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HomeMy WebLinkAbout0019 CESARS WAY - Health 19 Cesar's Way Marstons Mills P A = 122 029 1 .._ c , Commonwealth of Massachusetts a 3 Title 5 Official Inspection Form Ir I� w: PI Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 19 Cesars Way Property Address Amanda Hough Owner Owner's Name information is required for every Osterville MA 02655 7-22-20 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. A. Inspector Information SfIr Shawn Mcelroy Name of Inspector Upper Cape Septic Services Company Name P.O. Box 73 Company Address East Falmouth MA 02536 City/Town State Zip Code 508-495-0905 S13971 Telephone Number License Number B. Certification I certify that:[ 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 theproperty 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 7-22-20 1 s Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system 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 4 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 19 Cesars Way Property Address Amanda Hough Owner Owner's Name information is required for every Osterville MA 02655 7-22-20 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) Syste'm 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: System is in good working order with no sign of failure. 2) System Conditionally Passes: ❑ One or more system components as described in the tonditionalPass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND) for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y El ❑ ND (Explain (below): F t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 Commonwealth of Massachusetts r� Title 5 Official Inspection Form II i, i�t Subsurface Sewage Disposal System Form Not for Voluntary Assessments 19 Cesars Way Property Address Amanda Hough Owner Owner's Name information is required for every Osterville MA 02655 7-22-20 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 El ❑ ND (Explain below): ❑ obstruction is removed ❑ Y El ❑ 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 ON ❑ .ND (Explain below): ❑ obstruction is removed ❑Y El ❑ 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.712 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts - 3 Title 5 Official Inspection Form ' III Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 19 Cesars Way Property Address Amanda Hough Owner Owner's Name information is required for every Ostefyille MA 02655 7-22-20 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 ❑ ® 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.712 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 18 Commonwealth of Massachusetts ;w Title 5 Official Inspection Form 1.1 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 19 Cesars Way Property Address Amanda Hough Owner Owner's Name information is required for every Osterville MA 02655 7-22-20 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® 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 V2 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 water supply well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ ® 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. 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 I Commonwealth of Massachusetts r� ,w Title 5 Official Inspection Form Y,Ci Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 19 Cesars Way Property Address Amanda Hough Owner Owner's Name information is required for every Osteryllle MA 02655 7-22-20 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 ® ❑ 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? ® ❑ Wasthe facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] t5insp,doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 18 r Commonwealth of Massachusetts Title 5 Official Inspection Form �i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments s 19 Cesars Way Property Address Amanda Hough Owner Owner's Name information is required for every Osteryille MA 02655 7-22-20 page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flowbased on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Description: Number of current residents: 6 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: 7-2020 Date t5insp.doc•rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form iCbl Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 19 Cesars Way Property Address Amanda Hough Owner Owner's Name information is required for every Osterville MA 02655 7-22-20 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No 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: Source of information: Owner---pumped 2017 Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Maintenance t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form 1)"I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments r...; 19 Cesars Way Property Address Amanda Hough Owner Owner's Name information is required for every Osterville MA 02655 7-22-20 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: 2007 Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 54"feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Good condition. