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HomeMy WebLinkAbout0188 CAMELBACK ROAD - Health 188 Camelback Road,Marstons Mills A= fit f�f9 II{4 f. c. i; I i Commonwealth of Massachusetts Title 5 Official Inspection Form �a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 188 Camelback Road ru.� Property Addressti Anne Holmes ` Owner Owner's Name 92. y. information is Marstons Mills Ma 02648 1-21-2019 required for every page. City/Town State Zip Code Date of Inspection _ 01 Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Impg out forms When fillip out f A. Inspector Information on the computer, Brett Hickey use only the tab key to move your Name of Inspector cursor-do not B&B Excavation use the return Company Name key. 374 Route 130 ry Company Address Sandwich Ma 02563 City/Town State Zip Code rim (508)477-0653 S113747 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.After conducting this inspection I have determined that the system: 1. ❑■ Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails L/ `.. ✓ 1-21-19 Inspector's Nignature 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 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 form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: 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. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 .. Commonwealth of Massachusetts Title 5 Official Inspection Form ~ I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 188 Camelback Road U- Property Address Anne Holmes Owner Owner's Name information is Marstons Mills Ma 02648 1-21-2019 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) 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: The system was in working order at the time of inspection. 2) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection,if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is les's than 20'years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 18 Commonwealth of Massachusetts �e Title 5 Official Inspection Form I'1 Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 188 Camelback Road v Property Address Anne(Holmes Owner Owner's Name information is Marstons Mills Ma 02648 1-21-2019 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts r� Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 188 Camelback Road Property Address Anne Holmes Owner Owner's Name information is Marstons Mills Ma 02648 1-21-2019 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ 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 b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ a Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ❑ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 Commonwealth of Massachusetts �e Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 188 Camelback Road Property Address Anne Holmes Owner Owner's Name information is Marstons Mills Ma 02648 1-21-2019 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ El Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ a Liquid depth in cesspool is less than 6"below invert or available volume is less than '/day flow ❑ 0 Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ El Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ El Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ 0 Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ El Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ 0 Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ a The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ElThe system fails. I have determined that one or more of the above failure El criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section CA. 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 c Commonwealth of Massachusetts ip Title 5 Official Inspection Form Ia Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 188 Camelback Road Property Address Anne Holmes Owner Owner's Name information is Marstons Mills Ma 02648 1-21-2019 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered"yes"to any question in Section C.5 the system is considered a significant threat, or answered"yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes" or"no"for each of the following for all inspections: Yes No ❑ 0 Pumping information was provided by the owner, occupant, or Board of Health ❑ 0 Were any of the system components pumped out in the previous two weeks? 0 ❑ Has the system received normal flows in the previous two week period? ❑ a Have large volumes of water been introduced to the system recently or as part of this inspection? El ❑ Were as built plans of the system obtained and examined?(If they were not available note as N/A) x Was the facility or dwelling inspected for signs of sewage back u ? ❑ ❑ Y 9 P 9 9 p 0 ❑ Was the site inspected for signs of break out? 0 ❑ Were all system components, excluding the SAS, located on site? El ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: El ❑ Existing information. For example, a plan at the Board of Health. ❑ a Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] l5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 18 Commonwealth of Massachusetts �n Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 188 Camelback Road V� Property Address Anne Holmes Owner Owner's Name information is Marstons Mills Ma 02648 1-21-2019 required for every page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: 4 4 Number of bedrooms(design): Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 440/gpd Description: 3 Number of current residents: Does residence have a garbage grinder? ❑ Yes 0 No Does residence have a water treatment unit? ❑ Yes 