inspection: + _ 7 199 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within IDO' (Locate where public water supply comes into house) 5 j /y F ,, (revived 04/25/57) Pape 0 of 10 WARD TITLE 3 P.O.BOB 1934,MANOWT.MA 02343 508-224-3749 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: O�� y - Ze.✓— v� Owner: Date of Inspection: �1 f�s _ 7 139 Depth to GroundwateoW Feet Please indicate all the methods used to 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 neaps ' s - Check pumping records Check local excavat;ors, installers Use USGS Data Describe in•your own words how you established the High Groundwater Elevation. Must be completed)- (revised 04/25/97) PaQe,10 of 20 n A T ION � SEWAGE PE RMIT. NO.. L 0 c -3 g' VILLAGE INST A IIER'S NAME i ADDRESS (' R o Ss s%� �( -rn1 AReKr' GUILDER OR OWNER DATE PERMIT ISSYED ®ATE C 0 M P L I A-NCE ISSUED Q , .4 . .f✓ti��✓ 3 t a • I Q� 1 'f WARD nrL,E s .2. P.O.BOB 1934,MANOMET.MA02345 ,,pper� r 509-224.5749 �30\ COMMONWEALTH OF MASSACHL•SETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIAR � Q "">1 DEPARTMENT OF ENVIRONMENTAL(PROTEhICTI,P 199� 1 , ONE WINTER STREET. BOSTON. NIA 02106 6t7-'9�µS'�00�h� SSpe�E WILLIAM F.WELD TRUDY CORE Govemo- d Secrcuvn ARGEO PAUL CELLUCCI DAVID B.STRUHS Lt.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Commissioner � PART A CEERRTIFICATION may, /-Ile A4 Property Address: Address of Owner: Date of`Inspection:KAy r 7, 1999 (If different) Name of-Inspector: I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (31 .000) Company Name; WARD TITLE S E r/.OrI�.G,ai Mailing Address: P.O.,BOB 1934, MANOStET.MA 02345 ��� Telephone Number: 50E•224.5749 CERTIFICATION STATEMENT 4> 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-Zpas,ses age disposal systems. The system: _ Conditionally Passes 'seeds Further Evaluation By the Local Approving Authority Fails Inspector's Signature: �� Date: MAY - 7 1998 The Svstem Inspector shall 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 Depar,ment 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) SY TEM PASSES: violates n f h failure criteria as defined in 31 MR 1 v" n found n information which'indicates that the system o ales a o the 0 C 5.303. I have of ou day ca es y y Any failure criteria not evaluated are indicated below. COMMENTS: BI SYSTEM CONDITIONALLY PASSES: t/s °One or more system components as described in the "Cond'itional 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) Pape I-of 20 DEP on the wont Woe Wet)- http./nvww rnapnet state.ma.uvoep Printed on Recyded Paper WARD T1TEX 3 P-0.BOB 1934-MANOMtT,MA 02W SM-224.3749 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM 1 PART A CERTIFICATION (continued) Property Address:G 01 C�CX�fE Tu-� QS/G/`//i•/�� Owner: /A•`�/`- // ✓`lisp ��� Date of Inspection: MAY ' 7 1998 I B) SYSTEM CONDITIONALLY PASSES (continued) _ 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). 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 pipets) are replaced obstruction is removed Cj FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: 1 Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the ,V 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 pricy is within 50 feet of.a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet to a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and the SAS is within'a Zone 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 I ess than 5 ppm. Method used to determine distance (approximation not valid). 3) OTHER (revised 04/25/57) Pays 2 OV IC f WA3LD TITU 3 f P.O. BOB 1934,MANOMFT,MA 02345 508-224-5749 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 9.7 ✓ � /�/`�Gt� v///L ,y . Owner: /�',� / Date of Inspection: MAY D) SYSTEM FAILS: You must indicate either "Yes" or"No" as to each of the following: I 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 i identified below. The Board of Health should n n will necessary to correct s be contacted to determine what be ry 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 112 day flow. Required pumping more than 4 times in the last year NOT due twclogged 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 o;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•pri�y 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 coliiorm bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E) LARGE