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form ill Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 19 Cesars Way Property Address Amanda Hough Owner Owner's Name information is Osterville MA 02655 7-22-20 required for every ` page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: 48"feet Material of construction: ® 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 Dimensions: 1000 gal Sludge depth: 12" Distance from top of sludge to bottom of outlet tee or baffle 20" Scum thickness 2" Distance from top of scum to top of outlet tee or baffle 6" i Distance from bottom of scum to bottom of outlet tee or baffle 14" How were dimensions determined? Tape Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank is in good condition with baffles installed and no sign of leakage. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts r� ;w Title 5 Official Inspection Form M Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 19 Cesars Way `r Property Address Amanda Hough Owner Owner's Name information is required for every Osterviile MA 02655 7-22-20 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date 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): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18 Commonwealth of Massachusetts 3 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 19 Cesars Way J Property Address Amanda Hough Owner Owner's Name information is required for every Osterville MA 02655 7-22-20 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): Depth of liquid level above outlet invert 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Good condition with water at working level and no sign of back-up from chambers. t5insp.doc•rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form w �i") Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,iri 19 Cesars Way Property Address Amanda Hough Owner Owner's Name information is required for every Osterville MA 02655 7-22-20 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 ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If 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: ❑ leaching pits number: ® leaching chambers number: 2-500's ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc-rev.712 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form PI Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 4 19 Cesars Way J' Property Address Amanda Hough Owner Owner's Name information is required for every Osterville MA 02655 7-22-20 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.): Leach chambers in good condition with water level and stain line at 6"off bottom of chamber. 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc-rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 c Commonwealth of Massachusetts 3 Title 5 Official Inspection Form 61 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments L._�. 19 Cesars Way Property Address Amanda Hough Owner Owner's Name information is required for every Osterville MA 02655 7-22-20 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. 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.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 18 Commonwealth of Massachusetts a Title 5 Official Inspection Form ir Yrl Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ` 19 Cesars Way Property Address Amanda Hough Owner Owner's Name information is required for every Osterville MA 02655 7-22-20 page. 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 r a _ r° 4`" 1 3 r o 7@e33 r - 437 t5insp.doc•rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18 r Commonwealth of Massachusetts ,w Title 5 Official Inspection Form I I Subsurface Sewage Disposal System Form Not for Voluntary Assessments 19 Cesars Way Property Address Amanda Hough Owner Owner's Name information is required for every Osterville MA 02655 7-22-20 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: 124 feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: ® Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database- explain: You must describe how you established the high ground water elevation: Original design plans show no groundwater at 12'. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form iM► Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 19 Cesars Way Property Address Amanda Hough Owner Owner's Name information is Osteryille MA 02655 7-22-20 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.7/2 612 0 1 8 Title:5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18 To wn of Barnstable. PC . P#Ing l j Department of Regulatory Services s Public Heaith Division Date .bJy Mrs$ 200 Main Street;Hyannis MA 02601 �Ep Ml►'t J I Date Scheduled /v 'Time Fee Pd. /" I . • I Soil Suitability Assessment foY ewage Dis osal 6 ►`' Performed By: � yD� Witnessed By: i ©5 LOCATION& GENERAL INFORMATION L.ccation."Ld�dresss . 3 owner's Name ��yi fr �;V 4�P�l Address ��/ ces4'6`s y y Assessor's Map/P4teel: ��� "'i Engineer's Name �/7��� / s L�/7�SSBC/ S /9 Lp NBW CONSTRUt 'i'[ON REPAIR Telephone# 33 O Land Use KE /GL/[° !1 Slopes(96) ' d ' Surface Stones Distances from: Open Water Body. k Possible Wet Area ft Drinking Water Well �' ft I ' ..r.-• ft �ainage.Way r� ft Property Line ft Other I SKETCH:(street name,dimensions of lot,exact locations of test holes&Pere tests,locate wetlands in proximity to holes) y • Ijp- " I -Y /y Parent material(geologic) d 'K /6� 001 e 1lZa /. /l Q/hDepth to Bedrock l/JDYJ`ly. I in from Pit Face 1 Depth to liroundwa�er. Standing Water in Hole: WeeP g dZ(o oLcJ C7s-. c Estimated Seasonal ifth Groundwater ONFOR HYII WATER TABLE DtTERMNSEASONAL Method Used In, Depth db�ery standing" obs.hole in. Depth to soli mottles: Depth toiweeping from side of ohs.hole I in, cwundwafpr Ad)ustmcot_ � L�......... Index Well#S �U.. Reading Date: Index Well level A .factor,,, _, .'