0 No If yes, discharges to: Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes 0 No information in this report.) Laundry system inspected? ❑ Yes RI No Seasonal use? ❑ Yes Q No Water meter readings, if available(last 2 years usage (gpd)): See below Detail: 2017-82,000gallons 2018-56,000gallons Sump pump? ❑ Yes ❑■ No current Last date of occupancy: Date t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments l 188 Camelback Road V Property Address Anne Holmes Owner Owner's Name information is Marstons Mills Ma 02648 1-21-2019 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: NA Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: p 9 Owner- date of last pump is unknown Source of information: Was system pumped as part of the inspection? ❑ Yes V No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 16 Commonwealth of Massachusetts �d ,�F Title 5 Official Inspection Form la Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 188 Camelback Road v Property Address Anne Holmes Owner Owner's Name information is Marstons Mills Ma 02648 1-21-2019 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: El Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest 'inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: 1986 Were sewage odors detected when arriving at the site? ❑ Yes ❑■ No 5. Building Sewer(locate on site plan): 2' Depth below grade: feet Material of construction: ❑ cast iron 40 PVC ❑other(explain): Town water Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 9 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 188 Camelback Road u Property Address Anne Holmes Owner Owner's Name information is Marstons Mills Ma 02648 1-21-2019 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): 1' Depth below grade: feet Material of construction: M concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No 1 Dimensions: 500gallons 811 Sludge depth: 2811 Distance from top of sludge to bottom of outlet tee or baffle 211 Scum thickness 611 Distance from top of scum to top of outlet tee or baffle 14" Distance from bottom of scum to bottom of outlet tee or baffle measured How were dimensions determined? Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): The tank was in workingorder at the time of inspection. The tank is in need of pumping P P P 9 at this time and should be pumped every two years for maintenance. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form � °I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 188 Camelback Road Property Address Anne Holmes Owner Owner's Name information is Marstons Mills Ma 02648 1-21-2019 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap(locate on site plan): NA Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): NA Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc•rev.7262018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 188 Camelback Road �u= Property Address Anne Holmes Owner Owner's Name information is Marstons Mills Ma 02648 1-21-2019 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.)" 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box(if present must be opened) (locate on site plan): 0" Depth of liquid level above outlet invert Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): The d-box was in working order at the time of inspection. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts �d Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 188 Camelback Road Property Address Anne Holmes Owner Owner's Name information is Marstons Mills Ma 02648 1-21-2019 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes Q No" Alarms in working order: ❑ Yes 0 No` Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): NA *iIf pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: El leaching pits number: (2) 61X6' ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 188 Camelback Road L Property Address Anne Holmes Owner Owner's Name information is Marstons Mills Ma 02648 1-21-2019 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): The leaching was in passing condition. Both pits were dry with staining 1/2 way up from the bottom. 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): NA Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 188 Camelback Road Property Address Anne Holmes Owner Owner's Name information is Marstons Mills Ma 02648 1-21-2019 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. Privy(locate on site plan): Materials of construction: NA Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.726/2018 Title 6 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 188 Camelback Road Property Address Anne Holmes Owner Owner's Name information is Marstons Mills Ma 02648 1-21-2019 required for every page.e. City/Town State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑■ hand-sketch in the area below ❑ drawing attached separately 1, ` YLLYr14G3R' s 1 3z �/ 7 � +l�S9C7R`S AV` >L+OT 1 S8F"1 G'T'AN' k C:XP1l CITY, '47 � x yy8��wxun y.�.. ; yyam�' H�wwyy yy yy s .IDDA ��.� 36 .+tt.x • � i* \un �1 k Zap, i��i ...�ir Y F I , x� .r � r � 0 t y 46 +�' F a•R W S A ' t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18 Commonwealth of Massachusetts �s Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 188 Camelback Road Property Address Anne Holmes Owner Owners Name information is Marstons Mills Ma 02648 1-21-2019 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ❑■ Check Slope © Surface water ❑ Check cellar ■❑ Shallow wells Estimated depth to high ground water: NoGW@12' feet Please indicate all methods used to determine the high ground water elevation: 0 Obtained from system design plans on record 6-24-86 If checked, date of design plan reviewed: Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: A plan on file with the Board of Health was used. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 18 Commonwealth of Massachusetts ,p Title 5 Official Inspection Form °l Subsurface Sewage Disposal System Form -Not for Voluntary Assessments u 188 Camelback Road Property Address Anne Holmes Owner Owner's Name information is Marstons Mills Ma 02648 1-21-2019 required for every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ❑■ A. Inspector Information: Complete.all fields in this section. �■ B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ❑■ C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria)and 6(Checklist)completed ❑■ D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 G TOWN OF BARNSTABLE c LOCATION �a CA�hL� �A�C SEWAGE JTE.LAGE 1M• ✓hips ASSESSOR'S MAP & LOT y 7' �y INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY 1S0 D// p LEACHING FACIL=,:.,;(type) (size) 9,4/. NO.OF BEDROOMS BUILDER OR OWNER PERMTTDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility), Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leac ng facility Feet Furnished by �i►t .� • / A_ O i 3 s a3 - 3 (,(, T7 y s3 sy y , TOWN OF BARNSTABLE LOCATION ld�7 49iYf! C V/41 SEWAGE # V VIi.LAGEVUqLS��yllASSESSOR'S MAP LOT 7 INSTALLER'S NAME & PHONE NO. Pf <O ��PD / •�9 SEPTIC TANK CAPACITY �®O LEACHING FACILITY:(type) JOO� NO. OF BEDROOMS 4_PRIVATE WELL O PUBLIC WATER BUILDER OR OWNER `J PA CIOA~41' DATE PERMIT ISSUED: :a �M DATE .COZiPLIANGE. ISSUED:� VARIANCE GRANTER: Yes ••No �N Q,� � �� � �Q ��' Q c� � 3� � �� �� I 0 r,BN � � �. . .:. _ .. .. _. �� .. ,, TOWN OF BARNSTABLE LOCATION SEWAGE # VILLAGE ASSESSOR'S MAP& LOT "1 — y2 INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPAC= LEACHING FACEL=: (type) � t (size) 6�G NO.OF BEDROOMS BUILDER OR OWNER �y PERMUDATE: COMPLIANCE DATE: D 1a V A? Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by ._ 7� t L� £S �£ �h � n� I . . o .... ...N � / Fus ...._ THE COMMONWEALTH OF MASSACHUSE'iTTS BOAR® OF HEA TH ~ OF Appfiration for Uhiposal Worko Tonstrnrtion ramit oitD �f Application is hereby made for a Permit to Construct (-/-Y or Repair ( ) an Individual Sewage Disposal Systemr Location-Ad Tess y / ,or L�oJlN,o.,/ y' /� ..............�..! ....J....A.'L-1 f ay.. ............................ FW1 •.......••S� !�. .... 11. .I�.LJ = ddress (J� Installer Address Type of Building Size Lot.,0k-Fl�O.Sq. feet V Dwelling—No. of Bedrooms...........2------ ------------•-----.-Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building No. of persons........6---------------- Showers (141,) — Cafeteria ( ) Otherfix purer---------------- -.........•............................ W Design Flow............ .......................gallons per person of d�y. Total ' ly figW......, ......................gal�,ons./ WSeptic Tank—Liquid capacity j gallons Length..-.l...-.. Width /./Q__ Diameter________________ Depth... . x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No........./.......... Diameter........ ....... Depth below inlet------- C�......... Total leaching area... .sq. ft. Z Other Distribution box ( 1 ) Dosing tank // '-' Percolation Test Results Performed by._... � /.,/,lY ,l11� 1 �. Date._.._._✓_ .- ,,� aTest Pit No. 1................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 Ovate •-------•- ....•- ....• .... . � �n 0 Description of Soil-----••--•--..04 -�.�.��-----����1.��_..-.... . .Z----------------------------------- x V -------------------------- ------- ------------------------ ------------------------------------------- •--------------------------------------------------------- ---.---------------------- ----•---.------- W -•----••------------------•------•--------. ---•---------------------•------------•-•-•-•------•--------------•--•-------•--•------•---•-•••-•-•--•••--•----•-•--••-•-••-•-••-•-•-----•---••. VNature 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 iITL L 5 of the State Sanitary Code— The undersigned further agrees not to place the system in 70petion until rti to 0 ompliance has bee issued b he d of Ith ......---•--• -----------------------------•. �cation Approved BY-------- ••-•-•••-•-•........ ....-- --•-----------•---•-•-••---•----•-------•-• .......--- Date Application Disapproved for the following reasons------------------•---------•--••------------------- .......................................................... ........................................................................................................................................................................................................ Date Permit No......... - ._.. Issued........................................................ �,� Date .................... THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH Appliratiun for Disposal Works Tonstrnrtion Prrmit Application is hereby made for a Permit to Construct (�) or Repair ( ) an Individual Sewage Disposal -System off t .......... _.... �. !:- = = -� 4 Location Address or Lot No.- r l ��!f'1.� ,i'7 f T f �'�� tr ! !J/t I/(i (.: x l -_.... •...._Vim. .• - -_ ........................................................... _.._......._.. . ..._....... ................... ........................................ ?� l} i1 ^ 'ftOwn!7 i f r 1 f address "- • r i' f )_ .............. ... t ..... ...................--- ....................................7!`lA.[.................................................. Installer Address -1 d e of Building _Type g �"� Size Lot..._-..^_._.