SYSTEM FAILS: � You must indicate either "Yes" or "1,'o" as to each of the following: The following criteria appiv to large systems in addition to the criteria above: The system serves a facilir• with a design flow of 10,000 god 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 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 owner or operator of any such system shall.bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (raviiiied 04/25/97) Page 3 of 20 I WARD TITLE 3 P.O.BOB 1934,M ANON ET.WA 02343 � 509-224-3749 F i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM J PART B CHECKLIST Property Address: Owner: /Ac C Date of Inspection: IMAY _ 7. 1998 Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: s 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 facile.• or dwelling v.•as inspected for signs of sewage back-up. _ The system does not receive non-sanitary or industrial waste flow. — The site �%as inspected for signs of breakout. _ All systern 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 ba*fles 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:. The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of Sub-Surface Disposal System. 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 . unaccepfab�e) [15.302(3)(b)J (revised 04/25/97) Page 4 of 10 WARD TIME 3 P-06 BOB 1934,MANOMET.MA 02343 301-224-3749 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ,'. PART C SYSTEM INFORMATION Property Ad�{ress / Owner: {� Date of Inspection: FiAp - 7 1�9� FLOW CONDITIONS RESIDENTIAL: Design flow: �� e.p.d./bedroorn for S.A.S. Number of bedrooms _ Number of current residents: -' Garbage gnr der (yes or no): _C, Laundry connected to system (yes or no):lab Seasonal use tyes or no): � Water meter readings, if available (last two (2) year usage (gpd):.liw� C Sump Pump (yes or no):nG� MAY - 7 1998 Last date of occupancy COMMERCI.ALIINDUSTRIALV Type of establishment: Design flow:_gallonslday Grease trap present: (yes or no)_ Industrial Waste Holding Tank present: Ives or no)— Non-sanitary waste discharged to the Tale 5 system: (yes or no) %Vater meter readings, if available Last(fate of occupancy: OTHER: (Describe; Last date of occupancy. GENERAL INFORMATION PUMPING RECORDS as source of iniormation: System pumped as part of inspection': (,yes or no) If yes, volume pumped t allons Reason for pumping TYP F 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. Copy of up to date.contract? Other APPROXIMATE AGE of all components, date installed (if known)and source of information: Sewage odors detecied when arriving at the site: (yes or no) /7 10 .(revised 04/25/97) Page 5 of 10 WAItD.TITL.L 3 ?.O.BOB 1934.MANOMLT.MA 02345 * 508-224-3749 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: �,;7 /e,�r a Lti �5. Owner: Date of Inspection: AY -M ? 1999 BUILDING SEWER: (locate on site plan) Depth below grade: Material of construction: _cast iron _40 PVC other (explain) Distance from private water supply well or suction. Iirr. Diameter Comments: (condition of joints, venting, evidence of leakage, etc.) SEPTIC TANK (locate on site an; Depth below grade:, H Material of construction: 2concrete metal Fiberglass _Polyethylene other(explain) If tank is metal, list age _ Is age cont Irmed by Cenificate of Compliance _(Yes,/No) Dimensions. /D0 0 Sludge depth Disfance,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 bonom of outlet tee or baffle: Now dimensions were determined. Comments: (recommendation for pumping, condition of inlet nd outlet teesorr baffles, de h ofliquid level in relation to ou t invert, structural integrity, evidence of leakage, etc.) a Gt� GREASE T /k (locate on site plan! Depth below grade Material of construction: _concrete metal _Fiberglass ,_Polyethylene _other(ezplain) 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: C 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/S^). Page 6 of 10` WARD TITLE 5 Pea BOB 19K MANOMET,MA 02345 Mg-n4sT49 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ): PART C _ SYSTEM INFORMATION (continued) Property Address: Owner: Date of Inspection: MAY - 7 1998 1 h1HT OR HOLDING TANK: (Tank must be pumped Prior to, or t time, of inspectio n) (locate on site plan) Depth below grade: Material of construction: concrete_metal Fiberglass _Polyethylene _other(explain) Dimensions: Capacrn: gallons Design fiowi galions'da Alarm level Alarm in v brking 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 irner., Comments (no',e if level and distribution is equal, evidence of solids carryoveJ, evi ence of leakage into or out of box, etc.) . PUMP CHAMBER: (locate on site plan Pumps in working order: (Yes or Not Alarms in working order (Yes or No; Comments: R (note condition of pump chamber, condition of pumps and appurtenances, etc.) (revised 04/25/97) Page 7 of 10 WARD TITLE 3 P.O.BOB 1934,MANOMET.MA 02343 $0E-224-5749 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C' SYSTEM INFORMATION (continued) Property Address: Owner:Date of Inspection: MAY - 7 1998 r k-f SOIL ABSORPTION SYSTEM (SAS (locate on site plan, if possible; ex ton not_required, but may be approximated by non-intrusive methods) If not determined to be present, explain: Type leaching pits, number: U 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 ding',condition of vegetation, etc.) CESSPOOLS: (locate on site plan) Number and configuration: Depth-top of liquid to inlet rover•,. Depth of solids layer: Depth of scum laver. Dimensions of cesspool: Materials of construction: Indication of groundwater. inflow (cesspool mus; be pumped as.part of.inspection) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc:) F PRIVY: _ (locate on site plan). Materials of construction: Dimensions: Depth of solids: Comments: (note condition of soil, signs of hydraulic failure, level of pondmg, condition of vegetation, etc.) (revised 04/25/97) Pay. I of 10 WARD TITLE S P-O-BOB 1931,MANOYLT,MA 02343 308-224-11749 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: Date of Inspection: MAY 7 1998 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) 0 7� y /,Y /✓1���-� 07 ' (zaviaad 64/25/5') Page 9 of 10 WAILD TITLE P.O.BOB 1934,MANOMET.MA 02343 30E-224-3749 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM . PART C SYSTEM INFORMATION (continued) L 1 I Property -C��COZ� Owner: e L Date of Inspection: 9 P. - 7- Depth to Groundwater Feet Please indicate all the methods used to 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 exca%-ators, installers Use USCS Data Describe in your"own words hogv you established the High Groundwater Elevation. Must be completed) i (zevised.04/25/97). Pay 10 of 10 01 TOWN OF BARNSTABLE, LOCAMON 5k7 y0tek Illec. SEWAGE V-90 J�33 VILLAGE �S'TTPtliil/r. ASSESSOR'S MAP & LOT INSTALLER'S NAME & PHONE NO. r- . eV, - SEPTtC.TANK CAPACITY LEACHING FACILITY:(type) ,O%l— (size) / av- NO. OF BEDROOMS PRIVATE WELL # PUBLIC WATER BUILDS R OWNER /yi//<f L�9.eDr�/�r DATE:PERMIT ISSUED: /yL Ald DATE;- COMPLIANCE ISSUED: e VARIANCE GRANTED: Yes No -�� 1 � h )Y \ e t, rwij&iv4q7=* _;1-1ggiPM 1 1 WARD TITLE, 5 Inspection Co. 508-224-5749 RECEI1 r® MAR ? 5 1995 HEALTH oc�: N of BARMABLE P.O. Box 1934 Manomet, MA 02345 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: 711j ����— �" �C��i � Address of Owner: Date of Inspection: 3/�'2 ti (If different) t Name of Inspector: G'ari Company Name, Address and Telephone Number: q 60 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: YPasses Conditionally Passes Needs Further Evaluation By the Local Approving Authority _ Fails Inspector's Signature: /J�� Date: r The System Inspector shall submit;a copy of this inspection report to the Approving Authority within thirty (30) clays of completing this msrectton :Lf,the system- o ;has.a.destgn flow of.10000 gpd-orgreater, theiinspectoi and the system?o�+rice Shall submit • "{ahe:repon to'the appropriate regional office*of the Depanment'of;.Environmental Protection ^ The original should be sent to the system owner and topics sent to the buyer,.if applicable and,the approving authority. INSPECTION SUMMARY- Check A, B, C, or D: �! 1 _ A) SYSTEM PASSES: I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 0,1R 15.303. Any failure criteria not evaluated are indicated below. ?) SYSTEM CONDITIONALLY PASSES: .... ^y+."" :—'`.�.._...�..._,..._.... .,��..;.,,............._» —._::_ .. .r,..:c,._.:,_,�.�_a..,.. •-.Inm�.,»N t'+,MI�:vk -z�.. «sir. T!