_ �4I.drnundwatcrlev+al.,.. � PERCOLATION TEST Date 74ne� Observation I TWO at 9" Hole# Time at b" Depth of Pere ..----- f Time(9'%6") Start Pre-soak Time.( -- End Pre-soak 7 Rite MinJlnch Site Suitability Assc$smenG Site Passed Site Failed; Additional Testing Needed(YIN)- Original.Public He$Ith Division Observation Hole Data To Be Completed on Back ***If P ercolatervation. test is to be conducted within 100'of wetland,,you must first notify the Barnstable C Division at least one(1)we&pijor to beginning- DEEP OBSERVATION.HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other .Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consiftency,%Gravel) DEEP OBSERVATION HOLE LOG Hole# 2 Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistencv.%Gravel) 0 5, /� DEEP OBSERVATION HOLE LOG Hole# Depth from' Soil Horizon Soil Texture Soil Color Soil • Other Surface(in.) ti. (USDA)„•..• (Munsell) Mottling (Structure,Stones,Boulders. Consistency, O vel I 1 DEEP OBSERVATION HOLE LOG f Hole# Depth from Soil Horizon Soil Texture _.Soil Color. •Soil Other Surface(in:) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency, Flood Insurance Rate Man: Above 500 year flood boundary No— Yes lLZ Within 500 year boundary No Yes Within 100 year flood boundary No Yes Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervious material exist.in all areas observed throughout the area proposed for.the soil absorption system? s _ If not,what is the depth of naturally occurring pervious material? Certification I certify that on (date)I have passed the soil evaluator examination approved by the Department of Environmental Protection and that the above analysis was performed by me consistent with the required trainin expertise and experience described in 3.10 CMR 15.017. SignatureL� Date QA.SEPTICtPERCFORM.DOC TOWN OF BARNSTABLE LOCA'ITO �� �3J�1.S ____ )l SEWAGE # VILLAG/ ! �9�� ASSESSOR'S MAP & LOT JZ\ INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) �-,/m� �� � r(size) NO.OF BEDROOMS BUILDER OR OWNER PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leac 'ng Facility(If any wetlands exist within 300 feet o e n ty) Feet Furnished by .d, � ..� i � � (�,, � ,. g� -9 �' ® •�� �.� �_ _ , � � � hS �� _ � \ -�-_ - a� ���� TOWN OF BARNSTABLE L C LOCATION SEWAGE# 3 iVILLAGE /' M&ZEASSESSOR'S MAP &LOT �- 'Da i INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) NO.OF BEDROOMS BUILDER OR OWNER i PERMTTDATE: COMPLIANCE DATE: f Z .Z6 O 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 leaching facility) Feet Furnished by . :r ; t W ar E c ►3 ` �a s eo �7 _ o z No. &©O 3 l9 3 Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: i., Yes a: i"4 PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS ZI pprtcatton for ]Dig poml *p6tem Construction Permit Application for a Permit to Construct( )Repair( j.,<pgrade( )Abandon( ) ❑Complete System 9�r�idividual Components Location Address or Lot No. Owner's Name,Address and Tel.No. --:�-dT-_3?f'—43(,J%' Assessor's Map/Parcel °I I j Cj C E,4 54R w Y 0S 7— ��"i� �'IMF Instal er's Name,Address,and Tel.No. �"Q �f f'p`�c��� Designer's Name,Address and Tel.No. Type of Building: /0 us £ Dwelling No.of Bedrooms r Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) /17/4 1,4.` Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been iss d by this Board of Health. Sign Date /oq 3 Application Approved by Date Application Disapproved for the following reasons Permit No. 3_&3 ( Date Issued � 'c3 Ja_3 O 11 31 f g No. � � Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: ✓� ! r Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLES MASSACHUSETTS 2pprtcatton for Ztgogal *pgtent Congtruction Permit Application for a Permit to Construct( )Repair(J.--)'Upgrade( )Abandon( ) El Complete System [P<vidual Components Location Address or Lot No. O ner's Name,Address and Tel.No. .3`O 8 q CE.05,440 w�f✓ TvCk)-£R Assessor's Ma /Parcel p Jai-U�°I �,n•,M� C£A.sAR a.�r9%aS r j Instal er's Name,Address,and Tel.No. $-418- �7.l�p`2 BOO Designer's Name,Address and Tel.No. �� C/jNCO 3So /ham/� 57-- L.cJ Type of Building: US £ Dwelling No.of Bedrooms f/0 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil i N Nature of Repairs or Alterations(Answer when applicable) £ 11 C£ /r//9/A/ i jet , Date last inspected: Agreement: . w. II` The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system '4 in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this Board of Health. Signs Date /� 3� 03 Application Approved by Date U Application Disapproved for the following reasons i j Permit No. =3—(97 3 Date Issued tD D `i>7Q 6A1 THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS - -Certificate of Compliance . THIS IS TO CERTIFY that the On-site Sewage Disposal System Constructed( )Repaired( 4--)Upgraded( ) Abandoned( )by 6 �A l/7 IV C`J 3So 7- w' Y�2 at / 9 C £A 5,41? W,4 t'' 0571 has been constructed in accordance s with the Pce ions of Title 5 and the for Disposal System Construction Permit No.a 0 a 3 -R/ dated I� d U Installer .. -C�c�.