%-----------Sq. feet� aDwelling—No. of Bedrooms........_h.............................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building h,_1A (_6 x, No. of persons.......4................. Showers ( ! ) — Cafeteria Otherfixt es --------------_-_----- ------------------------...-------•-- W Design Flow.._......__1 ................j_gallons per person.per dory. Total daily flow..._..__J_ .1 ._...._.._......._.___gallons. WSeptic Tank—Liquid ca.pacity,t�.��t.gallons Length._`_:�.r.. Width/ ..Z%__. 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 ( ) '� -t" /*(/ ? :_1 r .. Date.........................................' a Percolation Test Results Performed by ... E.. _. Test Pit No. 1----------------minutes per inch Depth of Test Pit.................... Depth to ground water................... A✓ 'L✓r,�i t ,� fsl Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water..._....._.........._... ODescription of Soil............ .4•1 t-.�..........................'� .0�%'_C: �' ,a ;%Z)-........... x r� . .. d .......:. -•- a� �i ----------------------------•------------------------....... V •----------------•---------------...-----------------------•--•---------------- W 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 TITIL 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Cer ipzate Co fiance has been issued by t e.board of health. r lLc.�? v/ Signed ef7......... Aplir tion Approved BY •--- '............. ............... Date Application Disapproved for the following reasons---------------------•--•---........--------------------•--------------------------•---------------------•------- ...................................................... •------•--•--•-------•-•--•------...........-------•----•--------•-•--•--------•-------•-•--••-•-------••-•-•-••-----------------•-••---•--•-•--- Permit No. SY . . Issued........................................... Date ....... ` Date THE COMMONWEALTH OF MASSACHUSETTS s BOARD OF HEALTH: .. ........ Treifiratr of ToutpliFanrr _ . _ _ THIS IS TO CERTIFY, That the Individual Sewage Disposal System constr cted ( ) or Repaired ( ) by..................................................................................................c r�-f_ f.�t'!� �_ '1 J�i ( - Z. �' ................................................ t �? r Installer K - ................................-............................... - • ......-----•-- • •-- has been installed in accordance with the provisions of TI F 5 of Tihe,S Sanitary Cody--a itrI the application for Disposal Works Construction Permit No............. _.___......._... e dated_....____.-. -_/__...._ 1`�-----------------•-- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE.=%................... ................ ...-.. .`�.c-:... ...................... Inspector_..... _........... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH No��...61g>....... FEE........................ Disposal Works. Tonutriirtiun Prrutit !I Permission is hereby granted..... f"_ / "� -' ? t� . ............•-`.....Z.....-••---•--•--•••---•••-------•-••--••-•-•---•-....---•-...............----......... to Construct (- ) or Repair ( ) an Individual Sewage Disposal,System at No..:-{ f1 -A` /t c7 - " . , t- '11�, \/t t` i- ''• /// ' mot: ! ,.. = - = - / ., _• Street r' t/•rr�. as shown on the application for Disposal Works Construction Permit No...............:n_.. at _.. ._..... ....................... (. Board of Health DATE.................. .................................................... FORM 1255 A. M. SULKIN, INC., BOSTON AN . v am Assessor's map and lot number ... ...... p�®� p � ���•" f � Q..��® 'g� ��AA9Mu�1.I �'� THE TLE 5 �QyoF Toff Sewage Permit number ..:-, .•p MENTAL CODF- A� ''� ggnn, r ���+'`?'�} ,'l�r,.� U�a'•� a�>i .9 Z B6S39T/IBLE, i House number ........................... .. ........................ ,;..... .. 1639.' 0m� OMAR A, TOWN OF B,; ► .NSTABLE BUILDING _ _ NSPECTOR APPLICATION FOR PERMIT TO ..:..... ��(` .C..:.I...................................................................... ............. ,,,,^^�� ` ............ !Y. .. ............................................ TYPE OF CONSTRUCTION ..... ,..,.....1.a.......19.��.� TO THE INSPECTOR OF BUILDINGS: j �lJ The undersigned hereby applies for Tat permit according to the following information: y� Location ..... .Q.. ..............� 1`.. ..........C... ` ......... ProposedUse ....... ...t. .�� ..r..a...... -- Y1.. .`\I......... .�A.l.. ..` ,. ... 1. . .................................. Zoning District .........................Fire District ma- °v .. %-�' k Name of Owner �...`.\C.�� ......Cm .`....... -. ....Address,� .�..... . . ....�C.:...:....4?.:���M�L Name of Builder �!1+�. .......'.. 4 c,�" K4��dress �1.../7 Name of Architect -�.�. . ..��.C ''�V�.......................Address ....5 . .. �!� .U.��t. �,. ...... Number of Rooms ..` .... �.....�.3�'�\..... 0.)X..Foundation .'(... .. ... ... �,�1 .. �`ufC. f ;q Exterior1. ,.. T�1.;�{.... .`!�1.Y� �,�C............_ Roofing !: �1 ,.1 .... .�. .�.�. .��9............... Floors .E' `. .. .. .` ,11.�.......................................Interior .............................................. Heating ...... H...L,Q. ..................................Plumbing d. ( � Fireplace . ......... ..... 1... .. > . .Approximate Cost ...........! ...c .:... ..C.... ....... Definitive Plan Approved by Planning Board -----t,-�---------------------19�- --. .Area `S•- �......`..Z. o. Diagram of Lot and Building with Dimensions Fee ` ��e........................ SUBJECT TO APPROVAL OF BOARD OF HEALTH } t o° e� OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS I hereby agree to conform to all the Rules and Regulations the Town of Barnstable regarding the above construction. Name . `.:............................................ Construction Supervisor's License � �� Town of Barnstable ,MN . ' Regulatory Services Department Public Health Division 200 Main Street,Hyannis MA 02601 Office: 508-8624644 Thomas F.Geiler,Director FAX: 508-790-6304 Thomas A.McKean,CHO October 11, 2006 RE: 188L Camelback Road, Marstons.Mills To Whom It May Concern: In accordance with the Building Permit#30874 dated June 16, 1987, and in accordance.to the septic "As Built" card, a four bedroom house.was constructed and a septic was built for a four bedroom. The property at 188 Camelback Road in Marstons Mills, MA, is approved as a four bedroom by the Public Health Division of the Town of Barnstable. Sincerely yours, T omas A. McKean TOWN OF BARNSTABLE LOCATION O Idl l.►9 �// SEWAGE # y . � /I')j� C . I t •VILLAGE �` ASSESSOR'S MAP LOT IINSTALLER'S NAME & PRONE NO. f f a ��PQ �f!//f•� � J !\&SEPTIC TANK CAPACITY. �o o LEACHING FACILITY:(tJ6� ) ,©Ov NO. OF BEDROOMS PRIVATE WELL O PUBLIC WATER BUILDER OR OWNER �'+¢ DATE PERMIT ISSUED: y DATE .COUPLIANCE ISSUEDi VARIANCE GRANTED: Yes No �r NO M TII a. �lJ DING . R. -+Y a_ OWN QF BARNSTABLE, MASSACHUSETTS , s -� I I"T 1.49= ' y DATE _ iii:'i? Lfi 19 7 PERMIT �IPPt ANT DLTtY':fA T}PP7}T;ar{(j 14 ADDRESS I_ 1.1111 Al:^ LA.ritsv T ,n• t U F, Ti(STREET) l`Or) t .�� t � (9CONTR'S IICEN5E1 r PERMIT TO Rtsy?rl �#w:.??{rta ( 1 ) STORY - na. NUMBER OF \\ Il°' � rrF` 'I1`.� DWELLING UNITS .1_zy, (TYPE OF.IMPR OVEMF.N N _ (PROP SED USE) - �\ AT' 4R C sa tic 4i 1 c ZONING r tr(LOCATICNI i"F (NO.) (STREET) DISTR ICT BETWEEN`. "„ AND (CROSS STREET) - (CROSS STREET) �;�'-r�;r`.. •SUBDIVISION a,s_ .. LOT B LOTLOCK SIZE i BUILDING IS.TO BED FT, WIDE BY FT. LONG BY FT. IN HEIGHT AND SHALL CONFORM IN CONSTRUCTION TO TYPE USE GROUP : BASEMENT WALLS OR FOUNDATION (TYPE) REMARKS:' �N_Wi3ti.E: j!tr$(?-G1(U AREA OR aL�:uU • tv. ESTIMATED COST �}f' VOLUME 137b 6Q PERMIT , FEE SIG.00 ':a - (CUBIC/SQUARE FEET)' _ - OWNER Theo ,consDructio'n Co. ADDRESS 24 CY �c�t i�Utld l�ic1V@.9 SOUL ': ii 'i y BUILDING DEPT. By THIS PERMIT.'.CONVEYS NO RIGHT TO OCCUPY ANY STREET, ALLEY OR SIDEWALK OR ANY PART THEREOF. EITHER TEMPORARILY OR 'PERMANENTLY. ENCROACHMENTS ON PUBLIC PROPERTY, NOT SPECIFICALLY. PERMITTED UNDER THE BUILDING CODE, MUST BE AP- -.,PROVED:6Yi THE JURISDICTION. STREET-OR ALLEY GRADES AS WELL AS DEPTH AND LOCATION OF PUBLIC SEWERS MAY BE OBTAINED �`,FROM'THE DEPARTMENT OF PUBLIC WORKS. THE ISSUANCE OF THIS PERMIT DOES NOT RELEASE THE APPLICANT FROM THE CONDITIONS :.OF-ANY,',APPLICABLE SUBDIVISION.RESTRICTIONS. MINJM INSPECTIONS ...THREE IR CALL gpPROVED PLANS MUST BE RETAINED ON JOB AND THIS WHERE APPLICABLE SEPARATE '.INSP.ECTIONS REQUIRED FOR � �+ y.., ::;A_LL,;CONSTRUCTION WORK: C'A`�2D,;KEPT POSTED UNTIL FINAL INSPECTION HAS BEEN PERMITS ARE REQUIRED .FOR MAD'y ? ELECTRICAL, PLUMBING AND .1'. FOUNDATIONS'ORFOOTINGS. � EWHERE A CERTIFICATE OF OCCUPANCY IS RE- MECHANICAL INSTALLATIONS. .;.`PRIOR TO COVERING STRUCTURAL QUIRED,SUCH BUILDING SHALL NOT BE OCCUPIED UNTIL .•`, > 'MINAL INSPECTION DY TION.O LATHE FINAL INSPECTION HAS BEEN MADE. ':3.:FINAL'INSPECTION BEFORE - OCCUPANCY - s = .POST THIS CARD SO IT IS VISIBLE FRONT• STREET �� <,""% .BUILDING INSPECTION APPROVALS PLUMBING INSPECTION APPROVALS,„: ELECTRICAL INSPECTION APPROVALS e. 2 2 ^— � 2 l Ale"? 3SL.S HEATING INSPECTION APPROVALS ENGINEERING DEPARTMENT' OTHER 2 qhe Q BOARD OF HEALTH a /OAK SHALL t jOT PROCEED UNTIL THE INSPEC• PERMIT 'W!L L BECOME NULL AND VOID I F CONSTRUCTION INSPECTIONS INDICATED ON THIS CARD CAN BE JR HAS APPROVED THE VARIODUS STAGES OF I WORK IS NOT STARTED WITHIN SIX MONTHS OF DATE THE ONSTRUCTION& PERMIT IS ISSUED AS N ARRANGED,FOR BY TELEPHONE O WRITTEN $-J EDf*BOVE. j NOTIFICATION. fib:,`�.:-. -', � .. ►• ._� �. 14'-0" 14'-6" Kneewall 4'-0" co Bath 11=6" 2'--2 N a 2-4"x 6'-8" r-s" s Bedroom New insulation& sheetrock co N Co N O fo C\� �? N Hall N Storage o N Bedroom 3,o„ �` cn � � � 4'0"x 6'-8" 4'0"x 6'8" ' 7,FX-10"1—� X-711 " 14 40" 2'-4"x 6'-8" 14'10" �? `r .2-1j �' li ^loSt. I� '-6"x 6'-8" ----------- 14-1"111 8'-9" Kneewall 13'--10" I. 40'-0" 188 Camelback SECOND FLOOR Marston Mills, MA + f \ `ry COMMONWEALTH OF MASSACHUSETTS t; .ii34.'t4.�� EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICI.AL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 188 Camelback Road Marstons Mills. MA 02648 Owner's Name: Carolyn Todd Owner's Address: SZ .3;t Co Date of Inspection: Aul;ust 30, 2005 Name of Inspector: (Please Print) James M. Ford Company Name: James M. Ford Mailing Address: P.O.Box 49 Osterville,MA 02655-0049 Telephone Number: (508)862-9400 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and.complete as of the time,of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP -approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ✓ Passes Conditionally Passes Need urther Evaluation by the Local Approving Authority Fails Inspector's Signature- Date: September 7, 2005 The system inspector shall sub i a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completi g 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. Title 5 Inspection Form 6/15/2000 page 1 Page 2 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 188 Camelback Road Marston Mills. MA Owner: Carolyn Todd Date of Inspection: August 30, 2005 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: ✓ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not 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 