-,. One or more system components need to be replaced or repaired The system; upon completion of the replacement or repai► passes inspection. iridtc.iie yes, no, or not determined (Y,.N, or ND). Describe basis of determination in all instances. If "not determined", e\pl;tin why not) _ The septic tank is,metal, .cratskod'strupturally unsound., shows,sL�bstantial,,infiltration.or exfiltration,.or tank,fa.ilure is imminent. The system will past; inspection if':the existing septic tank is replaced with a conforming septic tank ac aooroved bv'the'Board'o(He'1Nfi SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) _ Property Address: oZ ] ✓ Date of Inspection: 6] SYSTE,,,t CONDITIONALLY PASSES (continued) Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or Joe 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 C] I UR1 HlR I VALUATION IS REQUIRED BY THE BOARD OF HEALTH: Condrtums exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the I)ublic health, safety and the environment. SYSILM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WIiICH 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) sYSII:M WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT IIit. SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a Septic tank and soil absorption system and is within 100 feet to a surface water supply or tributary to a surface ••vater supply. The system has a septic tank and soil absorption system and is within a Zone I of a public water supply well. The systen, has a septic tank and soil absorption system and is within 50 feet of a private water supply well. l he system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free.from pollution from that facility,an.d the presence of ammonia,nitrogen and nitrate nitrogen is equal.to or less than 5 pprn• D] SYSTEM FAILS: I h,; -• determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis io! dii> dc•terminitiori is identified below. The Board of Health should be contacted to determine what will be necessary to correct th" f-I'm bdL.kup of •sewage intu facility or system cumponenl 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. . �M+w..^...... ..^...r-..+.,.-•�..+..-.-ri�:rY -r�..�, r:-.ir.'e--�mriaeFas`mr I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICA ION (con t ued) yr Tcrr '4"e Os '��.� v� f' Property Address: ,I 7 y Owner: 6rc, r.-- Date of Inspection: f��y/�� �'G✓� D] SYSTEM FAILS (continued): 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 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: The following criteria apply to large systems in addition to the criteria above: The design flo", of system is.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: 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 owner or operator of an such system shall bring the system and facility into full compliance with the groundwater treatment program pe Y requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (reJised 8/15/95) 3 i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Ile Property Address: �/'� y (Sca Owner: r d/n e,— Date of Inspection: t— Check if the following have been done: ,/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. 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. . ,L 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 existing information or approximated by non-intrusive methods. Y Tht: faula) occupants, if different from owner) were provided with information on the proper maintenance of Sub Surface Disposal System. (revised 8/15/95) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: yO.^ t s Xe 0%%ner: �TR•NA e" Date of Inspection: � , FLOW CONDITIONS RESIDENTIAL: Design flow: .1Z0 gallons 6-'o1 Number of bedrooms:A Number of current residents: Garbage grinder (yes or no): Laundry connected to system (yes or no):n C Seasonal use (yes or no):�� \Water meter readings, if available: 176,9- efikIN21 ^e Last date of occupancy: (COMMERCIAL/INDUSTRIAL: Type of establishment: Design flow: gallons/day Grease trap present: (yes or no)_ Industrial Waste Holding Tank present. (yes or no)_ Non-sanitary � aste discharged to the Title 5 system: (yes or no)_ \Water meter readings, if available: Last date of occupancy: - _ OTHER: (Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: /J"-"a 4 Py '6 .•/-01' System pumped as part of inspection: (yes or no)_ If yes, volume pumped gallons Reason for pumping: TYPE OF SYSTEM ✓ Septic tanVdistribution box/soil absorpuon;;system Single cesspool Overflow cesspool° Ln 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) and source of information: Sewage odors detected when arriving at the site: (yes_or no) z!21) ........ _..�_..... .` .. — -- - _ SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C T SYSTEM INFORMATION (continued) Property Address: 7 y �r �4"Y or Owner: V Date of Inspection: -1/0­61q SEPTIC TANK: (locate on site plan) Depth below grade:�a , Material of construction: ✓concrete _metal _FRP_other(explain) Dimensions: Sludge depth: e --A 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 le k e, etc.) s 7/ w Lvr7�L' r'•6� 4iu S iin %C P �:l yl i P.%, e/e-n G �_,ixl Po ;f t� GREASE•TRAP.&,4 (locate on site plan) Depth below grade: Material of construction: _concrete metal _FRP—other(explain) Dimensions: Scum tnicknes.�: Distance from top of scum to top of outlet tee or baffle: Distance from bottom t,f scorn tr, bottom of outlet tee or baffle: Commenis: (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.i ..,_... w.,;...e.....n»n-+,••..I ...r..+.+.r-m.r.a.+n r•a•- r-�w..Ne'ee.+re,. r«., , _. - ___ .-. .n.. (revised 8/15/95) _.6 - --- - SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address:, �7 d'` TBR�Liter 'L// Ile - Owner: Date of Inspection: TIGHT OR HOLDING TANK:Ay14 (locate on site plan) Depth below grade: Material of construction: _concrete _metal _FRP—other(explain) Dimensions:_ Capacity: gallons Design flo"•: gallons.!day Alarm level: Comments: (condition of inlL:t tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX: -V (locate on site plan) Depth of liquid level above outlet invert:_t� Comments: (note if level and distribution is equal, evidence of solids carryover, evtd nce of leakage into or out of box, etc.) PUMP CHAMBER:_�jy (locate on site plan) Pumps in working order.(yes or no) Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) 's i nn':,r.n_ n...,-.— 1^� a...w. ,. rn•e.nc...,�+.rii...e, ..��atr+ .,+..—.,-:1.,. ._...._ .,..._..e.-,�m:nnm;^le+!nr,.•T+ rtm inn.•...: SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION 'FORM PART C SYSTEM INFORMATION (continued) Property Address:a2 7 Owner: (j1,141. 0✓ Date of Inspection: c/4 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: i Type: leaching pits, number: leaching chambers, number:_ f leaching galleries, 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,etc.) 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 groundvater: 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.) 4.t • F+S 9 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.) (revised-8/15/95) - - .'.�� ".��. 4-i?,.�:•'1tt�VOt,,,i:; :''r ., .- ..':`�,�tt`'v 'r�f.st'.}4°.� ,1"iti..M�.:ll':+•;. - SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C . SYSTEM INFORMATION (continued) Xe Property Address: 7 �� — Owner: �:•'Gfi� P✓' Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' i / o 0 � a ly \ �N�s-i✓ r.. V DEPTH TO GROUNDWATER Depth to groundwater: feet method of determination or approximation: M 7� (revised 8/15/5 51 a - - .. .. a .;i;�il:.... rf�b�7�.'l.oC i -)�1..°!b:. 4y i...,i. P�.tl";•:4 � .!i'i. t,.h;,`. TOWN OF BARNSTABLE, _ LOCA:'I'ION a7 YO&L Tt ec-, SEWAGE # 70 7J)-u VILLAGE Uil/ ASSESSOR'S MAP & LOT JV19 INSTALL:ER'S NAME faPHONE NO. 111CKr" `'U, �� � SEPTIC,TANK CAPACITY 1 U 0 LEACHING FACILITY:(type) �!`r (size),--�'UU v NO-OF BEDROOMS PRIVATE WELL PUBLIC WATER (B:U:I�L;lb)E R OWNER /y7//0 CiggddkK DATE PERMIT ISSUED: /zz' a Ah DATE.;COMPLIANCE ISSUED: VARIANCE GRANTED: es No Y 1 , -.. _.._ ._.._. -----�..,,, - .V.---.,_......,--�..�.,+en.-...,-..>.-•w. ....-•.---._.-r,,•..,,..r..-...-,.�.-.:.«,...,...«..e:e +er.n<y+.rrmw+ �. - '*rr!een.*!n.,•!e.•mraa*r*rn+r.?+ .. - .'. . v..,,' .•.r_�t to..... .. _ WARD TIT7LE Inspection Coo 508-224-5749 RECEI4 ED MAR ? 5 1995 HEALTH DrYi" P.O. Box 1934 TOWN OF BARNSTAUE Manomet, MA 02345 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: a 7 ^ 4 �^u-6` or 16-4-.,Ae Address of Owner: Date of Inspection: a- S&v (If different) 'Fame of Inspector: �0G ,(f L�/G,r-� ��/� �✓�`a: Company Name, Address and Telephone Number: CERTIFICATION STATEMENT I crrttfy 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 ` G • Date: Incppctor's Signature: .,Q / The System Inspector shall 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. 