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HomeMy WebLinkAbout0108 CHOPTEAGUE LANE - Health IL 08 Chopteague Lane !M t stons Mills= 011 006 1` r 1 r ''TOWN OF EP �o SABLE Lc.FkfI'ION G.,, -� SEWAGE # VILL;WE r� � , � ASSESSOR'S MAP &LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY �/� i� ►�s 1 — LEACHING FACILITY: (type LSACk G (size) NO.OF BEDROOMS BUILDER OR OWNER PERMITDATE: - -!�Z- T_COMPLIANCE DATE: % ::z- 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' ✓ , �/� ���.�J% i(/ �7 �, ,�` - - �, r r ®�� �r`� ,�� . �a a a Fee ✓ Z!� THE MMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVIS ON -TOWN OF BARNSTABLE., MASSACHUSETTS 01pplication for Migonl *pztem Con6truction Permit a Application for a Permit to Construct( )Repair( Upgrade( )Abandon( ) ❑Complete System El Individual Components Location Address or Lot No. /Q ®� Owner's NamAddress and Tel.No.re Assessor's Map/Parcel611�-40 `�1 Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. „ Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Rypairs or Alterations(Answer when pplicable /`i` GNP f'c`D��_ �� c�✓i 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 ' e 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance h been ' t d of H Zned Date Application Approved Date 11�'' Application Disapproved for the following reasons Permit No. Date Issued No: ` � _ Fee i THE MMONWEALTH OF MASSACHUSETTS Entered in computer: Yes ' f PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS ZI r lication for dig aaf 6pelem Construction Permit T z Application fora Permit to Construct( ):Repair(,,Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No.,xv— AL Owner's Name,Address and Tel.No. Assessor'sMap/Parcel ''� 114 Installer's Name,Address,and Tel.No. Designer's Name;Address and Tel.No. d-A& Type of•Building: Dwelling 1 No.of Bedrooms Lot Size sq. ft. Garbage Grinder( ) Other`,- Type of Building No. of Persons Showers( Cafeteria( ) Other Fixtures! -Design Flow, a 3cp gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date -� Title Size of Septic'Tank Type of S.A.S. - D scription,of Soil ffature of Ry/� airs or,Alterations,(Answer.when pplicable) --�� ,3Ae 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 e 5 of the Environmental Code and not to place the system in operation until a Certi i- . rate of Compliance has been • t d of H � Si ned Date -� Application Approved r, Date Application Disapproved for the following reasons 1 i. r' Permit No .^ Date Issued f37 20' , i - —+———— —— ————— ———————————— ——————THE COMMONWEALTH OF MASSACHUSETTS r BARNSTABLE, MASSACHUSETTS Certif irate of•Co fl-oriance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired ( pgraded( ) Abandoned( )by u� at o ti `� � has been constructed in accordance with the pr v`sions of Title 5 and a for Disposal'System Construction Permit No. �' ated I , Designer ;�----�. The issuance of ermit shall not be construed as a guarantee that the-system will function as designed. Date C� _ ! > Gf``7 Inspector ' 1 No. Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION BARNSTABLE, MASSACHUSETTS Miopogaf *pOtem Construction permit Permission is hereby granted to Construct( )Repair( pgrade( )Abandon ) System located at -Pi �Q +, V 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 of this t. Date: Approved b 1 j AA� ir : T 3 Cp a ' r F t V ri 1 C� ,� I✓mil r `1) /_`rl I i i Safe Earth Systems, Inc. P.O. Box 1359 Marstons Mills, MA 02648 11 l2 (508) 477-2999 0 (508) 420-2803 s � r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM `` �A PART A ,� .���� tz CERTIFICATION �� Property Address: 108 Chopteague Lane Address of Owner: Joe Porcaro A�99tis9 J`9�9 C' Date of Inspection: 9/25/97 Marston's Mills MA 02648 �`r Name of Inspector: Michael J. DiMaggio Company Name, Safe Earth Systems 5 P.O. Box 1359 -- Marstons Mills, MA 02648 (508)420-2803 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: ✓ Passes Conditionally Passes Needs Further Evaluation By the Local Approving Authority Fails Inspector's Signature• T�) Date: September 25,1997 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 e fa thilure criteria as defined in 310 CMR 15,303. Any failure criteria not evaluated are indicated below. B] SYSTEM CONDITIONALLY PASSES: One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair, passes inspection. Indicate yes, no, or not determined(Y, N or ND). Describe basis of determination in all instances. If"not determined", explain why not. no The septic tank is metal,cracked, structurally unsound, shows substantial infiltration or e xfiltration,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. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM !` PART A r CERTIFICATION(continued) Property Address: 108 Chopteague Lane, Marstons Mills, MA Owner: Joe Porcaro Date of Inspection: September 25, 1997 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 leveled or replaced The system required pumping more than four times a year due to broken or obstructed pipe(s). The_system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed C] FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health, safety and the environment. 1) 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 system has a septic tank and soil absorption system and 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 is within a Zone I of a public watery 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. D] 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 overload or clogged SAS or cesspool. _Discharge or ponding off effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. 2 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 108 Chopteague Lane, Marstons Mills, MA Owner: Joe Porcaro Date of Inspection: September 25, 1997 D] SYSTEM FAILS(continued): _Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day `flow: _Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped _Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. _Any portion of a cesspool or privy is within a Zone I of a public well. _Any portion of a cesspool or privy is within 50 feet of a private water supply well. _Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E] LARGE SYSTEM FAILS: The following criteria apply to large systems in addition to the criteria above: The design flow of system is 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: _the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply _the system is located in a nitrogen sensitive area, Interim Wellhead Protection Area(IWPA), or a mapped Zone II of a public water supply well. The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. 3 I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 108 Chopteague Lane, Marstons Mills, MA Owner: Joe Porcaro Date of Inspection: September 25, 1997 Check if the following have been done: V Pumping information was requested of the owner, occupant, and Board of Health. N/A 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. Largdg volumes of water"have not been introduced into the system recently or as part of this inspection. —,(—As built plans have been obtained and examined. Note if they are not available with N/A. The facility or dwelling was inspected for signs of sewage back-up. —,(—The system does not receive non-sanitary or industrial waste flow. The site was inspected for signs of breakout. All system components,excluding the Soil Absorption System, have been located on the site. �/ The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. ,/ The size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods. The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of Sub-Surface Disposal System. 4 i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 108 Chopteague Lane, Marstons Mills, MA Owner: Joe Porcaro Date of Inspection: September 25, 1997 FLOW CONDITIONS RESIDENTIAL: Design flow: 330 gallons Number of bedrooms: 3 Number of current residents:-4 _ Garbage grinder(yes-or no): NO Laundry connected to system (yes or no): yes Seasonal use(yes or no): NO_ Water mete readings, if available: N/A Last date of occupancy: September 25, 1997 COMM ERCIAL/INDUSTRIAL: Type of establishment: Design flow: gallons/day 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: OTHER:(Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: SYSTEM HAS NEVER BEEN PUMPED BY OWNER System pumped as part of inspection: (yes or no) yes If yes,volume pumped gallons 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) Other(explain) APPROXIMATE AGE of all components,date installed(if known)and source of information: APPROXIMATELY 15 YEARS ACCORDING TO OWNER Sewage odors detected when arriving at the site: (yes or no) no i II 5 I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 108 Chopteague Lane, Marstons Mills, MA Owner: Joe Porcaro Date of Inspection: September 25, 1997 SEPTIC TANK: ./ (locate on site plan) Depth below grade: 12" Material of construction: [_concrete _metal _FRP _other(explain) Dimensions: 6'x10'x6' Sludge depth: 0" Distance from top of sludge to bottom of outlet tee or baffle: N/A" Scum thickness: 0" Distance from top of scum to top of outlet tee or baffle: N/A Distance from bottom of scum to bottom of outlet tee or baffle: N/A 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.) System pumped as part of inspection. Reason for pumping: S.A.S. replaced as part of inspection. GREASE TRAP: (locate on site plan) Depth below grade: Material of construction: _concrete _metal _FRP _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: 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.) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 108 Chopteague Lane, Marstons Mills, MA Owner: Joe Porcaro Date of Inspection: September 25, 1997 TIGHT OR HOLDING TANK: (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: 0" Comments:_ New D-Box installed as part of inspection. (condition of inlet tee, condition of alarm and float switches,etc. PUMP CHAMBER: (locate on site plan) Pumps in working order(yes/no) Comments.- (note condition of pump chamber,condition of pumps and appurtenances,etc.) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 108 Chopteague Lane, Marstons Mills, MA Owner: Joe Porcaro Date of Inspection: September 25, 1997 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: _3_ 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.) r31 500 gallon leachinq chambers with 3' of stone all around installed as part of inspection 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: (location 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.) 8 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 108 Chopteague Lane, Marstons Mills, MA Owner: Joe Porcaro Date of Inspection: September 25, 1997 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' 7' a� DEPTH TO GROUNDWATER Depth to groundwater: 35 feet method of determination or approximation: Site Well f COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAus DEPARTMENT OF ENVIRONMENTAL PROTECTION RECEIVED SEP Z 2 2003 TITLE 5 T�WF BARNSTABLE HE�ALTH DEPT. OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: /02 6-170 U e— MAP : r�(s PARCEL : O (0 Owner's Name Owner's Address: c, L c LOT , Date of Inspection: Name of Inspector: lease print)����" Company Name: Mailing Address: a vx Telephone Number:(209.) 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 groper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title S(310 CMR 15.000). The system: c/passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority J Fails Inspector's Signature: f I GZ� Date: The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments ""This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future,under the same or different conditions of use. Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: O D ►�!S 0�a�' Owner: (SD d J G/ Date of Inspection: O Inspection Summary: Check A B,C,D or E I ALWAYS complete all of Section D A. Sy st Pagses; I have not found any information which indicates that any of the failure criteria described in 310 CMR 15303 or in 310 CMI2 15.304 exist,!°±-'failure criteria not gvaluate are indicated below, Comments: B. System Conditionally Passex: 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(9stribution 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: f Page 3 of 11 OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A // CERT/IF_ICATION(continued) Property Address: (0 ors . C q8 Owner: o afi Date of Inspection: Q 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 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 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: Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: ue Owner: Gm d /' �14 Date of Inspection: D. System Failure Criteria applicable to all systems: You must indscate"yes"or"no"tD each of the following for all inspections; Yes N-,o ackup of sewage into facility or system component due to overloaded or clogged SAS or cesspool Discharge or pending of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool c liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool _ Y Aiquid depth in cesspool is less than 6"below invert or available volume is less than'/Z day flow I/ _Required pum wn __ __ _ Year __pr�more than 4 times in the last ear NOT due to clogged or obstructed pipe(s), Number �of times pumped _ y portion of the SAS,cesspool or privy is below high ground water elevation. Any portion of cesspool or privy is within I00 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. _ tr//�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 paswes 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.] (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 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. 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 dhnldng 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. Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: /Of 640 o� o K r: ? O�G Owne �o �r Date of Inspection: i p Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes o �g information was provided by the owner,occupant,or Board of Health Wereny of the system components pumped out in the previous two weeks C/ _ Has the system received normal flows in the previous two week period e 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 Z-Z 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 es 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: �Yz/ho xisting 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 CNM 15.302(3)(b)] f Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: T�c� LA C �� Owner: Cho Date of Inspection:` :Vat FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): .3 Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): Number of current residents: 0 Does residence have a garbage grinder(yes or no): � Is laundry on a separate sewage system(yes or no):�/Aif yes separate inspection required] Laundry system inspected(yes or no):,& Seasonal use: (yes or no): Water meter readings,if available(last 2 years usage(gpd)): Sump pump(yes or no): Last date of occupancy: COMMERCIAL/INDUSTRUL 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: 9 Was system pumped as part of the inspection(yes or no): If yes,volume pumped:___gallons—How was quantity pumped determined? Reason four pumping: TYP�'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) _Tight tank _Attach a copy of the DEP approval _Other(describe): Approximate age of all com nents,date installed(if known)and source of info lion: Were sewage odors detected when arriving at the site(yes or no):LGV Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C Q SYSTEM INFORMATION(continued) Property Address: �"O 64C ✓��i 4'"-e_ Owner: Date of Inspection: I 0 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction._cast iron L40 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: Z g 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: Sludge depth: 3 �� Distance from top of sludge to bottom of outlet tee or baffle: 3� Scum thickness: aZ / Distance from top of scum to top of outlet tee or baffle: 7�� /, Distance from bottom of scum to bottom of outlet tee or}lafll How were dimensions determined:_ o fe a t ey) _ e Comments(on pumping recommendations,inlet and outletfee or baffle condition, structural integrity,liquid levels as related to outlet inverel v 7' of leakage,etc.): R wt 1 /17 E Fv! J O M O QC.Wj GREASE TRAP:ZAocate 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.): Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART.0 SYSTEM INFORMATION(continued) Property Address: l d C 4 al�e L e L—IV Vf �� /�4 Od-C&-6 Owner: o Date of Inspection: I7 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: pnons/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: Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage' to or out of box,etc.): PUMP CHAMBER /(locate 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.): Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: �o �e�i Owner: 6�O jC4c✓C �v� ills /� � �6 � Date of Inspection: - 612 SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why: Type - r �hmg pits,number:_ hing chambers,number: S00 p,,��p� (�✓ ? S leaching galleries,number: J leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number: innovative/altemative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition'of vegetation, etc.): 0 PIC, IV? 4 ("1 O Sc CESSPOOLS: ,,e(ccsspool 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: (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.): r r Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSR02M SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C. SYSTEM INFORMATION{coati) Prep"Address: ( C�"L O P.Gis t�e Z--/1 cam: / �f Der w o a SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks..Lore all wells within 100 feet Locate where public water sapply emery he building. -. G 30� I 6 - . , c �3 , Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE INSPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: ,i�2 6— 1 4 `v �s 45 C;�a? Owner: Date of Inspection: / SITE EXAM Slopg SurfAce water Check cellar Shallow wells Estimated depth to ground water/3-7rfeet 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 : Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must escribe how you est�shedthe high and water eleyation: fs tea. e47 o 11 .4 os oil, 7-' P etc tGb .z�)j) �� r o k vn C t✓e-- Y ! J �Ypf ifgsh* R Page: 1�C "• ,I o r: m CERTIFICATE OF ANALYSIS Barnstable County Health Laboratory SEP 0 5 2003 9sr 1Cttt`?