ti Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 188 Camelback Road Marstons Mills, MA Owner: Carolyn Todd Date of Inspection: August 30, 2005 C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone I of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: 3 Page 4 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 188 Camelback Road Marston Mills, MA Owner: Carolyn Todd Date of Inspection: Auyust 30, 2005 D. System Failure Criteria applicable to all systems: You must indicate either"yes"or"no"to each of the following for all inspections: Yes No ✓ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ✓ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ✓ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ✓ Liquid depth in cesspool is less than 6"below invert or available volume is less than ''/z day flow ✓ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped_. ✓ Any portion of the SAS,cesspool or privy is below high ground water elevation. ✓ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ✓ Any portion of a cesspool or privy is within a Zone 1 of a public well. ✓ Any portion of a cesspool or privy is within 50 feet of a private water supply well. ✓ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] No (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large System: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) Yes No the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes"in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 4 Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 188 Camelback Road Marston Mills. MA Owner: Carolyn Todd Date of Inspection: August 30, 2005 Check if the following have been done: You must indicate"yes"or"no"as to each of the following: Yes No ✓ Pumping information was provided by the owner,occupant,or Board of Health ✓ Were any of the system components pumped out in the previous two weeks? ✓ _ Has the system received normal flows in the previous two week period? ✓ Have large volumes of water been introduced to the system recently or as part of this inspection? ✓ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ✓ Was the facility or dwelling inspected for signs of sewage back up? ✓ _ Was the site inspected for signs of break out? ✓ _ Were all system components,excluding the SAS,located on site? ✓ _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? ✓ _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes No ✓ _ Existing information. For example,a plan at the Board of Health. ✓ - Detennined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)]. 5 Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 188 Camelback Road Marston Mills. MA Owner: Carolyn Todd Date of Inspection: Auzust 30, 2005 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 4 Number of bedrooms(actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 220 Number of current residents: 1 Does residence have a garbage grinder(yes or no): No Is laundry on a separate sewage system(yes or no): n/a [if yes separate inspection required] Laundry system inspected(yes or no): No Seasonal use(yes or no): No Water meter readings, if available(last 2 years usage(gpd)): Unavailable Sump Pump(yes or no): No Last date of occupancy: Currently occupied COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no) Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Pumped 4 years ago-per owner Was system pumped as part of the inspection(yes or no): No If yes,volume pumped: _gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM Septic tank, distribution box,soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no) (if yes,attach previous inspection records,if any) Innovative/A.lternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight Tank Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: Installed on 8124187_per as built card Were sewage odors detected when arriving at the site(yes or no): No 6 Page 7 of l 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 188 Canielback Road Marstons Mills. MA Owner: Carolyn Todd Date of Inspection: August 30, 2005 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction: _cast iron _40 PVC _other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: ✓ (locate on site plan) Depth below grade: 16" Material of construction: ✓ concrete _metal _fiberglass _polyethylene _other(explain) If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of certificate) Dimensions: 1500 oral. Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle: 30" Scum thickness: 2" Distance from top of scum to top of outlet tee or baffle: 6" Distance from bottom of scum to bottom of outlet tee or baffle: 10" How were dimensions determined: Measuring stick Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): Tees were present. The liquid level was even with the outlet invert. There did not appear to be any signs of leakage. GREASE TRAP: None (locate on site plan) Depth below grade: Material of construction: _concrete _metal _fiberglass _polyethylene _other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments (on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): 7 Page 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 188 Camelback Road Marstons Mills. MA Owner: Carolyn Todd Date of Inspection: .August 30. 