1 he 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: I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CloR 15.303. Any failure criteria not evaluated are indicated below. s1 SYSTEM CONDITIONALLY PASSES:_` ------ One or more system components need to be replaced or repaired. The system, upon completion of the rcplat:cment or repair,. passes inspection. indic.uc yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If "not dewfmined", explain why not) _ The septic tank is metal, cracked;•struoprally,unsound, shows su'bstantial infiltration or exfiltranon, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a confnrming septic tank as approved by the Board of Health!"'ra.•_•.: �: r, _ r ti a.�r;..,. u.-..i•,;.. ,,r, SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) _ Property Addrrss: .a7 Owner: 6a R }71 a//I Date of Inspection: is] SYSTE,4t CONDITIONALLY PASSES (continued) 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 C] FURTHER EVALUATION IS REQUIRED BY THE BOARD.OF HEALTH: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health, safety and the environment. Sl S I L,m 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. S0II M WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT Ilit. SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE LNVIRONMENT: The system has a septic tank and soil absorption system and is within 100 feet to a surface water supply or tributary to a surface r%ater supply. _ The system has a septic tank and soil absorption system.and is within a Zone I of a public water supply well.. The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. the system has a septic tank and soil absorption system and is less than 100 feet but 50.feet or more from a private water Supply well, unless a well water analysis for cohiorm 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• G] SYSTEM FAILS: I I r„ determined th st the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis io! ilii> determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct lliC Iciil.11'. fi.,,:kup of •.et,-age 11110 facility or system component due to an overloaded-or clogged SAS or cesspool. _ Discharge ur ponding of effluent to the surface of,the ground or surface waters due to an overloaded or clogged SAS or i esspoul. ...... ..._-- _.....r..— rnr�q.e�P,r.. ...— _ .....rr«.p�..•w sw.we.w1M► y."h,.,,.. .�'.tir�'F'MA/gNi 94F r _ .. '—+fin n.MC-.� ..r.nrt.lT.err....._w.s..�.r••—.......r.. »r..y,.�. .ter P:. �..n P i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: .�7 yL''� /C�r84.,C �T�efs�i 11-e Owner: `T4.,�/d Date of Inspection: 3 j4�/G r D] SYSTEM FAILS (continued): _ 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 112 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 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: The following criteria apply to large systems in addition to the criteria above: The design flow of system is 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: 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 owner or operator of any such system shall bring the system and facility into'full compliance with the groundwater treatment program n :0 . Please consult the local re Tonal office'of the Department for further information. requirements of 314 CM'R 5.00 and 6 0 a c p q g trevrsea-B/15-/95 -- - . •"�►� e SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 7 / O r Owner: Date of Inspection: Check if the following have been done: _/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 a5 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 LThe site was inspected for signs of breakout. L 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 existing information or approximated by non-intrusive methods. _Tire f cihtt u.-.nc. (a, d occupants, if different from owner) were provided with information on the proper n-aintenance of Sub- Surface Disposal System. -...- .ec n+a-�n . '---^ --..�-.r•••..,— .. ...»�--«» .u..ch!r,T*+urs►,i»:r, ... (revised' B/15f 95) 4. __. i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SY''STTlEM�(INFORMATION Property Address7 d Owner: Date of Inspection: / /91 4(//P / FLOW CONDITIONS ' bi;ESIDENTIAL: Design flow: y D.gallons Number of bedrooms: 1 + Number of current residents: ..2 /�.,�.. 