— Designer The issuf this permit shall not be construed as a guarantee that the syPAS w�ilftunction designed- Date 1� I�`fn �J i)7 Inspector ,N 1 K v � V --------------------------------------- No. CJp 3- 6 72( Fee $0 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS lwtgool *pgtem Congtructton Permit Permission is hereby granted to Construct( )Repair(4-)-Upgrade( )Abandon( ) System located at 9 C Ell 5,4iP 44.1/0 G.S/— and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date f thispe i . Date: ( r 3) Approved by �J� f TOWN OF BARNSTABLE LOCATIO SEWAGE # VII LAGS, ASSESSOR'S MAP &-LOT ♦y INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) �✓� // r(size) NO. OF BEDROOMS BUILDER OR OWNER PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leac 'ng Facility(If any wetlands exist within 300 feet o e ty) Feet Furnished by � � s � CS - - �jh5 52- P s. 4�' TOWN OF BARNSTABLE LC C c� LOCATION .� /-� SEWAGE # 04 - 3 _ VILLAGE ��� /��i� _ASSESSOR'S MAP & LOT r INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY � LEACHING FACILITY. (typed (size) NO.OF BEDROOMS BUILDER OR OWNER PERMTTDATE: o COMPLIANCE DATE: z1.2 6 0 _ 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 leaching facility) Feet Furnished by j� iI I 1 ar let 13 35 ti e � COMMONWEALTH OF MASSACHUSETTS F EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS s C) DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE REINTER STREET. BOSTON. MA 02108 617-292-5500 R7LLIAM F.WELD TRUDY CORE Governor Secretary ARGEO PAUL CELLUCCI DAVID B.STRUHS Lt,Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Commissioner PART A f ( ! CERTIFICATION - \ Michel Manalo Property Address: '�'7"Cesars Way, (lcf-orzLi 1 1 P Address of Owner: g Date of Inspection: /-P/ (If different) P 0 Box2128Hyannis, A 0 2 6 01 Name of Inspector: Wm E Robinson Sr 1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (3 15.0 Company Name: him E Robinson Septic Service Mailing Address: PO Box 1 089 , Cent-c--rvi 1 1 r�r I'dA 02632 A, �p Telephone Number; .5 0 8T, 7 7 5_R 7 7 f; A " ?i y^ 2- CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the in a elow 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: _V Passes _ Conditionally Passes Needs Further Evaluation By the Local Approving Authority _ Fails Inspector's Signature: �I Date: 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. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. INSPECTION SUMMARY: Check A, B, C, or D: A) SYSTEM PASSES: I have not found any information which indicates that the system violates any of the failure criteria as defined in 3W CMR 15.303. Any failure criteria not evaluated are indicated below. COMMENTS: BI SYSTEM CONDITIONALLY PASSES: One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain why not. _ The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection; or the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 04/25/97) Page 1 of 10 DEP on the World Wide Web: http twww.magnet.state.ma.us/dep ej Printed on Recycled Paper r 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 17 Cesars Way, Osterville Owner: Mangalo Date of Inspection: 1--✓9"'CZ 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 pipe(s) are replaced obstruction is removed C] F RTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health, safety and the environment. 1) 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 PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet to a surface water supply or tributary to a surface water supply. _ The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well. _ The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine distance (approximation not valid). 3) OTHER (revised 04/25/97) Page 2 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 17 Cesars Way, Osterville Owner: Mangalo Date of Inspection: DJ SYSTEM FAILS: You ust indicate eit•:er "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 bonding 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 1i2 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. EJ LAIR E SYSTEM FAILS: You m st indicate either "Yes" or "No" as to each of the following: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Ye 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 wner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program re irements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. h (revised 04/25/97) Page 3 of 10 w SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 17 Cesars Way, Osterville Owner: 'Mangalo Date of Inspection: /—/?-997 Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Yes/ No _✓ _ Pumping information was provided by the owner, occupant, or Board of Health. None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. As built plans have been obtained and examined. Note if they are not available with N/A. L." The facility or dwelling was inspected for signs of sewage back-up. t/ The system does not receive non-sanitary or industrial waste flow. The site was inspected for signs of breakout. ✓ All system components, excluding the Soil Absorption System, have been located on the site. _ The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. The size and location of the Soil Absorption System on the site has been determined based on: I/ _ The facility owner land occupants, if different from owner) were provided with information on the proper maintenance of / Sub-Surface Disposal System. V Existing information. Ex. Plan at B.O.H. Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) (15.302(3)(b)) (revised 04/25/97) Page 4 of 10 r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 17 Cesars Way, Osterville Owner: Mangalo Date of Inspection: FLOW CONDITIONS RESIDENTIAL: Design flow: 330 g.p.d./bedroom for S.A.S. Number of bedrooms:3 Number of current residents: Garbage grinder (yes or no):Anlo Laundry connected to system (yes or no)�� �Seasonal use (yes or no): 0 Water meter readings, if available (last two (2) year usage (gpd): 1996 — 1 1 1 , 000g Sump Pump (yes or no):!- - 1997 - 75, 000g Last date of occupancy: COM ERCIAUINDUSTRIAL: Type o establishment: Design f ow: gallons/day Grease t1p present: (yes or no)_ Industrial Waste Holding Tank present: (yes or no)_ Non-sani ary waste discharged to the Title 5 system: (yes or no)_ Water Teter readings, if available: Last LR ( of occupants. OTHDescribe) Last of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of System pumped as part of inspection: (yes or no)/—(j If yes, volume pumped: gallons Reason for pumping: TYPE O YSTEM 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 detected when arriving at the site: (yes or no) (revised 04/25/97) Page 5 of 10 w SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 17 Cesars Way, Osterville Owner: Mangalo Date of Inspection: BUILDING SEWER: (Locate n site plan) Depth bel w grade: Material of construction: _cast iron _40 PVC _ other (explain) Distance fr 7 m private water supply well or suction line Diameter Commen I, (condition of joints, venting, evidence of leakage, etc.) SEPTIC TANK:_ (locate on Site plan) i Depth below grade: .3 Material of construction: _concrete —metal —Fiberglass _Polyethylene —other(explain)/ If tank is metal, list age _ Is age confirmed by Certificate of Compliance _(Yes/No) Dimensions: .� ��` ''r C , 9. Sludge depth: e Distance from top of sludge to bottom of outlet tee or baffle: 3 `/ Scum thickness: S Ar (� ' - I Distance from top of scum to top of outlet tee or baffle: a , Distance from bottom of scum to bottom of outlet tee or baffle: jD How dimensions were determined: 0 �i. i`— �r ✓� Comments (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outle invert, structural integrity, evidence of leakage, etc.) �/�' �w� / �. �� is ° `� ' R A t---T& GREAS TRAP: (locate n site plan) Depth b low grade: Materiallf construction: _concrete _metal _Fiberglass _Polyethylene —other(explain) Dimensi Ins: Scum th ckness: Distan from top of scum to top of outlet tee or baffle: Distan a from bottom of scum to bottom of outlet tee or baffle: Date f last pumping: Comm nts: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural iniegri�, evidence of leakage, etc.) (revised 04/25/97) Page 6 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 17 Cesars Way, Osterville Owner: Mangalo Date of Inspection: TI TOR HOLDING TANK: (Tank must be pumped prior to, or at time, of inspection) (le on site pl ocat an) Depth be w grade: Material o construction: _concrete _metal _Fiberglass _Polyethylene _other(explain) Dimensio s: Capacity: gallons Design f ow: gallons/day Alarm evel: Alarm in working order _ Yes; _ No Date o previous pumping: Comme ts: (conditio of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX.---' (locate on site plan) Depth of liquid level above outlet invert:_ Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) PUM CHAMBER:_ (looat on site plan) Pumps in working order: :(Yes or No) 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 w SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 17 Cesars Way, Osterville Owner: Mangalo Date of Inspection: /,/ 7 9 9- SOIL ABSORPTION SYSTEM (SAS): (locate on site plan, if possible; excavation not required, but imay 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: Alternative system: Name of Technology: Comments: (note condition of soil, signs of hydraulic failure, level of pording, condition of vegetation, etc.) y 45 -0 o t> r' S leszw Yn 1c - / , �i2 �' / /"ems CESSPOOLS: _ (locate on site plan) Numb\ee and configuration: Depth-top of liquid to inlet invert: Depth ofVolids layer: Depth of'scum layer: Dimensions of cesspool: Materials of construction: Indication Iof groundwater: jn`low (cesspool must be pumped as part of inspection) Comme ts: (note ndition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY: (locate on ite plan) Materials f construction: Dimensions: Depth of olids-____ Comment (note con ition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) i� (revised 04/25/07) Page 8 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 17 Cesars Way, Osterville Owner: Mangalo _ Date of Inspection: ) — ) —c S 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) i I - 1 3 j i z i (revised 04/25/97) Page 9 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 17 Cesars Way, Osterville Owner: Mangalo Date of Inspection/ g �� Depth to Groundwater 1,'2- 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 excavators, installers Use USGS Data Describe in your own wordshow you established the High Groundwater Elevation. (Must be completed) (revised 04/25/97) Page 10 of 10 ..a�,•