�h� Report Dated: 8/27/2003 TO�yN Report Prepared For: OF BARNSTg8L� HEALTH DEpT. Order Number: G0322443 Candi McShera 133 Chopteague Lane Marstons Mills, MA 02648 Laboratory ED#: 0322443-01 Description: Water-Drinking Water' Sample#: 22443 Sampling Location: 108 Chopteague Lane,Marstons Mills Collected 8/25/2003 Collected by: C.McShera Received 8/25/2003 Routine ITEM RESULT UNITS MCL Method# Tested LAB: IC Lab Nitrates 2.7 mg/L 10 EPA 300.0 8/26/2003 LAB: Metals Copper 0.9 mg/L 1.3 SM 311113 8/27/2003 Iron <0.1 mg/L 0.3 SM 311113 8/27/2003 Sodium 13 mg/L 20 SM 311113 8/27/2003 LAB: Microbiology Total Coliform Absent P/A Absent 307 8/25/2003 LAB: Physical Chemistry Conductance 116 umohs/cm EPA 120.1 8/25/2003 pH 6.6 pH-units EPA 150.1 8/25/2003 Note: Water sample meets the recommended limits for drinking water of all above tested parameters. Approved By: (Lab Director) k Superior Court House, PO.Box 427, Barnstable, MA 02630 Ph: 508-375-6605 i i Sewage Permit No. �,oeatlon: Village:. ( / •(o ``� Installer's Name & Address: Builder's Name & Address: Date Permit Issued Date Compliance Issued 5 — Z —S�5 l i..� "�' i . yy r /1.... THE COMMONWEALTH.OF MASSACHUSETTS vvl� BOAR® OF HEALTH &I - m©(b ..-----.TOWN...-------- 0F.......B.ARNS.T.ABLE.............................••••••••.............. Appliratwn for Disposal Works Tonstrnrtiun rnmit Application is hereby made for a Permit to Construct (X ) or Repair ( ) an Individual Sewage Disposal System at: ...Chopteague Lane ----•-------.Lod....33-------------•-•----------.---- .._.................................... ...... ---..._..... -.................. Marstons Mill s Location-Address or Lot No. .................•--.._........ Owner............. ...' -•---.......-•----------------•---------- ----------. -d•ress•••._...........--•-----•---..............------ Ad .................................. r Address 20,300 d Type of Building Size Lot.............................Sq. feet Dwelling—No. of Bedrooms..........................................Expansion Attic ( ) Garbage Grinder (io) `4 Other—T e of Building No. of persons............................ Showers Wf�.i —Type g ----------------------------" P --(--->--- Cafeteria ( ) Other fixtures . ....._.. ............. . - ..-........ W Design Flow......._.55............................gallons per person per day. Total daily flow........... WSeptic Tank—Liquid ca.pacity.10O.G.gallons Length...$'-6--".. Width...5!_-$!!. Diameter................ Depth._`�'.4".._. x Disposal Trench—No..................... Width.................... Total Length.....................Total leaching area....................sq. ft. Seepage Pit No..................... Diameter......12.'......_. Depth below inlet...a,.67'..... Total leaching area.251.........sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by..... ?n r g................... Date....7MA1................... as Test Pit No. 1...... ........minutes per inch Depth of Test Pit....12.!......... Depth to ground water..... Qne , , (i Test Pit No. 2___.._._._. n tes �� inch Depth of Test Pit..... 2'__._____ Depth to ground water_...Not1 ;= ws°4_9 `I`P -4� loam and silt subsoil 48"-144" clean coarse a .. X...--------••----•- -••--•------... ....,. Description of Soil Sand m xe4l fi ne q w-el.;--. ........................... ....... R x " MICH 1EWICZ V ..............••--------•--...--------•--•---------••-•--------•---•--.._..-•----•---........-•-•---•--••---•---------...._..---------•------•-----------------..._......-•-•------ ,i,='' ----lvo�30420 do •---•------...---•--.._......-----•--••-•------------------•--•----•--•------•---•--•-----------------•------••-----------------------................... ................ rA.. V1 Nature of Repairs or Alterations—Answer when applicable......;T_--_ .........i p �' •-•P.-i ..-..-•-----------------•-•-----------------------•----••---------••---•-----------------•- ...... ENG Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in a c dance with the provisions of TITLE 5 f the State Sanitary Code—The undersigned further agrees not to place the system in operation ur4il a Certifi a of ompliance has b n issued y the bo d of health. Signed ........• + l G^�� ......--•--••----- �` jo__- Date Aplicat on Approved y. .......... . • . --•--• ---•- ---•• ......................... ------... ? . Date Application Disapproved for the f o wing reasons:-------•----------•---•-------•--------•----•--•----•-----------------------••-•--••--•--•• ••-•••............. .. ... .... .. •. •-- ...--- •--...-•- .............................................-................................................. Date tR ...� - � Permit No 4 iz .... *s �y •`y� X A", y!ntY �N _, Fxs ...... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 0ob TOWN._------------------O F......BARNS' 81;1§� - „� r irtt tlan: for Uiipn,ial Works Tunstrnrtiun ami# Application is hereby made for a Permit to Construct (X ) or Repair ('' ) an Individual Sewage Disposal System°at: n. ....Chopteague.diiiie................................................... -------------Lat•-•3,3---------------------------------------------- ....................... {. Location Address or Lot No. .......:.............................................. ..........-••-....................._..^•.... .......:..---------- *............. -....... . Owner Address W -----.... -----------------------•-•---•- -------•-••------.•-------...........-----•..Ad_---. Installer Address 20,300 d Type of Building Size Lot............................Sq. feet U Dwelling—No. of-Bedrooms..........I..............................Expansion Attic ( ) Garbage Grinder (jO) Other—Type.of Building ............................ No. of persons............................ Showers ( ) —'Cafeteria ( ) Q' Other fixtures s --=-------------------•••• =--•------•••-•-••• . -- W Design Flow.........55.............................gallons per person per day. Total daily flow...........220_........................gallons. WSeptic Tank—Liquid c4pacity..1000.gallons Length...8 1-6! . Width...r!_ !!. Diameter................ Depth-.5.' ....... x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No......I-------_.... Diameter......1.2....... Depth below inlet...3v6V----- Total leaching area..25.1...........sq. ft. Z Other Distribution box.( ) Dosing tank ( ) ~' Percolation Test Results Performed by..... ?.. -_Engirlee iag.................. Date_...71.ZV-8.1..................I ,tea Test Pit No. 1......2.......minutes per inch Depth of Test Pit..... _._.__.. Depth to ground water--::_�I (i OF Test Pit No. 2................minutes per inch Depth of Test Pit----- �____._._ Depth to ground water..... �N.. P4 ..TP#1 Q--4-8"Jo un and silty_subsoil.,..48°-144" cl� .. .. Q ROGER P yG Descri tion of Soil....:.sand--m3.�ted-•Witj3-file--gr-a4;a- .-TP#2-- as--TM----------------------•--------- - -PAUL o MICHNIEWICZ V ----------- -----------------------------------------•------- --••--......-- -T�76"10420 W .... .........................•-------•-----------------------.....••--•--•--•---•--•......--.......-- ---- -- '�1 �iVIL t �+ �I t p t7 p U Na ur of Repairs or tera ions Answer whfn applicable............................................................................ �.......................................t — f a............................................ .......................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accord a ce with the provisions of iiT 5 f the State Sanitary Code—The undersigned further agrees not to place the syst in opera ' ntil a Certi to o; ;Compliance has bee _issued.- e board/ of health. Signed_... -.' 'I A PP lication Approve ".B ... ! _ ` 11 .... Date Application Disapproved for the fo wing reasons:-.............................. ..............•-----------------------------••-------N...•l-....-•----------------......•... ----------------------- ......................................... Date 'Permit No........ ... .............�------------------- Issued............ .... e Date- - -•--^---•--..._..._._ w • THE COMMONWEALTH OF MASSACHUSETTS" BOARD OF HEALTH ..........................................OF...................:................................................................ wartifiratr of Tompfiatta THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( -�`or Repaired ( ) ...by.....................•------•-•-..__...................._...... ..--.......... ..-•-Installer--------'- ---------............................ -- ----•-•-•--•--•------------------- at............t- ------ 4 --------•--------------- --- ds't. has been inlled i accordance with the pro sl ions of T 5 of The State Sanitary Code as de ribed in the application for Disposal Works Construction Permit No.-___-` ------$.)............. dated---------- __2..... .. ..._._....__..... THE ISSUANCE_OF_THIS,CERTIFICATE ,SHALL NOT,BE-CONST E®"AS A G RANT E THAT THE SYSTEM WILL FUNCTION SATISFACTORY. � BJ - DATE................................................ Inspector THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .........:..................................OF................................. ............_................................. i rr tt1 nrk n r van rmi# f Permission is hereby granted... lam_ to Construct ( r Repair ( ) an Individual Sewage Disposal System atNo............... - -------------------------•----------•-•-••••-•-••---•----•-••-•---....... St—ree{, - . t as shown on the application for Dispos�7orksCpnstructi'on Permit No ..._.__ Dated__________________________________________ • ; -----.......................... ; ----------• Board DATE-•-- FORM 1255 HOBBS & WARREN. INC.,"PUBLISHERS ^