2005 TIGHT or HOLDING TANK: None (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: _concrete _metal _fiberglass _polyethylene _other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: ✓ (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Even Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): . The D-box was level. No soi.ids were present. PUMP CHAMBER: None (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no) Continents(note condition of pump chamber,condition of pumps and appurtenances,etc.): 8 f Page 9 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 188 Camelback Road Marston Mills, MA Owner: Carolyn Todd Date of Inspection: August 30, 2005 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type ✓ leaching pits,number: 2-6'x 6'(1000 gal.) leaching chambers,number: leaching galleries,number: leaching trenches,number, length: leaching fields,number,dimensions: overflow cesspool,number: Innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): One pit 01) had 1'ofliguid on the bottom. The other pit(#2)was dry. There did not appear to be any signs of failure CESSPOOLS: None (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments (note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): PRIVY: None (locate on site plan) Materials of construction: Dimensions: Depth of solids: Commnents(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): 9 Page 10 of I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 188 Carnelback Road Marstons Mills. MA Owner: Carolyn Todd Date of Inspection: Auzust 30, 2005 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. � O y55-3 sy � 10 Page 11 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 188 Camelback Road Marstons Mills, MA Owner: Carolyn Todd Date of Inspection: August 30, 2005 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 30+/- feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) ✓ Checked with local Board of Health-explain: topographic and water contours naps Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: Using Barnstable topographic and water contours snaps, the reaps were showing approximately 30'+1-to ground water at this site. This report has been prepared and the system inspected and passed as of the date of inspection. This report is not a warranty or guarantee that the system will function properly in the future. There have been no warranties or guarantees, either expressed, written or implied, relating to the system, the inspection and/or this report. 11 l TROY WILLIAMS SEPTIC INSPECTIONS Certified by MA Department of Environmental Protection (508) 760-1819 40 Old Bass River Road South Dennis,MA 02660 cofmionwelatth of MOssachusetts Executive Office of EMOrmentai Affairs D M De artment of Environmental Protection %%=am F.Wald eaml, r "", XUII D"M&Struts cal-rd"104W SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION MG Fr,h 5 Property Address: 188 Ca ys, 6«`� /z�( Address of Owner. Ro 1st,�c4 L?e-K h cr Date of Inspection: I I /a c( /r, (if different) p Name of Inspector---7a yy W, ( /:CA ✓Y,S (j Y /�G✓Gv+ s c ✓a'C� Company Name,Address arfd Telephone Number: ,/ Sew uSJJL. Yercioo, C c, ►,�, . U6 6G6 _CERTIFICATION STATEMENT 1 certify that I have personally inspected the sewage disposal system at this address and that the infomtation 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' 9 110, Inspector's Signature: Date: 1.2 The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(3 says of Ak ing�i' N inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,'the inspector and =system owner<�Ralj s 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. , 9�� �+ INSPECTION SUMMARY: �`�• vR Check A. B, C, or D: AI SYSTEM PASSES: —ZI 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. 81 SYSTEM CONDITIONALLY PASSES: One or more system components need to be replaced or repaired. The system m, upon completion of the replacement or repair, passes i nspection. 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, cracked, structurally unsound, shows substantial infiltration or exfihration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved try the Board of Health. Irevi■ed r/15/951 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: g C p rti, . Owner: Date of Inspection: �✓H �✓ 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): 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 Cl 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. 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 FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The wstem nas a septic tank ano soli aosorpuon system anti is within 100 feet to a surface water supply or tributary to a surface water supply. The s\•stem ha, 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 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 tl SYSTEM FAILS: 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. 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 :evised 8/15/95) 2 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Owner: 13 Date of Inspection: / ( /a q / 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 dogged 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 1 of.a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. 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 o-ie 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 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 ,equirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 8/15/9s) 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: C«isi o/;6u Owner: w G r Date of Inspection: Check'if the following have been done: _L/Pumping information was requested of the owner, occupant, and Board of Health. 