4-v,/ ILu ea0`/ Garbage grinder (yes or no): GcS Laundry connected to system (yes or no):yS Seasonal use (yes or no): !2 0 �,1 Water meter readings, if available:�� u ar- '�� �'c+d e-�1- Ai' Alai Last date of occupancy: :-OMMERCIAUINDUSTRIAL: Type of establishment: Design flow: gallons/day Grease trap present: (yes or no)_ Industrial \Waste Holding Tank present: (yes or no)_ Non-sanitary �%aste discharged to the Title 5 system: (yes or no)_ Water meter readings, if available: Last date of occupann-: OTHER: (Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: System pumped as part of inspection: (yes or no)!f p If yes, volume pumped: gallons Reason for pumping: TYPE OF SYSTEM Septic tank/distribution b6x/so0 abso.rptioti system' Single cesspool Overflow cesspool Privy Shared system (yes of no) (if yes, attach previous inspection records, if any) Other.(explain) APPROXIMATE AGE of all components, date installed (if known) and source of information: Sewage odors detected when arriving at the site: (yes or no) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM. PART C SYSTEM INFORMATION (continued) Property Address: ,;t 7 1do Owner: .-U//!pr Date of Inspection: j SEPTIC TANK:1r , - (locate on site plan) Depth below grade:�,� Material of construction: _zconcrete _metal _FRP_other(explain) Dimensions: /.1 a 0 Sludge depth: IoL'- 5- " Distance from top of sludge to bottom of outlet tee or baffle:i� Scum thickness: J-S Distance from top of scum to top of outlet tee or baffle: -7 Distance from bottom of scum to bottom of outlet tee or baffle: /6t 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.) e.. .- :.� �r>>► T r, ., c' �� GREASE TRAP:a/) (locate on site plan) Depth below grade: Material of construction: concrete metal _FRP—Other(explain) Dimensions: Scum thickne». Distance from top of scum to top of outlet tee or baffle: Distance from bottom Oi scum tn 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, et(.) (revised 8/15/95) 6 " i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C LL ? SYSTEM INFORMATION (continued) Property Address: Owner: 62:i 4 G-, + ISate of Inspection: TIGHT OR HOLDING TANK-.,A//� (locate on site plan) Depth below grade: Material of construction: _concrete metal _FRP—other(explain) Dimensions: Capacity: gallons Design flol+•:_ gallons!day Alarm level: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) . DISI RIBUTION BOX: (locate on site plan) Depth of liquid level above outlet invert: G Comments: (note if level and distribution is equal, evidence of solids carryover, evid%nce of leakage into or out of box, etc.) . n PUh1P CHAMBER, /� (locate on site plan) Pumps in working order.(yes.or no) Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) _ 0t610^1 ........... I , SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART.C l/ SYSTEM INFORMATION (continued) Property Address: !°„� �e�faG C Pr le- vo ,! Owner: Ciy,, -/7-e, 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, number, dimensions: overflow cesspool, number: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,etc.) CESSPOOLS:-1-4/'Y. (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) 4 Materials of construction: Dimensions: Depth of solids: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation; etc.) .._.._.�...�._.......r.�..wn•.,rw-wsi.�•r+.r.nrw�r„�..--.��-.-.��n«-..-....-�.��-...-.-.�.:-r�-,-...r.,...r..�----- -_........ ........�.._....�-,-i.._. ......-..-. .-._-....-..�-.mow+.... -_�._ .. n +i -K- •r.r (revised 8/15/95) :. YV ��'�'i'.,S�,FLS.C:'1d+1'1"4'�hb-�.I.-1�i3°.•Yd-i}:•Tl '.N..71' cJf.tgrrt}�'ti;4.a��(,`Y4;..fit�,t:�.rL'i, SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) /E�-✓"/EGG t' �S �'�f r l/� ��P Property Address: Owner: 09C; P Date of Inspection: G �'� dy j SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' ..... ....... � Ke� sF a M 1 ,f t DEPTH TO GROUNDWATER Depth to groundwater: 6 feet f method of determi nation or approximation: ximation: �9 72 _ �... (revised 8/15/95) —- - :_ .;.....';�j"i�.._."' ft't/5r 1 N;d,� :.ili?ht..iir.: .. M...r�AiN .�;�?';fl: �...,�'•°ti �h..;6i�: . AT10N ` SEWAGE PERMIT; N0' lO C 3o r VILLAGE INSTALLER'S NAME i ADDRESS MA 'o S U 1 L D E N OR OWNER DATE PERMIT ISSUED QAtE COMPLIANCE ISSUED Q a SCMVW'llnloo'9soZxo9'Od - - - - - - - 7MS3SI /Y90NO15WOY y — I d - SI10I.LUAONNI'1NI'IH2If1SD�.LIHO7IV }y. 31111 .. .133HS 96Z6-Bz4(8DS)xed - I -'1 I hI I_I - .a3lYOS �!i I%QI I�il rb4�Y1 9kl 61 Zt-8Z6190S) rZ 1 AS NMYHO SNOISIA3tl _:.;ol-SNOI�d/�ory3� -,ry du v -iO3ro8a .3ivO { II I u=7d === _ 9 ft -- - - a. aAz --I r. _ - I Z. Pvt 13 � a 2 fA-3rGS I t z �waa 41 C( 9 —44 i6 I- qZl a I T:-.:1 r I lsti� /M rMrrd� A a z a � I 14 Ll IT- 14 IV � �, . �o t I ,ems,,-� • I hg.�Z _ � ,� . p� _ �L. \1 . i+— / I REVISIONS: TEST PIT DA TA = DATE CF TEST(NG: -- PERC. TEST DATA : SEPT/C TANK DETAIL : sizE- _ _ GAL. DIST. BOX DETAIL : LEACHING FACILITY DETAIL: NO. DATE TEST BY —.— ---------- ------ DATE OF TESTING' TANK TO CONFORM TO TITLE 5 REQUIREMENTS. TO CONFORM TO TITLE 5 REOUIREMENTS. T f' WITNESSED BY: ------------- - TEST BY -------- - - -- - ----- NO. OF OUTLETS: -- --------- --- -- - - -- W/TNESSED BY - --- _ ---- -- �,' .�a�., I� ,i�, .�,. .�t� -- - - -- - --- — i 5�,r i/i 1n3ii>ni r a . \\�! v' �� - - REMOVEABL E COVER /2 , _ MANHOL BROUGHT TO . :_. . o ,• FINISH GRADE. . . .. .. 2 PEASTOA(E /2"MIN. -- -- -- -- - -- ---- - -- °• - 3 CLEAR 3 CLEAR o -- �iLCa4M FILL q, -.'�f-1� OUTLET PIPES a 6 MIN. 2 M!N• 6 MG1I ° , AS REOU/RED DEPTH OF TEST: -__ - __._ — _-� - �- I t +. A I - INLET_ l II \ t 1 l --- - RATE �/ '_/ C fi�.: .- `� - /O"M/N I r� l i`` 1 D/ST. - -- -- ` car•! NtJT INLET TEE - --- — OUrLEr TEE ,L 1� �� / t BOX .zY 4 C.I. . ` w- GAL. INLET AND OUTLET 4'0" MINIMUM OUTLET TEE DEPTH � " 24,f I TEES TO BE CAST L IOUID DEPTH 14 AT LIQUID DEPTH OF 4 i 2 6 r PTIC I PRECAST OR BLACK -- --- --- -- --- - ---- --- - --- IRON, SCHEO. 40 /9" " " " 5' CONS i, : SEEPAGE P/T -- DEPrH OF TESr� 24 „ 6' — /o' t� ► . . ---- ------- P.V.C. OR CAST IN ,, o a „� o ,.o: C CONCRETE � t PLACE CONCRETE 29 T' . �.._� MIN. RATE.- - -- CONCRETE 34" " " " " B' BOTTOM ON LEVEL STABLEBASE CONSTRUC /ON __ --- -------- -- _- -- ---- ►, (WATERY/GHTI ' INLET TEE PROVIDED WHERE SLOPE FOUNDAr/ON • t OF INLET PIPE EXCEEDS O.OB / OR BOTTOM OF TANK ON LEVEL STABLE BASE ` TANK rO BEABLE TO WITHSTAND IN A PUMPED SYSTEM. 20 M/N. H-/0 L 04 D I NG UNL ESS UNDER -- / 'WASHED STONE _, - - — --- ---- ---- -- - - - - - -- - - - --- --- -- ----- --- PAVEMENT OR/N DRIVE. H-20 t v LOAD/NG UNDER PAVEMENT OR / -- t NOTES : PLAN VIEW INVERT ELEVA T/ONS: I. THIS PLAN IS FOR THE DESIGN AND CONSTRUCT/ON OF THE SEWAGE DISPOSAL FACIL/T Y ONL Y. SCALE : / INV. AT BUILDING _ �• 3 s ox .a4 2. AL L CONSTRUCT/ON METHODS AND MATERIALS SHALL CONFORM TO IN AT SEPTIC TANK(IN) MASS. D.E.Q.E. TITLE 5 AND THE _ .. y BOARD OF a + :•� ` - --- /NV. AT SEPTIC TANK(GYJT) s.�� _ Fkh�,, { � HEALTH REGULATIONS. �` -- -- - `x ► v,.rl,+,rx 'a �, THE' .5�r f'T14:' .✓r�?'e�M :���5'�'1.' .�.Hc,}icf,V /S �'it D..%EC 7" ".'^ �::u''r-?:=.i.:' c�P�'" hE�E.T1Y / pJ4t,i/ l '�:.' /1» ,L^�f: �'17 C`J/�` ..5 . i H L?�+:..r f! G'�i'. .��'J�.S ,~�'.:, a `�`•�•-5� V-i�`,' ,I . ,, IN ATD/sT Box(/N> gar: „ � .�.J,d� '""4�.R/`ri/ii:r L' •�r ;%�'1� ,���.�Fo?p. /V C r!t'"Y .?"tic:= ,�3G>�.R L� ::�G' {•i��.. r`r>' _ - c-,/vU,�' �.'�i'.'4!R Ta C'u vs TN Jti rfCJA✓, - - �,« ';i f ,' � '` "� AT LEACHING FACILITY: 2 4.A BOSTON, MASS. WORCESTER, MASS. \ AT BOTTOM OFPIT- `3 , t HALIFAX, MASS. NORWELL, MASS. BEDFORD, MASS. LEXINGTON, MASS. HYANNIS, MASS. MANSFIELD, MASS. CRANSTON, R.I. DERRY, N.H. B C 0 77 ... 710 z8 ' DESIGN DA TA DESIGN FLOW- _4 a-9 I r T'N ti I -- E3 !E; I f ',� I i REQUIRED SEPTIC TANK: 66D GAL. , ' A SEPTIC TANK PROVIDED = /�5G GAL. CAPE COD SURVEY ,`uS ; CONSULTANTS z7 / :, REQUIRED SIZE LEACHING FACILITY• _— --__---- ------- _____ 76 ENTERPRISE ROAD H YA N N I S, MASS. 02601 t � �•- - �-t��x - , � '' � 1 , __--__ ------ — --- (617) 775 -7155 775-7815 .A1W. 'tt E `rt� �RES, � t I J �r z a.z a / / , I I ►. - - - - - - - --- DIVISION OF BOSTON SURVEY CONSULTANTS INC. SIZE OF LEACHING FAC/L/rYPROV/DED: ;ENGINEERING • SURVEYING • PLANNING F 7- TYPE OF SYSTEM: J-�-- TITLE: Wl2 s row ir 1 I © "? / �"' 1 1 � h 0 :5 t p€urA►..L !'7 a 5 rm .�. Z�t'..I~'Li 1 }- = 44 5 u Y i� C # � --- •'ate . , ( � � 'l� I � ::y•.t••!9rzi---__.�".1._��'_�l,/1 .' �D!S�_ G '. t (nh L a 9 i -- --- --- SEWAGE DISPOSAL SYSTEM -� — - - - - - --------- - x PD DESIGN T-o 4!%-- 2 C'�o 4.W p z o�p I I I `�4 G o T s, VIP,Ir_ ,&C _7 e--Ai-- 1Z .47 l � 111b LOCUS PLAN^ --'' �f P�y-7- { FOR: SCALE: AS SHOWN METERS FEET 0 DATE: N, COMP./DESIGN: Aw CHECK: ��� DATUM' DRAWN: cF a l��:: . ELF{/fIrICS:V;�`" �"/,✓Cith+./1' 7-1 -r-HAr W7,16AM4. FIELD: car c, IrR7-IC114 �OA-7-UM, - ,CM uss-D ,. xrrps srwn o,v ,'24 iR FILE NO: �Ev 3.34 DWG. NO: �5 JOB NO: : ! ` , 06. SHEET: I OF: I