1/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. ZAs 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 :ion-sanitary or industrial waste flow ZThe site was inspected for signs of breakout. V All system components, excluding the Soil Absorption System, have been located on the site. —j—/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 b�, non-intrusive methods. The facility 0�vnP• (and orru-)ants, if different from owner) were provided with information on the proper maintenance of Sub- Surface Disposal System. (revised 8/15/9S) 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C /_ SYSTEM INFORMATION Property Address: $� C a e-11—a c-k. Owner: Date of Inspection: /I /a � /ys FLOW CONDITIONS RESIDENTIAL: Design flow: 4/4/° gallons Number of bedrooms:, Number of current residents:Q Garbage grinder (yes or no):,o Laundry connected to system (yes or no): `ems Seasonal use (yes or no):_,6LO Water meter readings, if available: 9 y z 8 d� o C'0 Last date of occupancy: V COMMERCIAUINDUSTRIAL: Type of establishment: Design flow: Aallons/day Grease trap present: (yes or no)_ industrial Waste Holding Tank present: (yes or no)_ Non-sanitary waste discharged to the Title S 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: U G J H,.0 c.cA ;r, : c�— / % .— ; h T� V,/r,, n-cc/ System pumped as pan of inspection: (yes or no)1�[0 If yes, volume pumped Rallons Reason for pumping: TYPE OF SYSTEM L/ 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) Other (explain) APPROXIMATE AGE of all components, date installed (if known) and source of information:f-j--ki 5 to /�e ����//s- Sewage odors detected when arriving at the site: (yes or no) trevised 8/15/95) S SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: / g 8 Ca N,c (b o Owner: Date of Inspection: l� /aq l`jf SEPTIC TANK: (locate on site plan) Depth below grade:, r Material of construction: _zconcrete _metal _FRP —other(explain) Dimensions: ' X /3 Sludge depth: a /�` Distance from top of sludge to bottom of outlet tee or baffle: a Scum thickness: /Vo/vE Distance from top of scum to top of outlet tee or baffle: 1`0 S L- .d "^ Distance from bottom of scum to bottom of outlet tee or baffle: '/d 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.) t S Lj-.e - e L-"f /C, c., w ir- /�; v 0 r h o i/ S L !�� GREASE TRAP:, /9 (locate on site plan) Depth below grade: Material of construction: _concrete _metal _FRP —other(explain) Dimensions: >cum thickness: Distance from top of scum to top of outlet tee or baffle: ni<_tance from bottom M crom to honer.+ of oU!lo! tee or barne Comments: recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural ,ntegrity, evidence of leakage, etc.) ,revised 8/15/95) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C v / / SYSTEM INFORMATION (continued) Property Address: k o C-G k", Owner. 9e✓ N ; '-✓ Date of Inspection: 1,2 p / 5- TIGHT OR HOLDING TANK:&Y/g (locate on site plan) Depth below grade: Material of construction: _concrete_metal_FRP—other(explain) Dimensions: Capacity: gallons Design flow: gallons/day Alarm level: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX: (locate on site plan) Depth of liquid level above outlet invert: o e- Comments: ,note if level an distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) C 7 PUMP CHAMBER:-Y-.'� (locate on site plan) Pumps in working order:(yes or no) Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) (revised 8/15/95) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: /R S C kr 44 6u c k Owner: i3cin; c v Date of Inspection: r/a-7 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.) 114J C.A CESSPOOLS: ,locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: indication of groundwater: inflow (cesspool must be pumped as part of inspection) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY• W/17 ,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) 8 I - • i w y SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continues!) Property Address: 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 yd ' �? i5eov• �Sy ' 53 a X 6 /L w / �5 DEPTH TO GROUNDWATER. Depth to groundwater: -- feet adjusted high groundwater level method of determination or approximation: S o, f Q r,{ a�, -t'b o -?e- �CZ, f irevised 8/,15/95) 9 _ ___ 4 *Tw '.l6'A t%✓"; fir.} A-rI o a I�;. t ( 0 (/(��' 1///\'�`J' 3 A44, PiP65 7 ,4NP PV 7 i :SYS`T'ri f +�ti, 4,,4_ i f t3 �A.S7" :t,r�'O/V BOA .SG U�.� 4 PVC. MAD. j �_ _. _ _ l� WSJ 1 4 ���, ,SEPfi T 41 'n,S, -To1 Kti Yerr 1 Y`" ':r.5 ,5. i.4.� �, :3 . + 1_ ice _.... , l w �„�1 _ _�_: _.... ✓_. — ti @ �� 0 00 TO ► --�— ,► _ � �. � �.._i 1, t ��j < '� '` OF ?;J-/E LEACN1n/G Pfr ,FOR A P1 TANG'S �.�" GC♦-/_ t .t� +� t.ec_. N. .,9l�� 1 - t+f 1 J �`1Y� � r k A', d''Y J C, . � F-I\�[�1.. . ._ _ ._ ,.� .._.... iG _•i"' i , ��J *,•�j y &'G.' ;. t ( '� 1 1 .t 1 Y/'"IC,44 IST IB�� ION 84OX _... YA r� c:.ir Z 4fi S �' `!V'C' ,. 1,1[� 1dlt,t1 � I is OUi.1T _s2 >rL7 /VC?3' :S ,l _ _ a..k ___ a ... __..__.._.J _ p3f "7' ?`i� IAA+ J�ST.N 4r�I'y� HEX+�.)HA4 �.. !Y 0i, - Y./`, t�Ifle..r T ON t. O A M �L�QQ rY,"7 4.. 1, 7' 7_ 6.7 tr,4�,G -,..._.�—.. .5_.id.- `Y Q f r�i"�FfC!✓" .`7.'h'7� /4' r7G '.,3 I4� �.�7 i J 191�. f'f C.?BJ ' '� `/r /�' '/Tt.S° � �Nl�c�,�� v � 1 ' ANx �� 7 ;-: ' f Op "` PT;! �c��i�:k':� �Y�tt;��'Y`,4!ti"v !�'�'r1r 1,�' 'C ddCX�"/4.�i:N6 �'r c?.(rr4?'4!�.` `t"iILf,Q:_ �.� -,% �Q�, U i7G+f�c. SEPTIC C t i��l� uN4ESS T h+E. 'l `r',SE : �� �c"1i' . ! .c. SY,ST �!r! 7 ! rf Q i'1iST-4�t k-CP i N PON. �� Ems C<�r,_`_.��,.+ ,4/VA-, R,6_0 'r0RC:`�-'' Th�:'l.J�GYjU7^ .F i.7,� 7t1�C :`;TltT�= i Y,/,,q ,e_4 %IZ " iA�t!/T-4R Y 6�,t_" P 4,"r',9 4 V,'' !;.C f'A�' t tir'LIJ_E,,5 NGINEE-� A2'�''ROW op•t�� eoTTom i'Y�'f�'%�r 0,4'v AP`P'k,Y r--) INI X Gf 44,E F;' Ei 5 ,; 4-666 4� __...�. _ .._.. - ` 7r .L y .'' •J�,FA Cf%�Nl;; 1...M...r. ram'! e o , k 777. 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